Fri., 10/9/09 Hip & Geriatric, Paper #40, 10:31 am OTA-2009
Complications Associated with Pharmacologic Reversal of Warfarin-Associated Coagulopathy in Patients with Hip Fractures
Mark A. Vitale, MD, MPH (n); Corrine Vanbeek, MD (n); Jeffrey A. Geller, MD (n);
Columbia University Medical Center, Department of Orthopaedic Surgery,
Hip Fracture Service, New York, New York, USA
Purpose: Patients with hip fractures who take chronic warfarin for anticoagulation present a significant challenge and their management remains controversial. The purpose of this study was to assess both thromboembolic as well as systemic complications associated with pharmacological reversal of warfarin-associated coagulopathy in a well-defined cohort of patients with operative hip fractures.
Methods: This case-control study retrospectively identified patients with operative hip fractures (OTA types 31-A, B, and C) on warfarin and with an international normalized ratio (INR) ≥1.5 on admission over a 10-year period at our institution. This identified 86 patients out of a possible 1,634 total admissions with operative hip fractures. The control (“watch-and-wait”) group consisted of patients whose warfarin was held upon admission without further intervention (n = 21). The treatment (“pharmacological intervention”) group consisted of patients who underwent pharmacological reversal of elevated INR (with vitamin K and/or fresh-frozen plasma) in addition to their warfarin being held (n = 65). Primary outcomes included thromboembolic complications such as deep venous thrombosis (DVT) and pulmonary embolism (PE) as well as nonthromboembolic complications and overall mortality within 3 months of presentation. Secondary outcomes included time to surgery, percent correction of INR, and likelihood of transfusion.
Results: The mean age of patients was 81.6 years (SD 9.0). Mean INR values at admission were higher in the control group with a mean of 1.69 (SD 0.60) versus those in the treatment group with a mean of 2.52 (SD 1.06) (P <0.001), although there was no difference in mean INR values between groups just prior to surgery. There was a greater percent correction in INR peak values in the treatment group which had a 44.4% decrease compared to those in the control group, which had a 21.9% decrease (P <0.001). Additionally, the overall delay to surgery was longer in patients in the control group at 4.9 days (SD 6.2) compared to 3.2 days (SD 2.1) in the treatment group (P <0.001). There were no significant differences between the likelihood of DVT, PE, myocardial infarction, stroke, pulmonary edema, wound complication, hematoma, ICU transfer, mortality, or reoperation between groups. There was a difference in the likelihood of postoperative blood transfusion between groups, with patients in the control group having a 28.5% transfusion rate versus a 48.0% transfusion rate in those in the treatment group (P = 0.038).
Conclusion: The increased likelihood of blood transfusion in patients treated with pharmacological reversal likely represents greater baseline coagulopathy. Nonetheless, pharmacological reversal of warfarin-associated coagulopathy appears to be a safe and effective way to prepare patients for operative intervention of hip fractures and is associated with a shorter delay to surgery.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant