Key result
Pre-admission warfarin and P2Y12 inhibitors, but not DOACs, are linked to up to ~3-fold higher post-hip fracture mortality.
Why the study?
Little prospective data exist regarding the perioperative management and long-term prognosis of elderly patients receiving antithrombotic drugs who undergo urgent surgery for a hip fracture.
Does pre-admission antithrombotic therapy increase mortality and complications in elderly patients undergoing urgent hip fracture surgery?
Cohort (n=421)
No
Does pre-admission antithrombotic therapy increase mortality and complications in elderly patients undergoing urgent hip fracture surgery?
In elderly patients with hip fractures, pre-admission use of warfarin or P2Y12 inhibitors, but not DOACs, is associated with increased 6-month mortality, despite similar perioperative bleeding rates.
Answers are grounded in this paper and cite their sources.
May signal higher long-term mortality with warfarin or P2Y12 inhibitors in elderly hip fracture surgery; leaves open causality and optimal antithrombotic strategies.
(1) Background: Little prospective data exist regarding the perioperative management and long-term prognosis of elderly patients receiving treatment with antithrombotic drugs and undergoing urgent surgery for a hip fracture. (2) Methods: The study included patients who required hip surgery and were receiving warfarin, DOAc or P2Y12 antiplatelet agents at the moment of trauma. Ongoing antithrombotic treatment was managed according to existing recommendations. The endpoints of the study were the time to surgery, perioperative bleeding, the need for transfusion and, finally, mortality, major cardiovascular events and re-hospitalization at 6 and 12 months. (3) Results: The study included a total of 138 patients. The mean age was 86 years; 75.4% were female. Eighty-two received DOAc, thirty-six received warfarin and twenty received P2Y12 inhibitors. The controls were 283 age- and sex-matched patients who did not receive antithrombotic treatment. A total of 38% of patients receiving warfarin underwent surgery <48 h, 52% receiving DOAc, 55% receiving P2Y12 inhibitors and, finally, 82% in the control group. Perioperative bleeding and the need for transfusion were not different between the four groups. Mortality at 6 months was higher in patients receiving warfarin and P2Y12 inhibitors (30% and 25%) in comparison to DOAc and the control group (11.6% and 10% p < 0.0001). Similarly, the other endpoints were more frequent in patients receiving warfarin and P2Y12 inhibitors. The trend was maintained for 12 months. No significant differences in mortality were found between early (<48 h) and late (>48 h) surgery independent of the type of treatment. (4) Conclusions: Our study confirmed that anticoagulants delay surgery in patients with hip fractures; however, intervention > 48 h is not associated with a poorer prognosis. This finding is relevant as it underlines that, in patients at high risk of postoperative cardiovascular complications, the careful management of anticoagulation before surgery may compensate for the delay of surgery with a very low in-hospital mortality rate (<1%). One-year survival was significantly lower in patients receiving warfarin, probably related to their worse risk profile at the moment of trauma survival.
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Rostagno et al. (2023) conducted a cohort in Fragility hip fractures (n=421). Antithrombotic therapy (DOAc, warfarin, or P2Y12 inhibitors) vs. No antithrombotic treatment (including low-dose aspirin) was evaluated on 6-month mortality (p=<0.0001). Pre-admission treatment with warfarin or P2Y12 inhibitors, but not DOACs, was associated with significantly higher 6-month mortality compared to controls (30% and 25% vs 10%, p<0.0001) in elderly patients undergoing hip fracture surgery.
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