warfarin and Hip-Fractures

Venous thromboembolic events, including deep venous thromboses and pulmonary embolisms, have a high risk of occurrence in patients treated with lower extremity arthroplasty and hip fracture surgery. Although the prevalence of these complications has been lowered with the use of venous thromboembolic prophylaxis, the current rate is still troublesome because of the possibility of death or the need for lifetime treatment of postthrombotic syndrome and/or pulmonary hypertension. Prophylactic methods currently include mechanical devices and pharmacologic agents. Mechanical devices are difficult to compare because they are not standardized, the devices are often used in multimodal prophylactic regimens, and the devices cannot be used when the patient is ambulating or at home. A new portable compression device allows use during ambulation and can be used by the patient at home. A recent study of this portable device in patients treated with total hip arthroplasty showed an efficacy similar to that of low-molecular-weight heparin, with fewer major bleeding complications. Pharmacologic prophylaxis includes low-molecular-weight heparin, synthetic pentasaccharide, warfarin, and aspirin. All of these agents have different degrees of efficacy and safety. New oral agents for thromboprophylaxis are on the horizon but are not yet approved by the Food and Drug Administration.

Topics: Anticoagulants; Arthroplasty, Replacement, Knee; Early Ambulation; Heparin, Low-Molecular-Weight; Hip Fractures; Humans; Intermittent Pneumatic Compression Devices; Orthopedic Procedures; Patient Compliance; Plastic Surgery Procedures; Vena Cava Filters; Venous Thrombosis; Warfarin

Without prophylaxis, rates of deep vein thrombosis (DVT) after major orthopedic surgery range from 40% to 60%. Randomized clinical trials over the past 30 years have provided evidence that primary thromboprophylaxis reduces DVT, pulmonary embolism (PE), and fatal PE, and prophylaxis to prevent venous thromboembolism (VTE) in patients at risk has been ranked as the highest safety practice for hospitalized patients. Since 1986, some type of prophylaxis has been recommended for total knee arthroplasty (TKA), total hip arthroplasty (THA), and hip fracture surgery. Orthopedic guidelines published in Chest provide a current evidence-based guide for prophylaxis for TKA, THA, and hip fracture surgery. In addition to following these recommendations for routine prophylaxis, surgeons should assess patients for additional VTE risk. Patients at higher risk may need more intense prophylaxis. Data from meta-analyses and placebo-controlled, blinded, randomized clinical trials have demonstrated little or no increase in rates of clinically important bleeding with prophylaxis.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Hip Fractures; Humans; Postoperative Complications; Practice Guidelines as Topic; Pulmonary Embolism; Risk Factors; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Aspirin; Chemoprevention; Heparin; Hip Fractures; Humans; Risk Assessment; Risk Factors; Thromboembolism; Time Factors; Venous Thrombosis; Warfarin

Oral anticoagulants are used extensively, although their risks are not always fully recognized. The prophylaxis of venous thrombosis after hip surgery, the prevention of deep venous thrombosis and pulmonary emboli after an acute episode of these, the prevention of arterial emboli from the heart in patients at risk, and the prophylaxis of thrombosis in patients with congenital deficiency of antithrombin III, protein C, or protein S are some of the indications for oral anticoagulant use. Warfarin sodium is contraindicated in pregnancy, however. The recommended prothrombin time is 1 1/2 to two times control, lower than previously. The major risk of oral anticoagulant therapy, bleeding, is treated with vitamin K or plasma, depending on its severity. Warfarin necrosis and the "purple-toe" syndrome are seen more frequently than realized.

Topics: Absorption; Administration, Oral; Biological Availability; Drug Interactions; Hemorrhage; Hip Fractures; Humans; Myocardial Infarction; Necrosis; Postoperative Complications; Protein Binding; Prothrombin Time; Pulmonary Embolism; Thrombophlebitis; Thrombosis; Vitamin K; Warfarin

Orthopedic patients are at a high risk for developing venous thromboembolism, yet only a fraction of eligible patients receive anticoagulation prophylaxis after hospital discharge. This pilot study compared the efficacy of a fixed 2 mg/d dose of warfarin versus an adjusted higher dose of warfarin for 1 month after discharge to prevent the development of proximal leg deep venous thrombosis among recently discharged orthopedic patients. After standard inhospital treatment with adjusted higher-dose warfarin and a predischarge leg ultrasound to exclude deep venous thrombosis, 96 orthopedic patients were randomized just prior to discharge to either fixed low-dose (n = 49) or adjusted higher-dose warfarin (n = 47). At the 6-week follow-up evaluation, ultrasonographically confirmed, asymptomatic, proximal leg deep venous thrombosis occurred in two patients (4%). Both patients were randomized to the fixed low-dose group, although one remained on adjusted higher-dose warfarin throughout the trial. No patient in either group developed major bleeding complications. Further studies should be undertaken to further test fixed low-dose warfarin for venous thromboembolic prevention in high-risk orthopedic patients.

Topics: Female; Follow-Up Studies; Hip Fractures; Hip Prosthesis; Humans; Knee Prosthesis; Male; Middle Aged; Postoperative Complications; Prospective Studies; Thrombophlebitis; Time Factors; Warfarin

Two studies evaluating the effect of Orgaran prophylaxis on the incidence of postoperative thrombosis in hip fracture surgery are reported. In one Scandinavian study, dextran was used in the comparative group, and in the US study, warfarin was used. In both, Orgaran was significantly more effective in reducing the frequency of deep vein thrombosis without producing an increase in bleeding complications or other side effects.

Topics: Aged; Aged, 80 and over; Chondroitin Sulfates; Dermatan Sulfate; Dextrans; Female; Glycosaminoglycans; Hemorrhage; Heparinoids; Heparitin Sulfate; Hip Fractures; Humans; Incidence; Male; Postoperative Complications; Pulmonary Embolism; Scandinavian and Nordic Countries; Single-Blind Method; Thrombophlebitis; United States; Warfarin

In a randomized, prospective trial, a low-molecular-weight heparinoid (Org 10172 [Lomoparan]) was compared with warfarin for efficacy and safety in preventing deep-vein thrombosis in 263 patients who had an operatively treated fracture of the hip. One group of patients received Org 10172 in a dose of 750 units subcutaneously every twelve hours until the ninth postoperative day; on the seventh postoperative day, warfarin was added to the regimen. The other group received only warfarin. Both drugs were begun preoperatively, immediately after the admission evaluation. In the patients who received warfarin, the desired prothrombin time was one and one-half times the control level. Deep-vein thrombosis was detected by 125I-fibrinogen scanning and impedance plethysmography and was confirmed by phlebography and compression ultrasonography. Deep-vein thrombosis was found in nine (7 per cent) of the 132 patients who received Org 10172 and in twenty-eight (21 per cent) of the 131 patients who received warfarin (p less than 0.001). Adverse reactions were not significantly different in the two groups. Major bleeding complications occurred in eight patients in the Org-10172 group, only four of whom were receiving the drug at the time of bleeding, and in five patients who were receiving warfarin (not significant). There was no difference in intraoperative loss of blood or in requirements for transfusion. We concluded that the low-molecular-weight heparinoid Org 10172 is a safe, convenient, effective antithrombotic agent for the prevention of venous thrombosis after an operation for fracture of the hip.

Topics: Aged; Aged, 80 and over; Blood Loss, Surgical; Chondroitin Sulfates; Dermatan Sulfate; Female; Glycosaminoglycans; Heparinoids; Heparitin Sulfate; Hip Fractures; Humans; Iodine Radioisotopes; Male; Middle Aged; Molecular Weight; Plethysmography; Postoperative Complications; Prevalence; Prospective Studies; Risk Factors; Thrombophlebitis; Warfarin

A randomized trial was carried out with 194 patients to compare the effectiveness of sodium warfarin or aspirin with that of placebo in the prevention of venous thromboembolism after surgery for fractured hip. Prophylaxis was commenced postoperatively and continued for 21 days or until patient discharge, whichever was earlier. All patients underwent surveillance with iodine 125-fibrinogen leg scanning and impedance plethysmography, with subsequent venography. Venous thromboembolism occurred in 13 patients (20.0%) in the warfarin group, 27 patients (40.9%) in the aspirin group, and 29 patients (46.0%) in the placebo group. Proximal vein thrombosis or pulmonary embolism occurred in 6 patients (9.2%) in the warfarin group, 7 patients (10.6%) in the aspirin group, and 19 patients (30.2%) in the placebo group. The results of this study show that sodium warfarin therapy is safe and effective in preventing thromboembolic complications in patients undergoing surgery for fractured hip, and that aspirin therapy is an equally safe and effective method for preventing proximal vein thrombosis or pulmonary embolism.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Clinical Trials as Topic; Female; Follow-Up Studies; Hemorrhage; Hip Fractures; Humans; Male; Middle Aged; Phlebography; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Random Allocation; Thrombophlebitis; Warfarin

Seven hundred and thirty-four patients were included in a prospective study for incidence of clinical venous thromboembolism under prophylaxis with either heparin, aspirin or warfarin and for the expenditure of hospital resources. Thromboembolic complications were more frequent (P less than 0.02) and hospital costs clearly higher in the low-dose heparin treated patient group compared with the aspirin and warfarin groups. There were no distinct differences between aspirin and warfarin treated patients neither in results nor in costs. However, carefully monitored treatment with warfarin with Thrombotest always less than 0.20, appeared to be the most effective prophylaxis in patients with hip fractures. In conclusion we now use aspirin as general prophylaxis in orthopaedic patients, and warfarin in patients with established risk of thromboembolic complications.

Topics: Adult; Aspirin; Cost-Benefit Analysis; Female; Heparin; Hip Fractures; Humans; Male; Prospective Studies; Pulmonary Embolism; Pulmonary Veins; Thrombophlebitis; Warfarin

Topics: Aspirin; Drug Therapy, Combination; Hemorrhage; Heparin; Hip Fractures; Humans; Thrombophlebitis; Warfarin

To evaluate the effect of warfarin on blood transfusion and postoperative complications in a low-energy hip fracture population compared with a non-anticoagulated comparison group.. Multicenter Retrospective Cohort.. Three Urban Level I Academic Trauma Centers.. Acute, low-energy, native hip fractures in patients 55 years of age or older on chronic warfarin anticoagulation, propensity score matched 1:2 to non-anticoagulated hip fracture patients meeting all other inclusion criteria.. Transfusion and postoperative complication rates.. Two hundred ten anticoagulated hip fracture patients were matched to 420 nonanticoagulated patients. A higher proportion of patients required blood transfusion in the warfarin cohort (52.4% vs. 43.3%, P < 0.001), attributable mostly to the subgroup of patients undergoing arthroplasty. Warfarin patients had higher incidence of overall 90-day complications (47% vs. 38%, P = 0.039) and readmissions (31.4% vs. 8.9%, P < 0.001). Day of surgery international normalized ratio (INR) did not influence transfusions or complications among warfarin patients. Warfarin patients undergoing surgery within 24 hours had no difference in transfusions and had fewer complications compared with those undergoing surgery after 24 hours. On multivariable logistic regression analysis, warfarin use and day of surgery INR were not predictors of transfusion or complications.. Patients on warfarin experienced longer time to surgery and higher incidence of overall transfusion and postoperative complications within 90 days of surgery. However, warfarin use and day of surgery INR was not independently associated with transfusions or complications. The reason for poorer outcomes in warfarin patients remains a topic of further investigation.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Anticoagulants; Hip Fractures; Humans; Postoperative Complications; Propensity Score; Retrospective Studies; Warfarin

To examine the relationship between anticoagulant and antiplatelet drugs and surgical blood loss for geriatric patients undergoing cephalomedullary nail fixation of extracapsular proximal femur fractures.. Multicenter, retrospective, cohort study using bivariate and multivariable regression analyses.. Two Level-1 trauma centers.. One thousand four hundred forty-two geriatric (ages 60-105 years) patients undergoing isolated primary intramedullary fixation of nonpathologic extracapsular hip fractures from 2009 to 2018 including 657 taking an antiplatelet drug alone (including aspirin), 99 taking warfarin alone, 37 taking a direct oral anticoagulant (DOAC) alone, 59 taking an antiplatelet drug and an anticoagulant, and 590 taking neither.. Cephalomedullary nail fixation.. Blood transfusion and calculated blood loss.. More patients taking antiplatelet drugs required a transfusion than controls (43% vs. 33%, P < 0.001), whereas patients taking warfarin or DOACs did not (35% or 32% vs. 33%). Median calculated blood loss was increased in patients taking antiplatelet drugs (1275 mL vs. 1059 mL, P < 0.001) but not in patients taking warfarin or DOACs (913 mL or 859 mL vs. 1059 mL). Antiplatelet drugs were independently associated with an odds ratio of transfusion of 1.45 [95% confidence interval (CI), 1.1-1.9] in contrast with 0.76 (95% CI, 0.5-1.2) for warfarin and 0.67 (95% CI, 0.3-1.4) for DOACs.. Geriatric patients taking warfarin (incompletely reversed) or DOACs lose less blood during cephalomedullary nail fixation of hip fractures than those taking aspirin. Delaying surgery to mitigate anticoagulant-related surgical blood loss may be unwarranted.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Aged; Anticoagulants; Aspirin; Blood Loss, Surgical; Cohort Studies; Hip Fractures; Humans; Platelet Aggregation Inhibitors; Retrospective Studies; Warfarin

The three direct oral anticoagulants (DOAC), rivaroxaban, apixaban and dabigatran have been associated with lower risks of fractures compared to warfarin. However, no large scale studies have explored the associations with the newest DOAC, edoxaban, with fracture risk. The present study aims to elucidate the effects of edoxaban on the risk of hip fracture amongst elderly patients by comparing the incidence of new onset hip fracture between edoxaban and warfarin users in a Chinese population.. This was a retrospective population-based cohort study of patients with edoxaban or warfarin use between January 1st, 2016 and December 31st, 2019 in Hong Kong, China. Patients with less than one-month exposure, medication switching between warfarin and edoxaban, those who died within 30 days after drug exposure, prior human immunodeficiency virus infection, age <50 years old, and those with prior hip fractures were excluded. Propensity score matching (1:2) between edoxaban and warfarin users using the nearest neighbour method was performed based on demographics, prior comorbidities, and use of different medications. The study outcomes were new onset hip fractures, medically attended falls and all-cause mortality.. A total of 5014 patients including 579 edoxaban users and 4435 warfarin users (median age: 70 years old [interquartile range (IQR): 62-79], 56.66% males) with a median follow-up of 637.5 (IQR: 320-1073) days were included. In the matched cohort, edoxaban users had significantly lower rates of new onset hip fractures, medically attended falls and all-cause mortality. The protective value of edoxaban use against new onset hip fracture (hazard ratio [HR]: 0.13, 95% confidence interval [CI]: [0.03-0.54], p = 0.0051), medically attended falls (HR: 0.47, [0.29-0.75], p = 0.0018) and all-cause mortality (HR: 0.61, [0.42-0.87], p = 0.0059) in comparison to warfarin use persisted after matching. The significant relationship between edoxaban use and lower fracture risk was preserved in all sensitivity analyses using different approaches using the propensity score.. Edoxaban use is associated with lower risks of new onset hip fractures, medically attended falls and mortality risks compared to warfarin after propensity score matching.

Topics: Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Cohort Studies; Female; Hip Fractures; Humans; Male; Middle Aged; Propensity Score; Pyridines; Retrospective Studies; Risk Assessment; Stroke; Thiazoles; Warfarin

Although the use of venous thromboembolism (VTE) chemoprophylaxis has markedly reduced VTE rates after hip fracture surgery, few studies have directly compared the efficacy of different anticoagulant agents in this setting. The purpose of this study was to compare outcomes of Lovenox, Eliquis, or Coumadin as VTE prophylaxis after hip fracture surgery.. The PearlDiver MHip national database was queried for patients older than 60 years undergoing first-time hip fracture surgery with no concurrent pelvic or distal femoral fractures. Prescriptions for Lovenox, Eliquis, or Coumadin were identified. Univariate and multivariate analyses of patient characteristics, 90-day incidences of VTE, adverse events, and readmissions were compared. Odds ratios (ORs) were calculated, and significance was set at P < 0.01 based on Bonferroni adjustment.. A total of 11,384 patients were identified, with the Lovenox used for 6835 patients (60.0%), Eliquis for 1092 patients (9.6%), and Coumadin for 3457 patients (30.4%). The prevalence of 90-day VTE in the Lovenox, Eliquis, and Coumadin groups was 3.1%, 3.8%, and 5.0%, respectively (P < 0.001). Multivariate analyses adjusting for demographic and comorbidity profiles were conducted with Lovenox as the referent. Those on Eliquis had significantly lower transfusions (OR 0.52, P = 0.005), but similar rates of other outcomes including VTE (P > 0.01). Conversely, patients on Coumadin had significantly greater odds of any adverse event (OR 1.18, P < 0.001) and VTE (OR 1.58, P < 0.001).. In evaluating Lovenox, Eliquis, and Coumadin as VTE chemoprophylactic agents after hip fracture surgery in anticoagulant-naïve patients, Lovenox and Eliquis had similar 90-day VTE, whereas patients on Coumadin had greater odds of 90-day VTE. Interestingly, patients on Eliquis had nearly two-fold lower odds of transfusions compared with patients on Lovenox. Although consensus on the optimal VTE prophylactic agent after hip fracture surgery does not exist, Eliquis and Lovenox may be comparable options and seem to be more effective than Coumadin.

Topics: Anticoagulants; Enoxaparin; Hip Fractures; Humans; Venous Thromboembolism; Warfarin

Hip fractures are a common problem and corrective surgery is recommended within 24 h. However, most peri-operative direct oral anticoagulant (DOAC) guidelines suggest a washout period of 48 h before major surgery. There are limited data on utility of drug levels.. To investigate the effect of DOAC therapy on time to surgery and patient outcomes, and to explore the impact of different pre-operative protocols on surgical delay.. A multi-centre, retrospective analysis of all adult patients that presented with acute hip fracture at three tertiary hospitals in Perth, Western Australia, was performed. Data were collated from the West Australian hip fracture registry and electronic records. Time to theatre, DOAC levels, bleeding and transfusion rates were compared between sites.. Of 1240 hip fracture patients, 146 (11.9%) were on anticoagulation, with more patients taking a DOAC than warfarin. The time to surgery was significantly longer for those on a DOAC compared with those on warfarin (P = 0.003). There was no difference in bleeding, transfusion requirement or 30-day mortality in patients taking a DOAC compared to those on warfarin. Fifty-eight (70.7%) patients had a DOAC level prior to surgery. Of 25 patients who had a level performed within 12 h of presentation, 13 (52%) had a result of ≤50 ng/mL. Outcomes were similar between sites.. People on DOAC treatment had a significant delay before corrective surgery compared with those on warfarin. The frequent finding of early DOAC levels <50 ng/mL suggests this delay may be unnecessary in a significant proportion of patients.

Topics: Adult; Aged; Anticoagulants; Australia; Hemorrhage; Hip Fractures; Humans; Retrospective Studies; Warfarin

To investigate if patients treated with oral anticoagulants (OAC) have delayed surgical intervention (more than 48 h) compared to patients without OAC therapy, and if there is an impact to surgery timing on hospitalization length and mortality. A retrospective cohort study of all patients aged over 65 registered with a new diagnosis of hip fracture who underwent surgery in one of the general hospitals run by Clalit, Israel between 01/01/2014 and 31/12/2017. Data was retrieved for patient demographics, OAC treatment, and Charlson comorbidity index. 5828 patients were operated for hip fractures, mean age was 82.8 years (65-108), 4013 (68.8%) were female. 415 were treated with direct oral anticoagulants (DOACs) (7.1%) and 311 with warfarin (5.3%) prior to their hospitalization. Patients taking OAC were less likely to be operated within 48 h from arrival to the hospital compared to patients not receiving OAC. The 30 day mortality was 4.2% among patients not receiving OAC, 6.0% among patients taking DOACs and 10.0% among patients receiving warfarin (p < 0.001). Adjusted odds ratio for mortality at 30 day among patients taking DOACs was similar to patients who didn't take OAC. (OR 1.0, CI 0.7, 1.6). The 30 day mortality rate of patients who were receiving OAC (either DOACs or warfarin) was not significantly different whether patients were operated within 48 h or not. Mortality rate was highest among patients taking warfarin. For patients who received DOACs, operation within 48 h wasn't associated with lower mortality rate. In these patients it seemed reasonable to adjust surgery time according to patients' characteristics and needs.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Female; Hip Fractures; Humans; Retrospective Studies; Warfarin

Hip fractures are a large burden on the health care systems of developed nations. Patients usually have multiple co-morbidities and the pre-injury use of anticoagulants and anti-platelet medication is common.. This study used a single hospital hip fracture database to facilitate a retrospective analysis of the impact of anti-coagulation and anti-platelet therapy on mortality and complications after surgical management of hip fractures. There were 92 patients on warfarin, 69 on DOAC, 260 antiplatelet patients and 617 control patients.. Mortality rates at 30 days were 4.8% for the control group, 12.6% for the antiplatelet group, warfarin 7.0%, 9.5% for Direct Oral Anticoagulant (DOAC) group, p = 0.004. Mortality rates at 1 year were 22.4% for the control group, 32.3% for the antiplatelet group, 29.3% for the warfarin group and 29.0% for DOAC group (p=0.007). Amongst complications, significant differences were found in transfusion (DOAC) and wound ooze (warfarin) rates, but the study did not detect significant clinical consequences arising from these differences. A matched analysis for age, sex, and ASA was undertaken to look in more detail at mortality data. Some mortality differences remained between groups with anti-platelet medication associated with increased mortality, but the differences no longer appeared to be significant. Our data suggests that this is a non-causal association, which could be incorporated into predictive mortality risk scores such as the Nottingham hip fracture score.. We believe that pre-injury antiplatelet therapy is a strong indicator for high risk patients with higher expected mortality after hip fracture surgery. We saw no evidence to support delayed surgery in patients taking DOACs.

Topics: Anticoagulants; Cohort Studies; Hip Fractures; Humans; Retrospective Studies; Warfarin

The management of patients with a hip fracture is affected by the use of oral anticoagulants. A cross-sectional analysis was undertaken to investigate health outcome differences in those anticoagulated compared to those not anticoagulated.. Patients aged 50 years and over presenting to a large university hospital with hip fractures were identified from the service registry. Patient characteristics and health outcomes between those not anticoagulated were compared with those anticoagulated (warfarin and direct oral anticoagulants, DOAC).. 200/2307 (9%) patients were anticoagulated. 84% were on warfarin, and the rest a DOAC. Compared to those anticoagulated, there was a higher prevalence of dementia (25% vs. 18%, p = 0.02) and a lower prevalence of cardiovascular disease (54% vs. 78%, p < 0.01), atrial fibrillation (10% vs. 82%, p < 0.01), and polypharmacy (55% vs. 76%, p < 0.01). Renal function was lower in the anticoagulated group. Time to operation for those not anticoagulated and anticoagulated was a median (IQR) of 25 (15) and 27 (18) hours. There was no difference in blood transfusion and hospital mortality. Postoperative complications were similar except a higher rate of renal failure (14% vs. 19%, p = 0.04) and heart failure (1% vs. 5%, p < 0.01), and a longer length of stay [median (IQR): 14 (10) vs. 16 (12) days] in the anticoagulated group. This was no longer significant after adjustment of confounders.. There was no statistically significant difference in health outcomes between those anticoagulated and those not after adjusting for patient characteristics. It was feasible to avoid significant delay in hip fracture surgery in those anticoagulated.

Topics: Anticoagulants; Antithrombins; Cross-Sectional Studies; Female; Fracture Fixation; Hip Fractures; Hospital Mortality; Humans; Male; Middle Aged; Outcome and Process Assessment, Health Care; Postoperative Complications; Registries; Warfarin

Warfarin is prescribed to patients with atrial fibrillation (AF) for the prevention of cardioembolic complications. Whether warfarin adversely affects bone health is controversial. The availability of alternate direct oral anticoagulant (DOAC) options now make it possible to evaluate the comparative safety of warfarin in association with fracture risk.. To test the hypothesis that, among patients with nonvalvular AF, use of DOACs vs warfarin is associated with lower risk of incident fracture.. This comparative effectiveness cohort study used the MarketScan administrative claims databases to identify patients with nonvalvular AF and who were prescribed oral anticoagulants from January 1, 2010, through September 30, 2015. To reduce confounding, patients were matched on age, sex, CHA2DS2-VASc (congestive heart failure, hypertension, age [>65 years = 1 point; >75 years = 2 points], diabetes, and previous stroke/transient ischemic attack [2 points], vascular disease) score, and high-dimensional propensity scores. The final analysis included 167 275 patients with AF. Data were analyzed from February 27, 2019 to September 18, 2019.. Warfarin and DOACs (dabigatran etexilate, rivaroxaban, and apixaban).. Incident hip fracture, fracture requiring hospitalization, and all clinical fractures (identified using inpatient or outpatient claims) defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes.. In the study population of 167 275 patients with AF (38.0% women and 62.0% men; mean [SD] age, 68.9 [12.5] years), a total of 817 hip fractures, 2013 hospitalized fractures, and 7294 total fractures occurred during a mean (SD) follow-up of 16.9 (13.7) months. In multivariable-adjusted, propensity score-matched Cox proportional hazards regression models, relative to new users of warfarin, new users of DOACs tended to be at lower risk of fractures requiring hospitalization (hazard ratio [HR], 0.87; 95% CI, 0.79-0.96) and all clinical fractures (HR, 0.93; 95% CI, 0.88-0.98), whereas the association with hip fractures (HR, 0.91; 95% CI, 0.78-1.07) was not statistically significant. When comparing individual DOACs with warfarin, the strongest findings were for apixaban (HR for hip fracture, 0.67 [95% CI, 0.45-0.98]; HR for fractures requiring hospitalization, 0.60 [95% CI, 0.47-0.78]; and HR for all clinical fractures, 0.86 [95% CI, 0.75-0.98]). In subgroup analyses, DOACs appeared more beneficial among patients with AF who also had a diagnosis of osteoporosis than among those without a diagnosis of osteoporosis.. In this real-world population of 167 275 patients with AF, use of DOACs-particularly apixaban-compared with warfarin use was associated with lower fracture risk. These associations were more pronounced among patients with a diagnosis of osteoporosis. Given the potential adverse effects of warfarin on bone health, these findings suggest that caution should be used when prescribing warfarin to patients with AF at high risk of fracture.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Comorbidity; Comparative Effectiveness Research; Dabigatran; Factor Xa Inhibitors; Female; Fractures, Bone; Hip Fractures; Hospitalization; Humans; Incidence; Male; Middle Aged; Osteoporosis; Proportional Hazards Models; Protective Factors; Pyrazoles; Pyridones; Rivaroxaban; Warfarin

Hip fracture is common in the elderly, many of whom are on anticoagulation. However, data are limited on outcomes with anticoagulation reversal in patients undergoing hip fracture surgery.. Adults ≥60 years old on oral anticoagulation who underwent hip fracture surgery at 21 hospitals in Northern California from 2006 to 2016 were identified through electronic databases. Outcomes were compared among patients treated and untreated with anticoagulation reversal preoperatively.. Of 1984 patients on oral anticoagulation who underwent hip fracture surgery, 1943 (97.9%) were on warfarin and 41 (2.1%) were on direct oral anticoagulants. Reversal agents were administered to 1635 (82.4%). Compared to a watch-and-wait strategy, patients receiving reversal agents were more likely to be white, male, comorbid, and with higher admission and preoperative international normalized ratios (P <0.001 for all comparisons). No difference for 30-day mortality was detected between reversal vs non-reversal (7.8% vs 6.0%, respectively; hazard ratio [HR], 1.30 [95% confidence interval (CI), 0.82-2.07]). For secondary outcomes, reversal was associated with higher risk of delirium (8.6% vs 4.9%, risk ratio [RR], 1.77 [95% CI, 1.08-2.89]) and increased mean length of stay (6.4 vs 5.8 days, P <0.05). After adjustment, associations were no longer significant for delirium (RR 1.60, 95% CI, 0.97-2.65) or length of stay (mean difference 0.08, 95% CI, -0.55-0.71). No associations were detected between reversal and other secondary outcomes.. No significant associations were found between reversal agents and 30-day mortality or other outcomes in patients on oral anticoagulation who underwent hip fracture surgery. Further investigation is needed.

Topics: Aged; Aged, 80 and over; Antibodies, Monoclonal, Humanized; Anticoagulants; Antifibrinolytic Agents; Arthroplasty, Replacement, Hip; Asian; Black or African American; Blood Coagulation Factors; Blood Loss, Surgical; Blood Transfusion; Cohort Studies; Delirium; Factor Xa Inhibitors; Female; Fracture Fixation, Internal; Hip Fractures; Hispanic or Latino; Humans; International Normalized Ratio; Length of Stay; Male; Mortality; Orthopedic Procedures; Plasma; Postoperative Complications; Postoperative Hemorrhage; Preoperative Care; Proportional Hazards Models; Retrospective Studies; Sex Factors; Vitamin K; Warfarin; White People

The incidence of venous thromboembolism (VTE) following arthroplasty and hip fracture surgery remains an important metric for quality and financial reasons. An audit at our institution between 2006-2010 showed a higher VTE rate than international data did at the time. This study aims to determine rates of DVT and PE in patients undergoing hip and knee arthroplasty and hip fracture surgery at Waitemata District Health Board (Waitemata DHB) between 1 January 2013 and 31 December 2016.. This study is a retrospective review of all VTE within three months of elective hip or knee replacement or hip fracture surgery. Data were identified for the period between 2013 and 2016 from Waitemata DHB patient databases, including a dedicated VTE database.. The current rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) at our institution following hip or knee arthroplasty or hip fracture surgery are 1.5% and 0.6% respectively, a lower rate than 2.3% and 0.9% respectively in 2006-2010. DVTs were significantly more prevalent after hip fracture surgery than after elective hip or knee arthroplasty, and 71% of DVTs were confined to the distal veins. Of the patients undergoing surgery, 93% received post-operative chemoprophylaxis, mainly aspirin or low molecular-weight heparin (LMWH).. There has been a significant reduction in VTE rates following elective hip and knee joint replacement and hip fracture surgery between the time periods. This occurred over a period when Waitemata DHB introduced a multi-modal, interdisciplinary team approach to VTE prophylaxis utilising enhanced recovery after surgery (ERAS) pathways. These measures may therefore have contributed to the reduction in VTEs.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Female; Heparin, Low-Molecular-Weight; Hip Fractures; Humans; Incidence; Male; Medical Audit; New Zealand; Orthopedic Procedures; Platelet Aggregation Inhibitors; Postoperative Complications; Pulmonary Embolism; Venous Thromboembolism; Venous Thrombosis; Warfarin

It is unclear whether anticoagulant type is associated with the risk for osteoporotic fracture, a deleterious complication of anticoagulants among patients with atrial fibrillation (AF).. To compare the risk for osteoporotic fracture between anticoagulants.. Population-based cohort study.. Territory-wide electronic health record database of the Hong Kong Hospital Authority.. Patients newly diagnosed with AF between 2010 and 2017 who received a new prescription for warfarin or a direct oral anticoagulant (DOAC) (apixaban, dabigatran, or rivaroxaban). Follow-up ended on 31 December 2018.. Osteoporotic hip and vertebral fractures in anticoagulant users were compared using propensity score-weighted cumulative incidence differences (CIDs).. There were 23 515 patients identified (3241 apixaban users, 6867 dabigatran users, 3866 rivaroxaban users, and 9541 warfarin users). Overall mean age was 74.4 years (SD, 10.8), ranging from 73.1 years (warfarin) to 77.9 years (apixaban). Over a median follow-up of 423 days, 401 fractures were identified (crude event number [weighted rate per 100 patient-years]: apixaban, 53 [0.82]; dabigatran, 95 [0.76]; rivaroxaban, 57 [0.67]; and warfarin, 196 [1.11]). After 24-month follow-up, DOAC use was associated with a lower risk for fracture than warfarin use (apixaban CID, -0.88% [95% CI, -1.66% to -0.21%]; dabigatran CID, -0.81% [CI, -1.34% to -0.23%]; and rivaroxaban CID, -1.13% [CI, -1.67% to -0.53%]). No differences were seen in all head-to-head comparisons between DOACs at 24 months (apixaban vs. dabigatran CID, -0.06% [CI, -0.69% to 0.49%]; rivaroxaban vs. dabigatran CID, -0.32% [CI, -0.84% to 0.18%]; and rivaroxaban vs. apixaban CID, -0.25% [CI, -0.86% to 0.40%]).. Residual confounding is possible.. Among patients with AF, DOAC use may result in a lower risk for osteoporotic fracture compared with warfarin use. Fracture risk does not seem to be altered by the choice of DOAC. These findings may help inform the benefit-risk assessment when choosing between anticoagulants.. The University of Hong Kong and University College London Strategic Partnership Fund.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Cohort Studies; Dabigatran; Female; Follow-Up Studies; Hip Fractures; Hong Kong; Humans; Male; Osteoporotic Fractures; Pyrazoles; Pyridones; Rivaroxaban; Spinal Fractures; Stroke; Warfarin

Topics: Anticoagulants; Factor Xa Inhibitors; Hip Fractures; Humans; Risk Factors; Warfarin

Patients with hip fracture who present anticoagulated with warfarin often require reversal of anticoagulation for safe hip fracture surgery. Vitamin K is typically administered for this, but requires 24-48 hours for maximal effect. These patients have an increased delay to surgery and increased mortality. Octaplex is a prothrombin complex concentrate (PCC) that reverses warfarin anticoagulation in less than an hour. This study assesses the effectiveness and safety of Octaplex for reversal of warfarin anticoagulation for hip fracture surgery.. We reviewed the medical records of all patients with hip fracture in Calgary who received Octaplex between 2009 and 2015. Timing of admission, Octaplex administration and hip fracture surgery were recorded. Mortality and cardiac, thrombotic and orthopedic complications were assessed.. Median time from Octaplex administration to an international normalized ratio of 1.4 or lower was 1.1 hours. The median time from admission to surgery was 22 hours. Thirty-day mortality was 15.2%, with 4 cases of cardiac arrest and 1 respiratory arrest. Patients who received both Octaplex and fresh frozen plasma (FFP) had a lower rate of 30-day survival than those who received only Octaplex (95.7% v. 60.0%,. There were significant rates of cardiac events and 30-day mortality among patients who received Octaplex, but this is unsurprising in this population with multiple medical comorbidities. We caution against administrering both FFP and a PCC in patients for warfarin reversal. Octaplex is effective for rapidly reversing warfarin anticoagulation and reducing delays to hip fracture surgery. Further study comparing Octaplex to reversal using only vitamin K is required.. Les patients avec fracture de la hanche qui sont sous anticoagulothérapie par warfarine au moment de consulter ont souvent besoin qu'on inverse leur anticoagulation pour être opérés sans danger. La vitamine K est généralement administrée à cette fin, mais il lui faut de 24 à 48 heures pour exercer son plein effet. Chez ces patients, le délai est plus long avant la chirurgie et la mortalité est plus élevée. Octaplex est un concentré de complexe prothrombique (CCP) qui inverse l'anticoagulation due à la warfarine en moins d'une heure. Cette étude évalue l'efficacité et l'innocuité d'Octaplex pour l'inversion de l'anticoagulation due à la warfarine lors d'une chirurgie pour fracture de la hanche.. Nous avons passé en revue les dossiers médicaux de tous les patients avec fracture de la hanche à Calgary qui ont reçu Octaplex entre 2009 et 2015. Nous avons enregistré le moment de l'admission, de l'administration d'Octaplex et de la chirurgie pour fracture de la hanche. Nous avons évalué la mortalité et les complications cardiaques, thrombotiques et orthopédiques.. L'intervalle médian entre l'administration d'Octaplex et l'obtention d'un ratio international normalisé de 1,4 ou moins a été de 1,1 heure. L'intervalle médian entre l'admission et la chirurgie a été de 22 heures. La mortalité à 30 jours a été de 15,2 %, incluant 4 arrêts cardiaques et 1 arrêt respiratoire. Les patients qui ont reçu Octaplex et du plasma frais congelé (PFC) ont eu un taux de survie à 30 jours moins élevé que ceux qui ont reçu Octaplex seulement (95,7 % c. 60,0 %,. On a observé des taux significatifs d'événements cardiaques et de mortalité à 30 jours chez les patients traités par Octaplex, mais cela est peu surprenant dans cette population présentant plusieurs comorbidités médicales. Nous formulons une mise en garde contre l'utilisation de PFC et d'un CCP chez les patients soumis à une inversion de l'effet de la warfarine. Octaplex est efficace pour inverser rapidement l'anticoagulation due à la warfarine et accélérer l'accès à la chirurgie pour fracture de la hanche. Il faudra approfondir la recherche et comparer l'inversion par Octaplex plutôt que par la vitamine K seulement.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation; Blood Coagulation Disorders; Blood Coagulation Factors; Female; Hip Fractures; Humans; International Normalized Ratio; Male; Retrospective Studies; Time Factors; Time-to-Treatment; Treatment Outcome; Warfarin

To assess the impact of direct oral anticoagulant (DOAC) intake compared with Coumadin (COU) in patients suffering hip fractures (HFs).. Retrospective cohort analysis.. Level 1 Trauma Center.. Timing of surgical hip fixation.. Three-hundred twenty patients 65 years of age or older with isolated HF were enrolled into the study: 207 (64.7%) without any antithrombotic therapy (no-ATT), 59 (18.4%) on COU, and 54 (16.9%) on DOACs.. Time to surgery, blood loss, mortality, hospital length of stay, red blood cell transfusion, use of reversal agents, and Charlson Comorbidity Index.. Patients on COU and DOACs had a higher Charlson Comorbidity Index compared with the no-ATT group (P < 0.0001). Despite the fact that significantly more patients received reversal agents in the COU group compared with DOAC medication (P < 0.0001), percentage of transfused patients were similar (54.2% vs. 53.7%). Time to surgery was significantly shorter in the no-ATT group when compared with DOAC patients (12-29.5 hours, respectively). No difference in postoperative hemorrhage, intensive care unit length of stay, and mortality was observed between groups.. DOAC medication in HF patients caused long elapse time until surgical repair. We found no evidence of higher bleeding rates in HF patients on DOACs compared with COUs. Earlier HF fixation might be indicated in DOAC patients.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Administration, Oral; Aged; Anticoagulants; Female; Fracture Fixation; Hip Fractures; Humans; Length of Stay; Male; Postoperative Hemorrhage; Retrospective Studies; Survival Rate; Time-to-Treatment; Treatment Outcome; Warfarin

Use of direct-acting oral anticoagulants (DOACs) is increasing, but knowledge about pharmacokinetics and safety in frail patients is lacking.. The aim was to determine serum concentrations and elimination rates of DOACs in older hip fracture patients hospitalized for surgery.. The study included patients ≥ 65 years of age hospitalized for acute hip fracture surgery over a period of 6 months. Use of antithrombotic drugs was registered and serum samples collected for analysis of DOACs (apixaban, dabigatran and rivaroxaban) at admission and surgery. Measured concentrations were assessed in relation to reference (therapeutic) ranges of the respective drugs and applied for half-life calculations. Furthermore, waiting time for surgery was compared between DOAC and warfarin users.. Of 167 patients included (median age 84 years), 11 and 14 used DOACs and warfarin, respectively. Seven of the DOAC-treated patients had concentrations above the upper reference range (> 300 nM) at admission, and concentrations were still in the reference range for five of these at surgery. Elimination half-lives could be estimated in eight patients and ranged between 14.6 and 59.7 h (median 21.6). The observed waiting time for surgery was longer for patients using DOACs than warfarin (median 44 vs. 25 h).. This pilot study indicates that older patients prone to hip fracture are at risk of being exposed to therapeutic serum concentrations of DOACs during surgery due to reduced drug elimination rates. The observation that almost 50% of the patients had therapeutic concentrations at surgery should be investigated further regarding safety of DOAC use in this frail elderly population.

Topics: Aged; Aged, 80 and over; Anticoagulants; Dabigatran; Female; Hip Fractures; Humans; Male; Pilot Projects; Prospective Studies; Pyrazoles; Pyridones; Rivaroxaban; Warfarin

To compare the rates of deep venous thrombosis (DVT), rates of pulmonary embolus (PE), and complication profiles of warfarin and low-molecular-weight heparin (LMWH) in patients undergoing operative fixation of hip fractures.. Retrospective cohort study.. Insurance-based database of more than 22 million patient records.. Adult hip fracture patients who were treated operatively and received chemoprophylaxis from 2007 to 2016. A total of 7594 patients met inclusion criteria and were available for final analysis.. Pharmacological anticoagulation with warfarin or LMWH to prevent postoperative venous thromboembolism after hip fracture surgery.. Development of DVT or PE within 30 and 90 days of surgery.. Patients prescribed warfarin had higher rates of DVT and PE compared with those prescribed LMWH. Patients on warfarin were more likely to develop a postoperative hematoma and to be readmitted within 30 and 90 days compared with those on LMWH. Patients in both groups had similar rates of total complications.. Patients prescribed warfarin after hip fractures had higher rates of DVT and PE compared with those prescribed LMWH, although both agents had similar complication profiles.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Aged; Aged, 80 and over; Anticoagulants; Chemoprevention; Female; Follow-Up Studies; Fracture Fixation, Internal; Heparin, Low-Molecular-Weight; Hip Fractures; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Retrospective Studies; United States; Venous Thrombosis; Warfarin

Surgical site infection (SSI) is a devastating complication of proximal femoral fracture surgery, related with an increased morbidity and mortality. As warfarin treatment has been described as a risk factor for SSI, we aimed to compare patient and SSI characteristics in warfarin and nonanticoagulated patients.. Retrospective cohort study.. Level-1 trauma center.. Individuals 65 years of age and older with fragility hip fractures.. Patients were divided into 2 cohorts: warfarin treated (n = 85) or nonanticoagulated (n = 771). Demographics, in-hospital characteristics, laboratory data, prior hospitalizations, recent antibiotic use, and 1-year incidence of SSIs and their characteristics were gathered.. Postoperative SSIs.. Twelve patients (14.1%) from the warfarin group and 21 patients (2.7%) from the noncoagulated group had SSI (P < 0.001). Both groups were comparable in terms of demographics and Charlson comorbidity score. Warfarin-treated patients had reduced white blood and neutrophils counts (10.1 ± 3.2 vs. 11.6 ± 4.0 cells/mm and 8.1 ± 3.2 vs. 9.6 ± 3.9 cells/mm for both comparisons respectively; P < 0.001 for both). They were more likely to be admitted to a geriatric ward than to orthopedics ward and were delayed to theater (58.5 ± 44.5 vs. 30.6 ± 27.4 hours; P < 0.001). Following surgery, there was no difference in blood transfusions required, in-hospital complications, or time to infection. Rates of prior hospitalizations, antibiotic use, or type of bacteria did not differ.. Warfarin treatment in fragility hip fracture surgery is correlated with an increased risk for SSI, regardless of in-hospital complications, and hospitalizations before surgery or to the infection itself.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Aged; Aged, 80 and over; Anticoagulants; Cohort Studies; Female; Fractures, Spontaneous; Hip Fractures; Humans; Male; Orthopedic Procedures; Retrospective Studies; Surgical Wound Infection; Warfarin

Guidelines underline the importance of early surgery in elderly patients with proximal femoral fractures. However, most of these patients present a high number of comorbidities, some of which require the use of warfarin. Waiting for INR decrease is a cause of surgical delay, and this influences negatively their outcome.. We retrospectively reviewed all patients with proximal femoral fracture admitted to our unit from March 2013 to March 2017 to determine whether warfarin therapy is associated with reduction of survival, delay of surgery, and increased blood loss. From 1706 patient, a total of 1292 fulfilled the eligibility criteria and were included. Data regarding general information (type of fracture according to AO/OTA classification), pharmacological history regarding anticoagulant therapy pre-admission, surgery (type of surgery and time to surgery), clinical findings (blood loss), and date of exitus were collected.. We identified 157 patients with warfarin, 442 with antiplatelet agents (aspirin, clopidogrel, ticlopidin), and 693 in the control group. We observed a significant difference in the warfarin group regarding an increased ASA score, Charlson Comorbidity Index, and blood loss. Patients taking warfarin experience delay to the theater significantly more than the other groups. Patients in warfarin therapy have a 42% higher risk of death within 1 year from their surgery. Patients who underwent surgery after 48 h have 1.5 times higher risk of mortality with respect to the patients who underwent surgery within 48 h.. Warfarin therapy at the time of proximal femoral fractures is associated with increased time to surgery, blood loss, and mortality.

Topics: Aged; Aged, 80 and over; Anticoagulants; Cross-Sectional Studies; Female; Hip Fractures; Humans; Male; Mortality; Retrospective Studies; Time Factors; Time-to-Treatment; Warfarin

Topics: Aged; Arrhythmias, Cardiac; Blood Loss, Surgical; Hip Fractures; Humans; Male; Perioperative Care; Risk Factors; Venous Thromboembolism; Warfarin

Hip fracture patients in general are elderly and they often have comorbidities that may necessitate anticoagulation treatment, such as warfarin. It has been emphasized that these patients benefit from surgery without delay to avoid complications and reduce mortality. This creates a challenge for patients on warfarin and especially for those with trochanteric or subtrochanteric hip fractures treated with intramedullary nailing, as this is associated with increased bleeding compared to other types of hip fractures and surgical methods. The aim of the study was to evaluate if early surgery (within 24 h) of trochanteric or subtrochanteric hip fractures using intramedullary nailing is safe in patients on warfarin treatment after fast reversal of the warfarin effect.. A retrospective case-control study including 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant. All patients were operated within 24 h with a cephalomedullary nail due to a trochanteric or subtrochanteric hip fracture. All patients on warfarin were reversed if necessary to INR ≤ 1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). Per- and postoperative data, transfusion rates, adverse events and mortality was compared.. There were no significant differences in the calculated blood-loss, in-house adverse events or mortality (in-house, 30-day or 1-year) between the groups. There were no significant differences in the pre- or peroperative transfusions rates, but there was an increased rate of postoperative transfusions in the control group (p = 0.02).. We found that surgical treatment with intramedullary nailing within 24 h of patients with trochanteric or subtrochanteric hip fractures on warfarin medication after reversing its effect to INR ≤ 1.5 using vitamin K and/or PCC is safe.

Topics: Aged; Aged, 80 and over; Anticoagulants; Bone Nails; Case-Control Studies; Female; Hip Fractures; Humans; Male; Patient Safety; Retrospective Studies; Time Factors; Time-to-Treatment; Urinary Tract Infections; Warfarin

The risk of osteoporotic fracture with dabigatran use in patients with nonvalvular atrial fibrillation (NVAF) is unknown.. To investigate the risk of osteoporotic fracture with dabigatran vs warfarin in patients with NVAF.. Retrospective cohort study using a population-wide database managed by the Hong Kong Hospital Authority. Patients newly diagnosed with NVAF from 2010 through 2014 and prescribed dabigatran or warfarin were matched by propensity score at a 1:2 ratio with follow-up until July 31, 2016.. Dabigatran or warfarin use during the study period.. Risk of osteoporotic hip fracture and vertebral fracture was compared between dabigatran and warfarin users using Poisson regression. The corresponding incidence rate ratio (IRR) and absolute risk difference (ARD) with 95% CIs were calculated.. Among 51 496 patients newly diagnosed with NVAF, 8152 new users of dabigatran (n = 3268) and warfarin (n = 4884) were matched by propensity score (50% women; mean [SD] age, 74 [11] years). Osteoporotic fracture developed in 104 (1.3%) patients during follow-up (32 dabigatran users [1.0%]; 72 warfarin users [1.5%]). Results of Poisson regression analysis showed that dabigatran use was associated with a significantly lower risk of osteoporotic fracture compared with warfarin (0.7 vs 1.1 per 100 person-years; ARD per 100 person-years, -0.68 [95% CI, -0.38 to -0.86]; IRR, 0.38 [95% CI, 0.22 to 0.66]). The association with lower risk was statistically significant in patients with a history of falls, fractures, or both (dabigatran vs warfarin, 1.6 vs 3.6 per 100 person-years; ARD per 100 person-years, -3.15 [95% CI, -2.40 to -3.45]; IRR, 0.12 [95% CI, 0.04 to 0.33]), but not in those without a history (0.6 vs 0.7 per 100 person-years; ARD per 100 person-years, -0.04 [95% CI, 0.67 to -0.39]; IRR, 0.95 [95% CI, 0.45 to 1.96]) (P value for interaction, <.001).. Among adults with NVAF receiving anticoagulation, the use of dabigatran compared with warfarin was associated with a lower risk of osteoporotic fracture. Additional study, perhaps including randomized clinical trials, may be warranted to further understand the relationship between use of dabigatran vs warfarin and risk of fracture.

Topics: Accidental Falls; Aged; Anticoagulants; Antithrombins; Atrial Fibrillation; Dabigatran; Databases, Factual; Female; Hip Fractures; Hong Kong; Humans; Male; Osteoporotic Fractures; Poisson Distribution; Propensity Score; Retrospective Studies; Risk; Spinal Fractures; Stroke; Warfarin

To compare blood loss, delay of surgery, and short-term adverse events in (1) patients admitted on warfarin versus nonanticoagulated controls and (2) warfarin patients with day of surgery (DOS) international normalized ratio (INR) of 1.5 or greater versus below 1.5.. Retrospective cohort.. Academic Level I trauma center.. One hundred twenty four patients treated surgically for hip fractures including patients presenting on warfarin (n = 62) and matched controls (n = 62).. Cephalomedullary nailing (CMN), hemiarthroplasty, or total hip arthroplasty.. The primary outcome was transfusion rate. Secondary outcomes included calculated blood loss, 30-day complication rate, and hours from emergency department presentation to surgery.. There was no significant difference in blood transfusion rates between the warfarin and control groups (P = 0.86). Blood transfusion was required in 58.1% of patients in the warfarin group (48.3% of arthroplasties and 65.5% of CMNs) compared with 56.6% of controls (41.9% of arthroplasties and 73.3% of CMNs). There were also no significant differences in calculated blood loss or in complication rates. Patients on warfarin had significantly longer time to surgery (P < 0.01). Subanalysis of the warfarin group showed that patients with DOS INR at or above 1.5 had similar transfusion rates, blood loss, and complications compared with patients with INR below 1.5. Treatment with CMN was the only covariate that was found to be a significant independent predictor of transfusion on multivariable analysis (P = 0.048).. Patients with hip fractures admitted on warfarin seem to be at similar risk of transfusion or adverse events compared with nonanticoagulated patients. Awaiting normalization of INR delayed surgery without reducing bleeding or preventing complications. Within reason, surgeons may consider proceeding with surgery in patients with INR above 1.5 if patients are otherwise medically optimized. The upper limit above which surgery causes increased blood loss is currently unknown.. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Age Factors; Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Case-Control Studies; Female; Follow-Up Studies; Fracture Fixation, Intramedullary; Hemiarthroplasty; Hip Fractures; Humans; Injury Severity Score; International Normalized Ratio; Logistic Models; Male; Middle Aged; Multivariate Analysis; Retrospective Studies; Risk Assessment; Sex Factors; Statistics, Nonparametric; Tertiary Care Centers; Time-to-Treatment; Treatment Outcome; Warfarin

The purpose of this study was to evaluate the effectiveness of Factor Xa inhibitors (XaI) for thromboprophylaxis following hip fracture surgery in a large cohort of patients, and compare XaI against warfarin and enoxaparin.. Patients undergoing hip fracture surgery from 2007 to 2015 were identified in a large claims database. Patients prescribed warfarin, XaI, or enoxaparin within 2 weeks of surgery were identified and grouped into cohorts. Medical comorbidities and complication incidences, including deep venous thrombosis (DVT), pulmonary embolism (PE), and bleeding complications were calculated. Chi-square analysis was performed and adjusted residuals calculated to determine significant differences.. DVT rates were significantly different between groups at thirty days only (5.03% warfarin, 2.91% XaI, 3.48% enoxaparin, p=0.047). PE rates were significantly different at all time points; enoxaparin had the lowest rates. There were no differences in the rates of other complications.. XaI are an option for thromboprophylaxis in hip fracture patients, although their possible decreased effectiveness against PE compared to enoxaparin should be considered.. This study compares the effectiveness of Factor Xa inhibitors to warfarin and enoxaparin for hip fracture patients, using a large national database. In this study, Factor Xa inhibitors had similar effectiveness for DVT prophylaxis compared to these agents.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Databases, Factual; Enoxaparin; Factor Xa Inhibitors; Female; Hip Fractures; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Secondary Prevention; Treatment Outcome; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Hip Fractures; Humans; Length of Stay; Pelvic Bones; Retrospective Studies; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Cause of Death; Female; Hip Fractures; Humans; Male; Patient Discharge; Patient Readmission; Stroke; Survival Rate; Thrombosis; United States; Warfarin

This study examined warfarin usage for elderly Medicare beneficiaries with atrial fibrillation (AF) who suffered traumatic brain injury (TBI), hip fracture, or torso injuries. Using the 5% Chronic Condition Data Warehouse administrative claims data, this study included fee-for-service Medicare beneficiaries who had a single injury hospitalization (TBI, hip fracture, or major torso injury) between 1/1/2007 and 12/31/2009, with complete Medicare Parts A, B (no Medicare Advantage), and D coverage 6 months before injury, and who were aged 66 years or older and diagnosed with AF at least 1 year before injury. About 45% of the AF patients were using warfarin before TBI or torso injury, and 35% before hip fracture. After injury, there was a dramatic and persistent decrease in warfarin use in TBI and torso injury groups (30% for TBI and 37% for torso injury at 12 months after injury). Warfarin usage in hip fracture patients also dropped after injury but returned to pre-injury level within 4 months. TBI and torso injury lead to significant decreases in warfarin usage in elderly AF patients. Further research is needed to understand reasons for the pattern and to develop evidence-based management strategies in the post-acute setting.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Brain Injuries; Drug Utilization; Fee-for-Service Plans; Female; Hip Fractures; Humans; Male; Medicare; Torso; United States; Warfarin

Hip fractures require operation within 36-48 h, and they are most common in the elderly. A high International Normalized Ratio should be corrected before surgery. In the current study, we analyzed the budget impact of various warfarin reversal approaches.. Four reversal strategies were chosen for the budget impact analysis: the temporary withholding of warfarin, administration of vitamin K, fresh frozen plasma (FFP), and a four-factor prothrombin complex concentrate (PCC).. We estimated that, annually, 410 hip fracture patients potentially require warfarin reversal in Finland. The least costly treatment was vitamin K, which accounted for €289,000 in direct healthcare costs, and the most costly treatment option was warfarin cessation, which accounted for €1,157,000. In the budget impact analysis, vitamin K, PCC and FFP would be cost-saving to healthcare compared with the current treatment mix.. The various warfarin reversal strategies have different onset times, which may substantially impact the subsequent healthcare costs.

Topics: Aged; Anticoagulants; Blood Coagulation Factors; Budgets; Female; Finland; Health Care Costs; Hip Fractures; Humans; International Normalized Ratio; Male; Plasma; Time Factors; Vitamin K; Warfarin

To evaluate our hospital protocol of low-dose vitamin K titration for preoperative warfarin reversal for early hip fracture surgery.. Records of 16 men and 33 women aged 63 to 93 (mean, 81) years who were taking warfarin for atrial fibrillation (n=40), venous thromboembolism (n=9), cerebrovascular accident (n=3), and prosthetic heart valve (n=3) and underwent surgery for hip fractures were reviewed. The 3 patients with a prosthetic heart valve were deemed high risk for thromboembolism and the remainder low-risk. The international normalised ratio (INR) of patients was checked on admission and 6 hours after administration of vitamin K; an INR of <1.7 was considered safe for surgery.. No patient developed venous thromboembolism within one year. The 30-day and one-year mortality was 8.2% and 32.6%, respectively. For the 46 low-risk patients, the mean INR on admission was 2.6 (range, 1.1-4.6) and decreased to <1.7 after a mean of 2.2 (range, 0-4) administrations of 2 mg of vitamin K. Their INR was <1.7 within 18 hours (mean, 14 hours). 78% of patients underwent surgery within 36 hours. In the 22% of patients who did not undergo surgery within 36 hours, the delay was due to insufficient operative time or the patient being medically unfit for surgery. The 3 high-risk patients underwent bridging therapy of low-molecular-weight heparin and received no vitamin K; their mean INR on admission was 3.2 (range, 3.1-3.3) and the mean time to surgery was 5.3 (range, 3-8) days. Two low-risk patients and one high-risk patient died within 5 days of surgery.. The low-dose intravenous vitamin K protocol is safe and effective in reversing warfarin within 18 hours. Hip fracture surgery within 36 to 48 hours of admission improves morbidity and mortality.

Topics: Administration, Intravenous; Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Female; Hip Fractures; Humans; International Normalized Ratio; Male; Middle Aged; Preoperative Period; Retrospective Studies; Vitamin K; Warfarin

Topics: Anticoagulants; Antifibrinolytic Agents; Female; Hip Fractures; Humans; Male; Vitamin K; Warfarin

We describe a case of a patient on warfarin who developed an extensive haematoma after a hip hemiarthroplasty and was successfully treated with embolisation. This case highlights the importance of regular haematology input, careful consideration of a suitable surgical approach, close monitoring of postoperative wounds in patients on warfarin and the emerging role of embolisation.

Topics: Aged, 80 and over; Arthroplasty, Replacement, Hip; Buttocks; Embolization, Therapeutic; Female; Femoral Neck Fractures; Fracture Fixation, Internal; Hematoma; Hemiarthroplasty; Hip; Hip Fractures; Hip Joint; Hip Prosthesis; Humans; Iliac Artery; Postoperative Complications; Warfarin

Up to 4% of patients presenting with a hip fracture may be on warfarin at admission. There is little consensus on the timing, dosage or route of vitamin K administration. We aimed to evaluate the impact of a locally developed, evidence-based protocol for perioperative warfarin management on the admission-to-operation time (AOT) in hip fracture patients.. Clinical and demographic data were collected prospectively for hip fracture patients who were on warfarin at the time of admission (post-protocol group) and compared to a historical control group of patients who were on warfarin before implementation of the protocol (pre-protocol group). Univariate analysis was undertaken to identify any significant differences between the two groups.. Twenty-seven patients in the pre-protocol group (27/616, 4.4%) and 40 patients in the post-protocol group (4.7%, 40/855) were on warfarin at admission. There was a significant reduction in the median AOT from 73 h (IQR 46-105) to 37.7 h (IQR 28-45) after implementation of the warfarin protocol (p < 0.001). The proportion of patients operated on within 48 h of admission increased from 30% (8/27) in the pre-protocol group to 80% (32/40) in the post-protocol group (p < 0.001). No significant differences in hospital length of stay (p = 0.77) or the postoperative warfarin recommencement time (p = 0.90) were noted between the two groups.. Implementation of a perioperative warfarin management protocol can expedite surgery in hip fracture patients, but did not reduce hospital stay in our cohort, possibly because of a delay in recommencing warfarin in these patients postoperatively.. Level III.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Drug Therapy, Combination; Evidence-Based Medicine; Female; Follow-Up Studies; Hip Fractures; Humans; Length of Stay; Male; Perioperative Period; Prospective Studies; Retrospective Studies; Risk Assessment; Time-to-Treatment; Treatment Outcome; Vitamin K; Warfarin

To determine the interventions taken to lower international normalized ratio (INR) in individuals with hip fracture using warfarin before admission for hip fracture surgery in a geriatric fracture center (GFC) and compare outcomes with those of individuals not taking warfarin.. Cohort study using retrospective chart review.. University-affiliated community teaching hospital.. Individuals aged 60 and older admitted to a GFC for surgical repair of a nonpathological, nonperiprosthetic hip fracture between April 2006 and April 2012.. Descriptive data collected from a quality improvement registry with additional information for individuals taking warfarin obtained from chart review.. Of the 1,080 individuals included in the analysis, 84 (7.8%) were taking warfarin on admission. Participants using warfarin had a higher average Charlson Comorbidity Index (3.8 vs 3.1, P < .001). Atrial fibrillation was the most common indication for anticoagulation (83.3%). Average INR before surgery was 1.7 (range 1.2-3.6). Vitamin K, fresh frozen plasma, or both were given to 100% of those taking warfarin with an admission INR of 2.0 or greater. There was a trend toward longer time to surgery in those taking warfarin than in those not taking warfarin (28.9 vs 21.7 hours, P = .05). Length of stay was longer for those taking warfarin than those not taking warfarin (4.8 vs 4.2 days, P = .04). Neither time to surgery nor length of stay were significantly different after adjustment for baseline comorbidity. Participants taking warfarin were not found to have any significant differences in thromboembolic event rates, bleeding complications rates, mortality, or 30-day readmission after surgery than those not taking warfarin on admission.. Active management in a GFC model to reverse anticoagulation before surgery may facilitate earlier surgery without increasing observed complications.

Topics: Aged; Aged, 80 and over; Anticoagulants; Comorbidity; Female; Hip Fractures; Hospital Mortality; Humans; International Normalized Ratio; Length of Stay; Male; Middle Aged; Patient Readmission; Postoperative Complications; Retrospective Studies; Treatment Outcome; Warfarin

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Blood Coagulation Factors; Hip Fractures; Humans; Warfarin

Association between warfarin use and fracture risk is unclear. We examined the association between long-term warfarin use and fracture risk at the hip, spine, and wrist in elders. No significant association was found between long-term warfarin use and fracture risk, despite biological plausibility.. Prior studies examining the association of warfarin use and osteoporotic fractures have been conflicting, potentially related to methodological limitations. Thus, we examined the association of long-term warfarin use with risk of hip, spine, and wrist fractures among older adults with atrial fibrillation, attempting to address prior methodologic challenges.. We included men and women ≥ 65 years of age with incident atrial fibrillation and without prior history of fractures from The Health Improvement Network followed between 2000 and 2010. Long-term warfarin use was defined in two ways: (1) warfarin use ≥ 1 year; (2) warfarin use ≥ 3 years. Propensity-score matched cohorts of warfarin users and nonusers were created to evaluate the association between long-term warfarin use and risk of hip, spine, and wrist fractures separately as well as combined, using Cox-proportional hazards regression models.. Among >20,000 participants with incident atrial fibrillation, the hazard ratios (HR) for hip fracture with warfarin use ≥ 1 and ≥ 3 years, respectively, were 1.08 (95%CI 0.87, 1.35) and 1.13 (95% CI 0.84, 1.50). Similarly, no significant associations were observed between long-term warfarin use and risk of spine or wrist fracture. When risk of any fracture was assessed with warfarin use, no association was found [HR for warfarin use ≥ 1 year 0.92 (95%CI 0.77, 1.10); HR for warfarin use ≥ 3 years 1.12 (95%CI 0.88, 1.43)].. Long-term warfarin use among elders with atrial fibrillation was not associated with increased risk of osteoporotic fractures and therefore does not appear to necessitate additional surveillance or prophylaxis.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Databases, Factual; Drug Administration Schedule; Drug Utilization; Female; Hip Fractures; Humans; Incidence; Male; Osteoporotic Fractures; Propensity Score; Risk Assessment; Spinal Fractures; United Kingdom; Warfarin; Wrist Injuries

Coagulation screening continues as a standard of care in many hip fracture pathways despite the 2011 guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) which recommend that such screening be performed only if clinically indicated. This study aims to evaluate the use of pre-operative coagulation screening and explore its financial impact.. Prospective data was collected in accordance with the "Standardised Audit of Hip Fractures in Europe" (SAHFE) protocol. All patients admitted to our hospital with hip fractures during a 12-month period from November 2011 to November 2012 were analysed. Data including coagulation results and the use of vitamin K or blood products were collected retrospectively from the hospital computer system. Patient subgroup analysis was performed for intraoperative blood loss, post-operative blood units transfused, haematoma formation and gastrointestinal haemorrhage.. 814 hip fractures were analysed. 91.4% (n=744) had coagulation tests performed and 22.0% (n=164) had an abnormal result. Of these, 55 patients were taking warfarin leaving 109 patients who had abnormal results and were not taking warfarin. When this group (n=109) was compared to those who had normal test results (n=580) and to all other patients (n=705) there was no difference in intraoperative blood loss (p=0.79, 0.78), postoperative transfusion (p=0.38, 0.30), postoperative haematoma formation (p=0.79, 1.00), or gastrointestinal haemorrhage (p=0.45, 1.00), respectively. In those who were not taking warfarin, but had abnormal results, none had treatment to reverse their coagulopathy with either vitamin K or blood products. By omitting pre-operative coagulation tests in patients who are not taking warfarin, we estimate a financial saving of between £66,500 and £432,250 per annum.. This study supports the hypothesis that routine pre-operative coagulation screening is unnecessary in hip fracture patients unless they take warfarin or have a known coagulopathy. Moreover, its omission represents significant cost-saving potential.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Tests; Cost-Benefit Analysis; Female; Hip Fractures; Humans; Male; Medical Audit; Middle Aged; Patient Selection; Practice Guidelines as Topic; Preoperative Care; Prospective Studies; United Kingdom; Unnecessary Procedures; Vitamin K; Warfarin

Hip fractures are common in the elderly population, but surgical treatment of these fractures within the first 48 hours decreases morbidity and mortality. The management of patients with hip fracture requiring surgery who are taking warfarin anticoagulation is unclear.. To determine the effect of vitamin K on hip fracture patients treated with warfarin.. We retrospectively examined the management of 21 patients with hip fractures who were being treated with warfarin at the time of admission. Vitamin K was given to 11 of the 21 patients. A third group, which served as a control, consisting of 35 hip fracture patients who were not being treated with anticoagulants was also evaluated.. Patients who received vitamin K took fewer days to reach target international normalized ratio (INR) (1.73 +/- 0.90 vs. 4.30 +/- 1.89, P < 0.001) and had less preoperative time (2.64 +/- 1.12 vs. 5.10 +/- 2.42 days, P < 0.008) when compared with patients who did not receive vitamin K. In addition, these patients had statistically significantly shorter hospitalization stays (9.4 +/- 1.9 and 13.2 +/- 4.9 days, one-sided P < 0.06). There was no difference in the amount of blood found in the wound drains (111.8 +/- 68.5 vs. 103.0 +/- 69.4 ml) or the number of blood units administered (1.45 +/- 1.29 vs. 2.00 +/- 2.75 units).. Treatment with vitamin K for hip fracture patients who receive warfarin shortens preoperative time, reduces the length of hospitalization and probably reduces morbidity and mortality.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Blood Coagulation; Chi-Square Distribution; Female; Hip Fractures; Humans; International Normalized Ratio; Length of Stay; Male; Orthopedic Procedures; Preoperative Care; Retrospective Studies; Treatment Outcome; Vitamin K; Warfarin

Topics: Anticoagulants; Female; Hip Fractures; Humans; Male; Warfarin

Risk for bleeding complications during and after early hip fracture surgery for patients taking clopidogrel and other anticoagulants have not been defined. The purpose of this study is to assess the perioperative bleeding risks and clinical outcome after early hip fracture surgery performed on patients taking clopidogrel (Plavix) and other oral anticoagulants.. Study design is a retrospective cohort analysis using data extracted from hospital records and state death records.. Regional medical center (level II trauma).. Data for 1118 patients ≥60 years of age who had surgical treatment for a hip fracture between 2004 and 2008 were reviewed. Eighty-two patients undergoing late surgery (>3 days after admission) were excluded. Patients taking clopidogrel were compared against those not taking clopidogrel. In addition, patients taking clopidogrel only were compared against cohorts of patients taking both clopidogrel and aspirin, aspirin only, warfarin only, or no anticoagulant.. Seventy-four of 1036 patients (7%) were taking clopidogrel, although control groups included 253 patients on aspirin alone, 90 patients on warfarin, and 619 taking no anticoagulants. No significant differences were noted between patients taking clopidogrel and those not taking clopidogrel in estimated blood loss, transfusion requirement, final blood count, hematoma evacuation, hospital length of stay (LOS), or mortality while in hospital or at 1 year. A higher American Society of Anesthesiologists score was seen in the clopidogrel and warfarin groups (P = 0.05 each), increased LOS in the clopidogrel group (P = 0.05), and higher rate of deep vein thrombosis seen in those patients taking warfarin (P = 0.05). Clopidogrel only versus aspirin versus both aspirin and clopidogrel, versus no anticoagulant versus warfarin showed no significant differences in estimated blood loss, transfusion requirement, final blood count, bleeding or perioperative complications, or mortality.. Patients undergoing early hip fracture surgery who are taking clopidogrel, aspirin, or warfarin (with regulated international normalized ratio) are not at substantially increased risk for bleeding, bleeding complications, or mortality. Comorbidities and American Society of Anesthesiologists scores were significantly higher in the clopidogrel group, which may have resulted in the increased postoperative LOS in this group.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Blood Loss, Surgical; Clopidogrel; Cohort Studies; Female; Hip Fractures; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Retrospective Studies; Risk Factors; Ticlopidine; Treatment Outcome; Warfarin

Delay in surgery for hip fractures in older patients may affect mortality and the risk of delirium. Delay in surgery may occur as a result of several factors. It has not been established whether certain patient-related factors, such as a high international normalized ratio (INR) caused by warfarin treatment is associated with delay in surgery. The aim of this study was to explore the associations between warfarin treatment, INR, and time from admission to surgery.. This is an observational study based on data from a database of all hip fracture patients aged ≥ 65 years who were admitted to an orthogeriatric unit. The database included data from 1192 consecutive patients admitted from January 2007 to April 2010. Data were collected during routine work. Use of warfarin, patient characteristics, medical complications, length of stay, and time from admission to surgery were registered from the patients' records, and INR at admission in warfarin users.. Warfarin was used by 117 (9.8%) patients at admission, which included more men (n = 42; 14.4%) than women (n = 75; 8.3%) (P = 0.003). The mean age was 85 years, with no difference between users and nonusers. Warfarin users had more comorbid diseases (mean, 2.1 vs 1.8; P = 0.003), poorer health status (American Society of Anesthesiologists score of 3-5 in 77.8% vs 51.0%), and longer waiting time for surgery compared with nonusers (mean, 23 vs 12 hours; P < 0.001). There was no difference in need for blood transfusions (28.2% of users compared with 25.3% of nonusers; P = 0.49). Length of stay was longer among warfarin users compared with nonusers (mean, 14.6 vs 11.7 days; P = 0.002). Warfarin users with an INR of ≥ 2 had a longer waiting time than those with an INR of < 2, but they had a longer waiting time than nonusers.. Hip fracture patients who are using warfarin experience a longer waiting time for surgery, most likely due to more comorbidities. A more active approach to better management of comorbidities may reduce waiting time for surgery in warfarin users.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Chi-Square Distribution; Comorbidity; Cross-Sectional Studies; Female; Hip Fractures; Humans; International Normalized Ratio; Male; Norway; Risk Factors; Statistics, Nonparametric; Time Factors; Waiting Lists; Warfarin

Topics: Anticoagulants; Hip Fractures; Humans; International Normalized Ratio; Preoperative Care; Warfarin

To assess if pneumatic compression in conjunction with chemoprophylaxis is an effective way to reduce the incidence of deep vein thrombosis in orthopedic trauma patients sustaining fragility hip fractures.. Two hundred patients admitted to the authors' institution between May 1998 and June 2002 for fractures of the hip were prospectively studied. All patients were treated operatively and received the VenaFlow calf compression device on both lower extremities immediately following surgery. Chemical prophylaxis of either aspirin (n = 67) or warfarin (n = 133) was administered in addition to mechanical compression. A noninvasive serial color flow duplex scan was performed 1 to 11 days postoperatively (mean 4.5 days) to determine the presence or absence of deep vein thrombosis. All patients were followed clinically 3 months postoperatively for a clinical evaluation of symptomatic deep vein thrombosis or pulmonary embolism.. Overall, the incidence of deep vein thrombosis was 3.5% (7 of 200) and included only 1 proximal thrombosis (1 out of 200, or 0.5%) and no pulmonary embolism. Five of the 7 patients positive for deep vein thrombosis were in the mechanical compression and warfarin prophylaxis group and 2 were in the aspirin arm of the study. For patients with deep vein thrombosis, the average number of risk factors was 3.71, whereas patients without clots averaged 1.75 clinical risk factors (P < or = 0.05). Three patients in the warfarin group developed bleeding complications (1 with a gastrointestinal bleed and 2 with minor bleeding not at the operative site). No evidence of a symptomatic deep vein thrombosis or pulmonary embolism was reported within a 3-month period following hospitalization.. Our findings suggest mechanical compression with the VenaFlow calf compression device in conjunction with chemoprophylaxis is an effective means of reducing thromboembolic disease in this high-risk population.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Female; Femoral Neck Fractures; Heparin; Hip Fractures; Humans; Male; Prospective Studies; Pulmonary Embolism; Risk Factors; Ultrasonography, Doppler, Duplex; Venous Thrombosis; Warfarin

The management of patients admitted with a fracture requiring surgery who are taking warfarin anticoagulation is unclear. We examined the anticoagulation management for 33 hip fracture patients on warfarin at the time of admission. Hospital course and complications were recorded on all patients. The mean INR on admission was 3.2 and prior to surgery 2.2. Eight patients (24%) had percutaneous cancellous screws for an intracapsular fracture regardless of the admission INR. In 21 (64%) patients, surgery was delayed whilst the INR came down, with an average delay of 72 h from admission to surgery. No specific treatment to lower the INR, other than wait and watch policy adopted in 11 (33%) of these patients. Pharmacological methods used to reduce the INR were fresh frozen plasma in nine cases, and intravenous Vitamin K in four patients. One patient died from post-operative haematemesis and three died from medical complications unrelated to the warfarin therapy. There were no wound haematomas or other bleeding complications. Delaying surgery whilst waiting for the INR to fall to acceptable levels may result in significant delays to surgery and we would recommend a more aggressive policy to enable earlier surgery.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Atrial Fibrillation; Female; Hip Fractures; Humans; International Normalized Ratio; Male; Middle Aged; Plasma; Postoperative Complications; Preoperative Care; Prospective Studies; Risk Factors; Time Factors; Vitamin K; Warfarin

To ascertain the relationship between warfarin therapy and subsequent hip fracture in a large elderly population.. Retrospective, population-based cohort study.. Population-based health care administrative databases for Ontario, Canada.. Elderly patients receiving warfarin (52,701 patients), thyroid replacement therapy (40,555), an oral corticosteroid (43,915), or a proton pump inhibitor (60,383). The proton pump inhibitor group served as controls.. The association between warfarin therapy and subsequent hospitalization for hip fracture in elderly patients was examined by researching administrative data from January 1, 1994-March 31, 1999, for the elderly population of Ontario. Relative to patients receiving proton pump inhibitors, patients receiving warfarin (adjusted risk ratio [aRR] 0.94, 95% confidence interval [CI] 0.81-1.09) or thyroid replacement therapy (aRR 1.02, 95% Cl 0.89-1.18) incurred similar risks of hip fracture. As expected, patients receiving oral corticosteroids incurred an increased risk (aRR 1.44, 95% CI 1.21-1.70) relative to patients receiving proton pump inhibitors.. Warfarin was not associated with increased risk of hip fracture.

Topics: Adrenal Cortex Hormones; Aged; Anti-Ulcer Agents; Cohort Studies; Female; Hip Fractures; Humans; Male; Ontario; Proton Pump Inhibitors; Retrospective Studies; Risk; Thyroid Hormones; Warfarin

The occurrence of deep vein thrombosis (DVT) following cases of major trauma, in particular pelvic and hip fracture, has ranged from 36% to 60%, depending on the study quoted and the method of detection. The frequency of fatal pulmonary embolism (PE) has been reported as 0.5%-12.9% of the cases. A retrospective study of 1000 consecutive hip fracture patients in a community hospital setting reveals that 95% received a combination of mechanical and pharmacologic prophylaxis for prevention of DVT. Sixty-one patients were excluded for insufficient data, leaving 939 for analysis. There were 724 female patients with an average age of 83 years and 215 male patients with an average age of 78 years. Fifty-one patients (18.4%) received no prophylaxis in the eligible population. Three hundred eighty-seven patients (41.2%) received only aspirin as the pharmacologic agent for anticoagulation. Four hundred twenty-nine patients (45.6%) were treated with the low-molecular-weight heparin (LMWH), enoxaparin. Ten patients (1.1%) received heparin for anticoagulation and 17 patients (1.8%) were treated with warfarin. A total of 43 patients received a combination of therapies. Four hundred ninety-five of the patients used concomitant intermittent pneumatic compression in addition to pharmacologic prophylaxis. There were 15 perioperative deaths from all causes, including five cases of DVT two distal and three proximal). One distal DVT occurred prior to surgery. A second distal DVT and one fatal PE occurred in the aspirin group. The rates of minor bleeding complications in the aspirin group, the < 12-hour postoperative dosing of the enoxaparin group, and the 12 to 24-hour postoperative dosing of the enoxaparin group were 3.1%, 5.7%, and 2.8%, respectively. There were no major bleeds in the aspirin group and 0.9% in the enoxaparin group. The LMWH group also had two proximal DVTs but no PEs. The combination of a relatively short half-life, predictable pharmacokinetics, and favorable safety profile makes enoxaparin an excellent drug for use in hip fracture patients. Additional trials will be necessary to establish an optimal duration of prophylaxis in this population.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Cohort Studies; Enoxaparin; Female; Fracture Fixation, Internal; Hip Fractures; Humans; Incidence; Injury Severity Score; Male; Middle Aged; Postoperative Complications; Prognosis; Pulmonary Embolism; Retrospective Studies; Risk Factors; Survival Rate; Treatment Outcome; Venous Thrombosis; Warfarin

Patients undergoing hip fracture repair are at significant risk for deep vein thrombosis and pulmonary embolism in the postoperative period without appropriate prophylaxis. Agents available in the United States that have undergone clinical trials as pharmacoprophylaxis for this indication include warfarin, dalteparin, and danaparoid. Safety and efficacy data from these trials were used to determine the most cost-effective agent for routine deep vein thrombosis prophylaxis in patients with hip fractures. Incremental cost-effectiveness ratio calculations demonstrate that warfarin dosed to an international normalized ratio of 2-2.7 is currently the most cost-effective agent in these patients.

Topics: Anticoagulants; Cost-Benefit Analysis; Dalteparin; Hip Fractures; Humans; Leg; Postoperative Complications; Venous Thrombosis; Warfarin

Warfarin is considered as a narrow therapeutic drug-an agent for which small changes in dosage can lead to significant changes in response. The precision of warfarin treatment is especially relevant in an acute-care setting. In this study, we examined the effect of various risk factors on warfarin response in the early postoperative period after total joint arthroplasty and hip fracture fixation. A total of 260 patients placed on warfarin for thrombosis prophylaxis were retrospectively studied. Risk factors for warfarin sensitivity include age 80 years or older and hip fracture fixation. Patients aged 80 years or older who had hip fracture fixation were 4.7 times more likely to experience an international normalized ratio (INR) at or greater than 4.0 than other patients (therapeutic target range of INR, 1.8-2.2). The largest subtherapeutic risk group in this study were men weighing 180 lb or more. They were 5.7 times less likely to achieve an INR of 1.6 than the other patients. Factors such as body weight, age, and gender should be considered when ordering warfarin therapy. Current hospital warfarin sliding scales should be reviewed for their efficacy to ensure that the target outcome is achieved.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Hip Fractures; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Thrombosis; Venous Thrombosis; Warfarin

Controversy exists as to whether patient age, either independently or as a marker of concomitant illness or medication use, is associated with the dose or complication rate of warfarin prophylaxis. The aim of this study was to assess this relationship in patients receiving warfarin prophylaxis after hip fracture repair.. We undertook a retrospective cohort study of 215 patients 55 years of age or greater who underwent surgery for a fractured hip between January 1, 1990, and December 31, 1991, and received warfarin prophylaxis. The mean age was 78.9 (SD 9.5) years. The average daily warfarin dose, the decrease in hemoglobin in the postoperative period, and the rate of bleeding complications were assessed.. Elderly patients required a significantly lower average daily warfarin dose than younger patients. This effect persisted even after controlling for the number of medical conditions, number of medications on admission, proportion of time the international normalized ration (INR) was in therapeutic range, and gender. Postoperative hemoglobin decrease was associated with patient age as well as with the use of antibiotics postoperatively. Factors associated with bleeding complications included a history of alcohol abuse and a smaller proportion of time spent in the targeted anticoagulant range.. Older age itself and not as a marker for polypharmacy or increased number of medical conditions is associated with lower requirements for warfarin and a greater hemoglobin decrease postoperatively even when the proportion of time the INR fell within the therapeutic range is controlled. Advanced patient age, in this study, was not associated with an increased incidence of bleeding complications.

Topics: Age Factors; Aged; Aged, 80 and over; Cohort Studies; Comorbidity; Female; Hemorrhage; Hip Fractures; Humans; Male; Middle Aged; Retrospective Studies; Risk Factors; Thrombosis; Warfarin

Topics: Aged; Female; Fracture Fixation, Internal; Hip Fractures; Humans; Necrosis; Postoperative Complications; Skin; Thromboembolism; Warfarin

Topics: Aged; Aged, 80 and over; Anti-Inflammatory Agents, Non-Steroidal; Drug Combinations; Female; Gastrointestinal Hemorrhage; Hip Fractures; Humans; Ketorolac Tromethamine; Tolmetin; Tromethamine; Warfarin