The effect of long-term antithrombotic therapies on perioperative morbidity and mortality in elderly patients undergoing hip fracture surgery
Abstract
ABSTRACT
Objective: Ischemic complications or massive bleeding are important perioperative complications in elderly patients using antithrombotic drugs. The need for blood product replacement, transfusion-related complications, prolonged stay in hospital and intensive care unit, and high mortality in the perioperative period can be seen. The aim of this study was to investigate the effects of long-term different antithrombotic therapies on morbidity and mortality in elderly patients undergoing surgery for hip fracture.
Materials and Methods: This retrospective cohort study included patients aged 65 years and older who underwent surgery for hip fracture between 2015 and 2018. Patients with no antithrombotic treatment (Group NonAT), warfarin (Group Warfarin), novel oral anticoagulants (Group NOACs), or dual antiplatelet therapy (Group DAPT) were compared in terms of major bleeding, deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE) complications, length of hospital stay (LOS), ICU admission, and 30-day mortality.
Results: The study included 668 patients; demographic data in Group NonAT (n=442), Group Warfarin (n=59), Group NOACs (n=30) and Group DAPT(n=137) were similar. Major bleeding and red blood cell transfusion did not differ statistically between all groups. (p>0.05) The preoperative and postoperative Hb values of the patients were not statistically different between the groups (p>0.05). Mortality, only there was statistically significantly higher in the dual antiplatelet group than the non user group. (p<0.05) In terms of survival, multivariate analysis showed no difference between the groups. (p>0.05) However survival was statistically significant different (p<0.05) in terms of the PTE and admission to ICU. Kaplan-Meier survival analysis showed that patients in the group NonAT have longer survival times than patients in the group warfarin, group NOACs, or group DAPT.
Conclusion: In this study, we found that the effects of antithrombotic drug classes (warfarin, new oral anticoagulants or dual antiplatelet therapy) on mortality were not different. Mortality rate was higher only in the dual antiplatelet group than in the no drug group. It is important to discontinue these drugs at the timing according to their half-lives and elimination times. Effective bridging therapy should be applied in the perioperative period. Thus, the risk of major bleeding or complications of DVT and PTE can be avoided. New bridging strategies should be researched in patients using antiplatelets.
Keywords
Hip fracture , elderly patient , warfarin , novel oral anticoagulants , dual antiplatelets
References
- 1. de Jong L, van Rijckevorsel V, Klem TMAL, Kuijper M, Roukema GR. Prospective cohort protocol examining the perioperative indicators for complications and early mortality following hip fracture surgery in the frail patient. BMJ Open. 2020 Sep 29;10(9):e038988.
- 2. Bohm E, Loucks L, Wittmeier K, Lix LM, Oppenheimer L. Reduced time to surgery improves mortality and length of stay following hipfracture: results from an intervention study in a Canadian health authority. Canadian Journal of Surgery 2015;58:257.
- 3. Omsland TK, Emaus N, Tell GS, Magnus JH, Ahmed LA, Holvik K, et al. Mortality following the first hip fracture in Norwegian women and men (1999–2008). A NOREPOS study. Bone 2014;63:81-6.
- 4. Moon JY, Nagaraju D, Franchi F, Rollini F, Angiolillo DJ. The role of oral anticoagulant therapy in patients with acute coronary syndrome. Therapeutic Advances in Hematology. 2017:353-66. doi:10.1177/2040620717733691
- 5. The European Agency for the Evaluation of Medicinal Products. Guideline on clinical investigation of medicinal products for prophylaxis of high intra- and post-operative venous thromboembolic risk. CPMP/EWP/707/98 Rev. 1.2007. http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2013/05/WC500143764.pdf. Accessed 30 June 2015.
- 6. Quach LH, Jayamaha S, Whitehouse SL, Crawford R, Pulle CR, Bell JJ. Comparison of the Charlson Comorbidity Index with the ASA score for predicting 12-month mortality in acute hip fracture. Injury. 2020 ;51:1004-10. doi: 10.1016/j.injury.2020.02.074.
- 7. Wilson D, Cooke EA, McNally MA, Wilson HK, Yeates A, Mollan RA. Changes in coagulability as measured by thrombelastography following surgery for proximal femoral fracture. Injury. 2001;32:765-70.
- 8. Song K, Yao Y, Rong Z, Shen Y, Zheng M, Jiang Q. The preoperative incidence of deep vein thrombosis (DVT) and its correlation with postoperative DVT in patients undergoing elective surgery for femoral neck fractures. Arch Orthop Trauma Surg. 2016;136:1459-64
- 9. Karadağ B, Ikitimur B, Öngen Z. Perioperative management in patients receiving newer oral anticoagulant and antiaggregant agents. Turk Kardiyol Dern Ars. 2012;40:548-51.
- 10. Dargham BB, Baskar A, Tejani I, Cui Z, Chauhan S, Sum-Ping J, et al. Intravenous Antiplatelet Therapy Bridging in Patients Undergoing Cardiac or Non-Cardiac Surgery Following Percutaneous Coronary Intervention. Cardiovasc Revasc Med. 2019;20:805-11.