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

Seema P. Anandalwar, Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland.
Lindsay O'Meara, Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland.
Roumen Vesselinov, Department of Epidemiology & Public Health, University of Maryland Medical Center, Baltimore Maryland.
Ashling Zhang, Department of Trauma Surgery, University of Maryland Medical Center, Baltimore, Maryland.
Jeffrey N. Baum, Mount Sinai South Nassau, Oceanside, New York.
Amanda Cooper, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
Cassandra Decker, Department of Surgery, UCHealth Memorial Hospital, Colorado Springs.
Thomas Schroeppel, Department of Surgery, UCHealth Memorial Hospital, Colorado Springs.
Jenny Cai, Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey.
Daniel Cullinane, Marshfield Clinic, Marshfield, Wisconsin.
Richard D. Catalano, Loma Linda University School of Medicine, Loma Lina, California.
Nikolay Bugaev, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts.
Madison LeClair, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts.
Christina Feather, Anne Arundel Medical Center, Parole Maryland.
Katherine McBride, Memorial Health University Medical Center, Savannah, Georgia.
Valerie Sams, Brooke Army Medical Center, Fort Sam Houston, Texas.
Pak Shan Leung, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
Samantha Olafson, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
Devon S. Callahan, Department of Surgery, Allina Health/Abbott Northwestern Hospital, Minneapolis, Minnesota.
Joseph Posluszny, Separtment of Surgery, Northwestern University, Evanston, Illinois.
Simon Moradian, Separtment of Surgery, Northwestern University, Evanston, Illinois.
Jordan Estroff, Department of Surgery, George Washington University, Washington D.C.
Beth Hochman, Columbia University Irving Medical Center, New York, New York.
Natasha Coleman, Columbia University Irving Medical Center, New York, New York.
Anna Goldenberg-Sandau, Cooper University, Camden, New Jersey.
Jeffry Nahmias, University of California Irvine Medical Center, Irvine, California.
Kathryn Rosenbaum, University of California Irvine Medical Center, Irvine, California.
Jason Pasley, McLaren Oakland Hospital, Pontiac, Michigan.
Lindsay Boll, McLaren Oakland Hospital, Pontiac, Michigan.
Leah Hustad, Sanford Health, Sioux Falls, South Dakota.
Jessica Reynolds, University of Kentucky Medical Center, Lexington Kentucky.
Michael Truitt, Methodist Medical Center, Dallas, Texas.

Document Type

Journal Article

Publication Date

4-10-2024

Journal

The journal of trauma and acute care surgery

DOI

10.1097/TA.0000000000004278

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.

Department

Surgery

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