학술논문
Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study
Document Type
Academic Journal
Author
Anandalwar, Seema P.; O’Meara, Lindsay; Vesselinov, Roumen; Zhang, Ashling; Baum, Jeffrey N.; Cooper, Amanda; Decker, Cassandra; Schroeppel, Thomas; Cai, Jenny; Cullinane, Daniel; Catalano, Richard D.; Bugaev, Nikolay; LeClair, Madison; Feather, Christina; McBride, Katherine; Sams, Valerie; Leung, Pak Shan; Olafson, Samantha; Callahan, Devon S.; Posluszny, Joseph; Moradian, Simon; Estroff, Jordan; Hochman, Beth; Coleman, Natasha; Goldenberg-Sandau, Anna; Nahmias, Jeffry; Rosenbaum, Kathryn; Pasley, Jason; Boll, Lindsay; Hustad, Leah; Reynolds, Jessica; Truitt, Michael; Ghneim, Mira
Source
Journal of Trauma and Acute Care Surgery. Apr 10, 2024
Subject
Language
English
ISSN
2163-0755
Abstract
INTRODUCTION: To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use. METHODS: Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were. CONCLUSIONS: Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.