Slovenská chirurgia 1/2023

Management of patients with proximal femur fracture treated with antithrombotic and anticoagulant therapy

Patients with proximal femoral fractures are usually polymorbid patients with a history of multiple medications. Approximately one-third of these patients are on antithrombotic or anticoagulants therapy such as antiplatelet agents, vitamin K antagonists, or direct oral anticoagulants. To date, there is no consensus on the perioperative use of antithrombotics in these patients, for whom early surgery is one of the priorities. Studies on the use of antiplatelet agents such as acetylsalicylic acid or clopidogrel in urgent proximal femur fracture surgery have concluded that there is no difference in blood loss or need for transfusion compared with patients without antiplatelet therapy. Even dual therapy (clopidogrel and acetylsalicylic acid) is now not considered a contraindication for early proximal femur fracture surgery. In cases of unexpected or severe bleeding, the antiplatelet effect can be reversed by transfusion of platelet concentrates. Early surgery in the warfarinized population is enabled due to rapid reversal of its effect with repeated administration of vitamin K and repeated checks of INR values. Prothrombin complex concentrates (PCC) may be used when urgent (< 6 hours) reversal of warfarin is required. In patients taking DOAC, the situation is more complex as we cannot use any specific routine tests to assess coagulation levels. The timing of reversal is largely based only on the name of the drug, the time of the last dose, and renal function. However, evidence regarding the use of new antiplatelet drugs (e.g. ticagrelor) and direct oral anticoagulants remains a largely unexplored area in the context of proximal femur fracture surgery. Management of such patients should consider patient and procedure related risk of bleeding and thrombosis.

Keywords: anticoagulants, antiplatelets, proximal femoral fracture