Emerging Barrier to Timely Care of Hip Fracture Patients: A Prospective Study of Direct Oral Anticoagulation and Time to Surgery

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Abstract

Introduction: Rapid surgical management of hip fracture patients is critical to reduce morbidity and mortality. These patients may be anti-coagulated and the new direct oral anticoagulants (DOAC) may introduce delays to treatment. Our purpose was to examine the impact of these DOAC on time to surgical management for hip fracture patients.Methods: A prospective audit of 55 consecutive operative hip fracture patients examined time from diagnosis to surgery. Indications for anticoagulation were recorded.Results: Time to surgery for the DOAC group was 66±16 hours, versus 38±21 and 25±19 hours for warfarin and control groups, respectively (P<0.05). Anticoagulation was for atrial fibrillation in 93%.Conclusion: Patients on DOAC faced significant delays to surgery. Given that both DOAC use and incidence of hip fracture are expected to rise, this presents a barrier to optimized care in this vulnerable group.

Most cited references 7

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How I treat anticoagulated patients undergoing an elective procedure or surgery.

Alex Spyropoulos, J D Douketis (2012)

The periprocedural management of patients receiving long-term oral anticoagulant therapy remains a common but difficult clinical problem, with a lack of high-quality evidence to inform best practices. It is a patient's thromboembolic risk that drives the need for an aggressive periprocedural strategy, including the use of heparin bridging therapy, to minimize time off anticoagulant therapy, while the procedural bleed risk determines how and when postprocedural anticoagulant therapy should be resumed. Warfarin should be continued in patients undergoing selected minor procedures, whereas in major procedures that necessitate warfarin interruption, heparin bridging therapy should be considered in patients at high thromboembolic risk and in a minority of patients at moderate risk. Periprocedural data with the novel oral anticoagulants, such as dabigatran, rivaroxaban, and apixaban, are emerging, but their relatively short half-life, rapid onset of action, and predictable pharmacokinetics should simplify periprocedural use. This review aims to provide a practical, clinician-focused approach to periprocedural anticoagulant management.

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Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery.

M W Sherwood, J D Douketis, A Spyropoulos … (2016)

The periprocedural management of patients receiving chronic therapy with oral anticoagulants (OACs), including vitamin K antagonists (VKAs) such as warfarin and direct OACs (DOACs), is a common clinical problem. The optimal perioperative management of patients receiving chronic OAC therapy is anchored on four key principles: (i) risk stratification of patient-related and procedure-related risks of thrombosis and bleeding; (ii) the clinical consequences of a thrombotic or bleeding event; (iii) discontinuation and reinitiation of OAC therapy on the basis of the pharmacokinetic properties of each agent; and (iv) whether aggressive management such as the use of periprocedural heparin bridging has advantages for the prevention of postoperative thromboembolism at the cost of a possible increase in bleeding risk. Recent data from randomized trials in patients receiving VKAs undergoing pacemaker/defibrillator implantation or using heparin bridging therapy for elective procedures or surgeries can now inform best practice. There are also emerging data on periprocedural outcomes in the DOAC trials for patients with non-valvular atrial fibrillation. This review summarizes the evidence for the periprocedural management of patients receiving chronic OAC therapy, focusing on recent randomized trials and large outcome studies, to address three key clinical scenarios: (i) can OAC therapy be safely continued for minor procedures or surgeries; (ii) if therapy with VKAs (especially warfarin) needs to be temporarily interrupted for an elective procedure/surgery, is heparin bridging necessary; and (iii) what is the optimal periprocedural management of the DOACs? In answering these questions, we aim to provide updated clinical guidance for the periprocedural management of patients receiving VKA or DOAC therapy, including the use of heparin bridging.

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The impact of oral anticoagulation on time to surgery in patients hospitalized with hip fracture.

Thomas Tran, Aurélien Delluc, Carine de Wit … (2015)

Current clinical guidelines recommend expedited repair of hip fracture to reduce morbidity and mortality. A significant number of hip fracture patients have concomitant cardiovascular disease requiring anticoagulation. Vitamin K antagonists (VKAs), which have been traditionally used, might be associated with an increased time to surgery (TTS) and it remains unknown what effect direct oral anticoagulants (DOACs) have on this metric. Our objective is to determine how anticoagulation with a VKA or DOAC affects TTS.

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Author and article information

Journal

Title: Canadian Journal of General Internal Medicine

Abbreviated Title: Can Journ Gen Int Med

Publisher: Dougmar Publishing Group, Inc.

ISSN (Electronic): 2369-1778

ISSN (Print): 1911-1606

Publication date Created: November 13 2018

Publication date (Electronic): October 16 2018

Volume: 13

Issue: 4

Pages: e6-e9

Article

DOI: 10.22374/cjgim.v13i4.272

SO-VID: 0c68a04c-6809-41de-bb06-d7ede4fd2002

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