A comparison of the effects of direct oral anticoagulants versus vitamin K antagonists and antiplatelet agents on the timing and outcomes of hip fracture surgery in patients older than 65 years: the ORTHO-GER-DOAC study.

Abstract

Introduction: The use of direct oral anticoagulants (DOACs) may delay surgery in older hip fracture patients.

Aim: To assess whether preoperative DOAC activity measurement enables surgery within 48 h in hip fracture patients at a similar prevalence compared to patients receiving other antithrombotics or no antithrombotics.

Methods: A retrospective observational cohort study of hip fracture patients older than 65 years admitted to three Orthogeriatrics units in Italy from 2015 to 2022 was conducted. At admission, demographical and comorbid conditions were recorded, and antithrombotics were stopped. Patients on vitamin K antagonists (VKAs) underwent international normalized ratio (INR) assessments and received vitamin K to achieve an INR below 1.5. Patients receiving DOACs who were enrolled before 2018 underwent daily drug testing, and surgery was performed only after DOAC levels were near or below trough levels. Hours from hospital admission to surgery, perioperative total blood loss, major bleeding and mortality at 90 days were recorded.

Results: Amongst the 747 patients (median age 85 years; M/F: 192/555), the prevalence of surgery within 48 h was significantly lower amongst patients receiving DOACs (47%) than amongst patients receiving antiplatelet agents (77%) and patients receiving no antithrombotic agents (73%). Preoperative DOAC measurements significantly delayed the time to surgery (median 51 vs. 42 h: P < 0.05). The major bleeding and mortality rates at 90 days did not differ based on the type of antithrombotics used. The degree of perioperative blood loss was greater in patients receiving DOACs, regardless of drug measurement, than in patients taking other antithrombotics.

Conclusions: DOAC measurement may delay hip fracture surgery, as even low presurgical levels of DOACs are associated with greater perioperative blood loss.