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You D, Xu Y, Ponich B, Ronksley P, Skeith L, Korley R, Carrier M, Schneider PS. Effect of oral anticoagulant use on surgical delay and mortality in hip fracture. Bone Joint J 2021; 103-B:222-233. [PMID: 33517730 DOI: 10.1302/0301-620x.103b2.bjj-2020-0583.r2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIMS Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically. METHODS We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 14 October 2019 to identify studies directly comparing outcomes among hip fracture patients receiving direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) prior to hospital admission to hip fracture patients not on OACs. Random effects meta-analyses were used to pool all outcomes (TTS, in-hospital mortality, and 30-day mortality). RESULTS A total of 34 studies (involving 39,446 patients) were included in our systematic review. TTS was 13.7 hours longer (95% confidence interval (CI) 9.8 to 17.5; p < 0.001) among hip fracture patients on OACs compared to those not on OACs. This translated to a three-fold higher odds of having surgery beyond the recommended 48 hours from admission (odds ratio (OR) 3.0 (95% CI 2.1 to 4.3); p = 0.001). In-hospital mortality was higher (OR 1.4 (95% CI 1.0 to 1.8); p < 0.03) among anticoagulated patients. Among studies comparing anticoagulants, there was no statistically significant difference in time-to-surgery between patients taking a DOAC compared to a VKA. CONCLUSION Patients presenting with a hip fracture who were taking OACs prior to injury experience a delay in time-to-surgery and higher mortality than non-anticoagulated patients. Patients on DOACs may be at risk of further delays. Evaluating expedited surgical protocols in hip fracture patients on OACs is an urgent priority, with the potential to decrease morbidity and mortality in this group of high-risk patients. Cite this article: Bone Joint J 2021;103-B(2):222-233.
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Affiliation(s)
- Daniel You
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Yan Xu
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Brett Ponich
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Paul Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Leslie Skeith
- Division of Hematology & Hematological Malignancies, University of Calgary, Calgary, Alberta, Canada
| | - Robert Korley
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Prism S Schneider
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Xu Y, You D, Krzyzaniak H, Ponich B, Ronksley P, Skeith L, Salo P, Korley R, Schneider P, Carrier M. Effect of oral anticoagulants on hemostatic and thromboembolic complications in hip fracture: A systematic review and meta-analysis. J Thromb Haemost 2020; 18:2566-2581. [PMID: 32574420 DOI: 10.1111/jth.14977] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hip fracture patients on oral anticoagulants (OACs) experience increased time-to-surgery and higher mortality compared to non-anticoagulated patients. However, it is unclear whether pre-injury OAC status and its associated operative delay are associated with worsening of peri-operative hemostasis or an increased risk of postoperative thromboembolism. METHODS We performed a systematic review to identify studies that directly compared hemostatic and thromboembolic outcomes among hip fracture patients on an OAC prior to admission with those not on anticoagulants. Random effects meta-analyses were used to pool all outcomes of interest (estimated blood loss, transfusion requirements, and postoperative thromboembolism). RESULTS Twenty-one studies involving 21 417 patients were included. Estimated blood loss was higher among patients presenting with OACs compared to those not anticoagulated (mean difference 31.0 mL, 95% confidence interval [CI] 6.2-55.7). Anticoagulated patients also had a 1.3-fold higher risk of receiving red blood cell transfusions (odds ratio [OR] 1.34, 95% CI 1.20-1.51); however, rates of postoperative thromboembolism were similar regardless of anticoagulation status (OR 0.96, 95% CI 0.40-2.79 for venous thromboembolism; OR 0.58, 95% CI 0.25-1.36 for arterial thromboembolism). No subgroup effect was found based on anticoagulant type or degree of surgical delay. CONCLUSION Hip fracture patients on OACs experience increased surgical blood loss and higher risk of red blood cell transfusions. However, the degree of surgical delay did not mitigate this risk, and there was no difference in postoperative thromboembolism. The impact of appropriate, timely OAC reversal on blood conservation and expedited surgery in anticoagulated hip fracture patients warrants urgent evaluation.
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Affiliation(s)
- Yan Xu
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Daniel You
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Halli Krzyzaniak
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Brett Ponich
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Leslie Skeith
- Department of Medicine, Division of Hematology & Hematological Malignancies, University of Calgary, Calgary, AB, Canada
| | - Paul Salo
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert Korley
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Prism Schneider
- Department of Surgery, Section of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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