scholarly journals Direct Oral Anticoagulants and Timing of Hip Fracture Surgery

2020 ◽  
Vol 9 (7) ◽  
pp. 2200
Author(s):  
Seth M. Tarrant ◽  
Michael J. Catanach ◽  
Mahsa Sarrami ◽  
Matthew Clapham ◽  
John Attia ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Primary Outcome ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Perioperative Outcomes ◽  
Surgical Timing ◽  
Serious Adverse Events ◽  
Hip Fracture Surgery ◽  
Geriatric Hip Fracture ◽  
Secondary Outcomes

Timely surgical intervention in hip fracture has been linked to improved outcomes. Direct Oral Anticoagulants (DOACs) are an emerging class of anticoagulants without evidence-based guidelines on surgical timing. This study aims to investigate how DOACs affect surgical timing and hence perioperative outcomes. A retrospective database/registry review was conducted for geriatric hip fracture patients aged 65 and over between 2011 and 2018. Primary outcome was 30-day mortality. Secondary outcomes included serious adverse events (SAE), transfusion and postoperative day (POD) 1 haemoglobin (Hb) levels. From a cohort of 3264 patients, 112 admitted subjects were taking DOACs; the annual proportion on DOACs increased over time. Mean time to surgery from last dose (Ts) was 2.2 (±1.0 SD) days. The primary outcome, 30-day mortality, occurred in 16 (14%) patients with secondary outcomes of SAEs in 25 (22%) patients and transfusion in 30 (27%) patients. Ts (days) did not significantly affect 30-day mortality (odds ratio (OR): 1.37, 95% confidence interval (CI): 0.80–2.33; p = 0.248), SAE (hazard ratio (HR): 1.03, 95% CI: 0.70–1.52; p = 0.885), transfusion (OR: 0.72 95% CI: 0.45 to 1.16; p = 0.177) or POD 1 Hb (OR: 1.99, 95% CI: −0.59 to 4.57; p = 0.129). Timing of surgery does not influence common surgical outcomes such as 30-day mortality, SAE, transfusion, and POD1 Hb in patients taking DOACs on admission.

scholarly journals Proximal femur fractures in patients taking anticoagulants

2020 ◽  
Vol 5 (10) ◽  
pp. 699-706
Author(s):  
Ioannis V. Papachristos ◽  
Peter V. Giannoudis
Keyword(s):  
Hip Fracture ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Femoral Fractures ◽  
Hip Fracture Surgery ◽  
Femur Fractures ◽  
Intravenous Vitamin ◽  
High Level

Thirty per cent of patients presenting with proximal femoral fractures are receiving anticoagulant treatment for various other medical reasons. This pharmacological effect may necessitate reversal prior to surgical intervention to avoid interference with anaesthesia or excessive peri/post-operative bleeding. Consequently, delay to surgery usually occurs. Platelet inhibitors (aspirin, clopidogrel) either alone or combined do not need to be discontinued to allow acute hip surgery. Platelet transfusions can be useful but are rarely needed. Vitamin K antagonists (VKA, e.g. warfarin) should be reversed in a timely fashion and according to established readily accessible departmental protocols. Intravenous vitamin K on admission facilitates reliable reversal, and platelet complex concentrate (PCC) should be reserved for extreme scenarios. Direct oral anticoagulants (DOAC) must be discontinued prior to hip fracture surgery but the length of time depends on renal function ranging traditionally from two to four days. Recent evidence suggests that early surgery (within 48 hours) can be safe. No bridging therapy is generally recommended. There is an urgent need for development of new commonly available antidotes for every DOAC as well as high-level evidence exploring DOAC effects in the acute hip fracture surgical setting. Cite this article: EFORT Open Rev 2020;5:699-706. DOI: 10.1302/2058-5241.5.190071

scholarly journals Preadmission Statin Prescription and Inpatient Myocardial Infarction in Geriatric Hip Fracture

2021 ◽  
Vol 10 (11) ◽  
pp. 2441
Author(s):  
Seth M. Tarrant ◽  
Raymond G. Kim ◽  
Jack M. McDonogh ◽  
Matthew Clapham ◽  
Kerrin Palazzi ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Hip Fracture ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Inpatient Mortality ◽  
Hip Fracture Surgery ◽  
Statin Prescription ◽  
Geriatric Hip Fracture ◽  
Fracture Surgery ◽  
Statin Use

Statins have been shown to reduce myocardial infarction (MI) in cardiac and vascular surgery. MI is common in hip fracture. This study aims to investigate whether statins decrease MI in hip fracture surgery and reduce mortality resulting from MI. Patients aged 65 years and above with a low-energy hip fracture were identified between January 2015 and December 2017. Demographics, comorbidities, predictive scores, medications and outcomes were assessed retrospectively. The primary outcome was inpatient MI. The secondary outcome was inpatient mortality resulting from MI, for which fatal and non-fatal MI were modelled. Regression analysis was conducted with propensity score weighting. Hip fracture occurred in 1166 patients, of which 391 (34%) were actively taking statins. Thirty-one (2.7%) patients were clinically diagnosed with MI. They had a higher inpatient mortality than those who did not sustain an MI (35% vs. 5.3%, p < 0.0001). No reduction was seen between statin use and the occurrence of MI (OR = 0.97, 95% CI: 0.45–2.11; p = 0.942) including Fluvastatin-equivalent dosage (OR = 1.00, 95% CI: 0.96–1.03, p = 0.207). Statins were not associated with having a non-fatal MI (OR 1.47, 95% CI: 0.58-3.71; p = 0.416) or preventing fatal MI (OR = 0.40, 95% CI: 0.08–1.93; p = 0.255). Preadmission statin use and associations with clinically diagnosed inpatient MI or survival after inpatient MI were not able to be established.

scholarly journals The effect of remote ischaemic preconditioning on myocardial injury in emergency hip fracture surgery (PIXIE trial): phase II randomised clinical trial

BMJ ◽  
2019 ◽  
pp. l6395 ◽  
Author(s):  
Sarah Ekeloef ◽  
Morten Homilius ◽  
Maiken Stilling ◽  
Peter Ekeloef ◽  
Seda Koyuncu ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Myocardial Injury ◽  
Primary Outcome ◽  
Troponin I ◽  
Peak Plasma ◽  
Major Adverse Cardiovascular Events ◽  
Control Group ◽  
Hip Fracture Surgery ◽  
Secondary Outcomes ◽  
Fracture Surgery

Abstract Objective To investigate whether remote ischaemic preconditioning (RIPC) prevents myocardial injury in patients undergoing hip fracture surgery. Design Phase II, multicentre, randomised, observer blinded, clinical trial. Setting Three Danish university hospitals, 2015-17. Participants 648 patients with cardiovascular risk factors undergoing hip fracture surgery. 286 patients were assigned to RIPC and 287 were assigned to standard practice (control group). Intervention The RIPC procedure was initiated before surgery with a tourniquet applied to the upper arm and consisted of four cycles of forearm ischaemia for five minutes followed by reperfusion for five minutes. Main outcome measures The original primary outcome was myocardial injury within four days of surgery, defined as a peak plasma cardiac troponin I concentration of 45 ng/L or more caused by ischaemia. The revised primary outcome was myocardial injury within four days of surgery, defined as a peak plasma cardiac troponin I concentration of 45 ng/L or more or high sensitive troponin I greater than 24 ng/L (the primary outcome was changed owing to availability of testing). Secondary outcomes were peak plasma troponin I and total troponin I release during the first four days after surgery (cardiac and high sensitive troponin I), perioperative myocardial infarction, major adverse cardiovascular events, and all cause mortality within 30 days of surgery, length of postoperative stay, and length of stay in the intensive care unit. Several planned secondary outcomes will be reported elsewhere. Results 573 of the 648 randomised patients were included in the intention-to-treat analysis (mean age 79 (SD 10) years; 399 (70%) women). The primary outcome occurred in 25 of 168 (15%) patients in the RIPC group and 45 of 158 (28%) in the control group (odds ratio 0.44, 95% confidence interval 0.25 to 0.76; P=0.003). The revised primary outcome occurred in 57 of 286 patients (20%) in the RIPC group and 90 of 287 (31%) in the control group (0.55, 0.37 to 0.80; P=0.002). Myocardial infarction occurred in 10 patients (3%) in the RIPC group and 21 patients (7%) in the control group (0.46, 0.21 to 0.99; P=0.04). Statistical power was insufficient to draw firm conclusions on differences between groups for the other clinical secondary outcomes (major adverse cardiovascular events, 30 day all cause mortality, length of postoperative stay, and length of stay in the intensive care unit). Conclusions RIPC reduced the risk of myocardial injury and infarction after emergency hip fracture surgery. It cannot be concluded that RIPC overall prevents major adverse cardiovascular events after surgery. The findings support larger scale clinical trials to assess longer term clinical outcomes and mortality. Trial registration ClinicalTrials.gov NCT02344797 .

scholarly journals Direct Oral Anticoagulants in the Prevention of Venous Thromboembolism Following Surgery for Hip Fracture in Older Adults: A Population-Based Cohort Study

2020 ◽  
Vol 11 ◽  
pp. 215145931989752 ◽  
Author(s):  
En Lin Goh ◽  
Pratha Kumari Gurung ◽  
Shaocheng Ma ◽  
Timothy Pilpel ◽  
James Henderson Dale ◽  
...  
Keyword(s):  
Older Adults ◽  
Hip Fracture ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Population Based ◽  
Vte Prophylaxis ◽  
Hip Fracture Surgery ◽  
Increased Risk ◽  
Risk Of Hemorrhage ◽  
Fracture Surgery

Introduction: Direct oral anticoagulants (DOACs) decrease the risk of venous thromboembolism (VTE) without increasing the risk of hemorrhage in elective lower limb orthopedic surgery. However, the role of DOACs in preventing VTE following hip fracture surgery in the older adults remains unclear. This study aims to evaluate the efficacy and safety of DOACs in older adults undergoing surgery for hip fracture. Materials and methods: Single-center, retrospective, population-based cohort study of patients receiving either a DOAC or low-molecular-weight heparin (LMWH) for VTE prophylaxis following hip fracture surgery. Data obtained included patient demographics, comorbidities, fracture classification, time to surgery, procedure performed, and length of stay. Main outcomes assessed were incidence of VTE, incidence of major hemorrhage, and death within 30 days of surgery. Results: A total of 321 patients were included. Incidence of VTE was 0% in the DOAC group and 3.4% in the LMWH group (risk ratio [RR]:0.26, 95% confidence interval [CI]: 0.02-4.34, P = .35). Hemorrhage occurred in 7.4% and 3.0% of patients in the DOAC and LMWH groups, respectively (RR: 2.47, 95% CI: 0.77-7.91, P = .13). Mortality from VTE was 0% in the DOAC group and 0.7% in the LMWH group (RR: 0.97, 95% CI: 0.05-20.02, P = .99). Mortality from hemorrhage was 1.9% in the DOAC group and 0.7% in the LMWH group (RR: 2.47, 95% CI: 0.23-26.78, P = .46). Discussion: The use of DOACs for VTE prophylaxis following surgery in older adults with hip fracture was associated with a similar rate of VTE compared to LMWH. However, there was a worrying trend toward an increased risk of hemorrhage. Conclusion: In the present study of a carefully selected cohort of patients, the effect of DOACs in reducing the risk of VTE following surgery for hip fracture in the older adults was comparable to LMWH. However, a trend toward increased risk of hemorrhage was noted. Larger prospective studies will be required to identify patients who will benefit the most from treatment.

scholarly journals Delayed Time to Emergency Hip Surgery in Patients Taking Oral Anticoagulants

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 2445-2445
Author(s):  
Teresa Cafaro ◽  
Vicky Tagalakis ◽  
Maral Koolian ◽  
Simard Camille
Keyword(s):  
Hip Fracture ◽  
Vitamin K ◽  
Action Plan ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Group Versus ◽  
Hip Fracture Surgery ◽  
Significant Difference ◽  
Time Of Admission

Abstract Introduction Surgical intervention within 48 hours of admission in patients with acute hip fractures has been associated to lower morbidity and mortality. Patients anticoagulated with Vitamin K Antagonists (VKAs) have longer time to corrective surgery than those not anticoagulated. Sparse data exists on time to surgery (TTS) in patients taking direct oral anticoagulants (DOACs). The aim of this study is to establish TTS among non-anticoagulated and anticoagulated patients taking either VKA or DOAC. Materials and Methods We conducted a retrospective cohort study of consecutive patients admitted with acute hip fracture between July 1, 2016 and December 31, 2017. Patient-, anticoagulant- and surgery-related characteristics were collected. The primary outcome was TTS calculated from time of admission. Median TTS with interquartile range (IQR) was compared among 3 groups of patients: DOAC, VKA and No OAC. Results A total of 472 patients were included: 12.5% (59/472) were anticoagulated (28/472 on VKAs and 31/472 on DOACs). Median TTS was longer in the VKA group [64 hours (IQR: 50-84)] and in the DOAC group [(61 hours; IQR: 42 to 77)] versus the No OAC group [44 hours (IQR: 28-63), p =0.0006 and p=0.003 respectively]. There was no significant difference in median TTS in the VKA group versus the DOAC group (p =0.6396). Conclusion Patients taking either VKA or DOAC have significant delays to emergency hip fracture surgery compared to those not anticoagulated. An action plan aimed at early identification and cessation of anticoagulation is warranted in this vulnerable group of patients. Keywords: Direct Oral anticoagulants, Vitamin K antagonists, Anticoagulation, Acute hip fracture, Emergency surgery Disclosures Tagalakis: BMS-Pfizer: Other: participated on ad boards; Sanofi Aventis: Other: investigator initiated grant;participated on ad boards; Pfizer: Other: participated on ad boards; Bayer: Other: participated on ad boards; Servier: Other: participated on ad boards.

scholarly journals Outcomes of COVID-19 Negative Hip Fracture Patients During the Acute and Subacute Pandemic

2021 ◽  
Vol 12 ◽  
pp. 215145932110066
Author(s):  
Naoko Onizuka ◽  
Lauren N. Topor ◽  
Lisa K. Schroder ◽  
Julie A. Switzer
Keyword(s):  
Hip Fracture ◽  
Length Of Stay ◽  
Healthcare System ◽  
Perioperative Complications ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Surgical Care ◽  
Admission Rate ◽  
System Response ◽  
Fragility Hip Fracture

Objectives: To better elucidate how the COVID-19 pandemic has affected the operatively treated geriatric hip fracture population and how the health care system adapted to pandemic dictated procedures. Design: Retrospective cohort study. Setting: A community hospital. Participants: Individuals ≥65 years of age presented with a proximal femoral fracture from a low-energy mechanism undergoing operative treatment from January 17, 2020 to July 2, 2020 (N = 125). Measurements: We defined 3 phases of healthcare system response: pre-COVID-19, acute phase, and subacute phase. Thirty-day mortality, time to operating room (OR), length of stay, time to start physical therapy, perioperative complications, delirium rate, hospice admission rate, discharge dispositions, readmission rate, and the reason of surgery delay were assessed. Results: The number of hip fractures has remained constant during the pandemic. The 30-day mortality rate, time to OR, and length of stay were higher in the pandemic compared to the pre-pandemic. Those who had a longer wait time to OR (≥ 24 hours) had more complications and increased 30-day mortality rates. Some of the surgery delays were related to OR unavailability as a consequence of the COVID-19 pandemic. Surgery was delayed in 3 patients who were on direct oral anticoagulants (DOACs) in pandemic but none for pre-pandemic period. Conclusion: This is the first study to compare the effect of the acute and subacute phases of the pandemic on uninfected hip fracture patients. In the age of COVID-19, to provide the best care for the vulnerable geriatric orthopedic populations, the healthcare system must adopt new protocols. We should still aim to promote prompt surgical care when indicated. It is important to ensure adequate resource availability, such as OR time and staff so that hip fracture patients may continue to receive rapid access to surgery. A multidisciplinary approach remains the key to the management of fragility hip fracture patients during the pandemic.

Examination of the Effectiveness of Direct Oral Anticoagulants in Comparison to Warfarin in an Obese Population

2021 ◽  
pp. 875512252110641
Author(s):  
Rachel M. Watson ◽  
Carmen B. Smith ◽  
Erica F. Crannage ◽  
Laura M. Challen
Keyword(s):  
Primary Outcome ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Efficacy And Safety ◽  
Class Iii ◽  
Vein Thrombosis ◽  
Class Iii Obesity ◽  
Recurrent Vte ◽  
The Individual ◽  
Deep Vein

Background: While commonly prescribed today, direct oral anticoagulants (DOACs) have historically been avoided in patients with class III obesity or a weight >120 kg due to limited literature regarding the efficacy and safety in this population. Objective: The overall objective was to examine the effectiveness of DOACs compared to warfarin in a population with obesity. Methods: Patients with a diagnosis of venous thromboembolism (VTE) or atrial fibrillation and a body mass index (BMI) ≥35 kg/m2 from August 1, 2015, to August 1, 2020, were included in this retrospective cohort study. Patients receiving a DOAC were matched in a 1:2 ratio to warfarin. The primary outcome was a composite of stroke or recurrent VTE. Secondary outcomes included the individual components of the primary outcome, hospitalization for bleed, and the primary outcome in patients with a BMI ≥40 kg/m2. Results: A total of 162 patients were included, with 54 and 108 in the DOAC and warfarin groups, respectively. Baseline BMI was similar between groups (45.7 kg/m2 for DOACs vs 43.8 kg/m2 for warfarin), with approximately 70% of patients having a BMI ≥40 kg/m2. The primary outcome occurred in 1 patient (1.9%) in the DOAC group and 2 patients (1.9%) in the warfarin group. The DOAC group had a higher, nonsignificant incidence of bleeding (5.6% vs 0.9%, P = 0.11). There was no difference between groups in incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), or stroke in patients with a BMI ≥40 kg/m2. Conclusion: DOACs may be as efficacious as warfarin in the prevention of stroke or recurrent VTE in patients with a BMI of ≥35 kg/m2. Prospective, randomized trials are warranted to further assess the efficacy and safety of DOACs in this population.

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