华法林而非直接口服抗凝剂或抗血小板治疗与急诊普通外科患者出血风险增加相关：新型抗凝药物时代的意义：EAST 多中心研究。
Warfarin, not direct oral anticoagulants or 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.
机构信息
From the Program in Trauma (M.G.), R Adams Cowley Shock Trauma Center, (S.P.A., L.O, A.Z.), University of Maryland; Department of Trauma Surgery (S.P.A., L.O., A.Z., M.G.) and Department of Epidemiology and Public Health (R.V.), University of Maryland Medical Center, Baltimore, Maryland; Department of Surgery, Mount Sinai South Nassau (J.N.B.), Oceanside, New York; Department of Surgery (A.C.), Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Department of Surgery (C.D., T.S.), UCHealth Memorial Hospital, Colorado Springs, Colorado; Department of Surgery (J.C.), Robert Wood Johnson Medical School, New Brunswick, New Jersey; Marshfield Clinic (D.C.), Marshfield, Wisconsin; Loma Linda University School of Medicine, Department of Surgery (R.D.C.), Loma Lina, California; Tufts Medical Center, Department of Surgery (N.B., M.L.), Tufts University School of Medicine, Boston, Massachusetts; Anne Arundel Medical Center, Department of Surgery (C.F.), Parole, Maryland; Memorial Health University Medical Center, Department of Surgery (K.M.), Savannah, Georgia; Brooke Army Medical Center, Department of Surgery (V.S.), Fort Sam Houston, Texas; Sidney Kimmel Medical College, Department of Surgery (P.S.L., S.O.), Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Surgery (D.S.C.), Allina Health/Abbott Northwestern Hospital, Minneapolis, Minnesota; Department of Surgery (J.P., S.M.), Northwestern University, Evanston, Illinois; Department of Surgery (J.E.), George Washington University, Washington, DC; Columbia University Irving Medical Center, Department of Surgery (B.H., N.C.), New York, New York; Cooper University (A.G.-S.), Camden, New Jersey; University of California Irvine Medical Center, Department of Surgery (J.N., K.R.), Irvine, California; McLaren Oakland Hospital, Department of Surgery (J.P., L.B.), Pontiac, Michigan; Sanford Health, Department of Surgery (L.H.), Sioux Falls, South Dakota; University of Kentucky Medical Center, Department of Surgery (J.R.), Lexington, Kentucky; Methodist Medical Center, Department of Surgery (M.T.), Dallas, Texas.
出版信息
J Trauma Acute Care Surg. 2024 Aug 1;97(2):225-232. doi: 10.1097/TA.0000000000004278. Epub 2024 Apr 10.
INTRODUCTION
This study aimed to assess perioperative bleeding complications and in-hospital mortality in patients requiring emergency general surgery presenting with a history of antiplatelet (AP) versus direct oral anticoagulant (DOAC) versus warfarin use.
METHODS
A prospective observational study across 21 centers between 2019 and 2022 was conducted. Inclusion criteria were age 18 years or older, and DOAC, warfarin, or AP use within 24 hours of an emergency general surgery procedure. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using analysis of variance, χ 2 , and multivariable regression models.
RESULTS
Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, and 40 (9.7%) warfarin use. The most common indications for surgery were obstruction (23% [AP], 45% [DOAC], and 28% [warfarin]), intestinal ischemia (13%, 17%, and 23%), and diverticulitis/peptic ulcers (7%, 7%, and 15%). Compared with DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (odds ratio [OR], 4.4 [95% confidence interval (CI), 2.0-9.9]). There was no significant difference in perioperative bleeding complication between DOAC and AP use (OR, 0.7 [95% CI, 0.4-1.1]). Compared with DOAC use, there was no significant difference in mortality between warfarin use (OR, 0.7 [95% CI, 0.2-2.5]) or AP use (OR, 0.5 [95% CI, 0.2-1.2]). After adjusting for confounders, warfarin use (OR, 6.3 [95% CI, 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 [95% CI, 0.39-4.7]), whereas intraoperative vasopressor use (OR, 4.7 [95% CI, 1.7-12.8]), medical history, and postoperative bleeding (OR, 5.5 [95% CI, 2.4-12.8]) were.
CONCLUSION
Despite ongoing concerns about the increase in DOAC use and 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 and comorbidities rather than type of AP or anticoagulant use.
LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level III.
简介
本研究旨在评估因紧急普通外科手术而需要接受治疗的患者中，围手术期出血并发症和院内死亡率在抗血小板（AP）、直接口服抗凝剂（DOAC）和华法林用药史患者中的差异。
方法
在 2019 年至 2022 年期间，在 21 个中心进行了一项前瞻性观察性研究。纳入标准为年龄在 18 岁或以上，且在紧急普通外科手术前 24 小时内使用过 DOAC、华法林或 AP。研究的主要结局为围手术期出血和院内死亡率。研究采用方差分析、卡方检验和多变量回归模型进行分析。
结果
在 413 名患者中，221 名（53.5%）报告使用 AP，152 名（36.8%）报告使用 DOAC，40 名（9.7%）报告使用华法林。手术的最常见指征为梗阻（AP 组占 23%，DOAC 组占 45%，华法林组占 28%）、肠缺血（13%，17%和 23%）和憩室炎/消化性溃疡（7%，7%和 15%）。与 DOAC 组相比，华法林组的围手术期出血并发症显著更高（比值比[OR]，4.4[95%置信区间（CI），2.0-9.9]）。DOAC 组和 AP 组的围手术期出血并发症无显著差异（OR，0.7[95%CI，0.4-1.1]）。与 DOAC 组相比，华法林组的死亡率无显著差异（OR，0.7[95%CI，0.2-2.5]），AP 组也无显著差异（OR，0.5[95%CI，0.2-1.2]）。在调整混杂因素后，华法林使用（OR，6.3[95%CI，2.8-13.9]）、医疗史和手术指征与围手术期出血并发症的增加相关。然而，华法林与死亡率增加无独立相关性（OR，1.3[95%CI，0.39-4.7]），而术中使用血管加压素（OR，4.7[95%CI，1.7-12.8]）、医疗史和术后出血（OR，5.5[95%CI，2.4-12.8]）则与死亡率增加有关。
结论
尽管人们一直对 DOAC 使用增加和缺乏可用的逆转剂感到担忧，但本研究表明，华法林而非 DOAC 与更高的围手术期出血并发症相关。然而，这种风险并未导致死亡率增加，这表明围手术期决策应根据患者的疾病和合并症，而非抗血小板药物或抗凝药物的使用类型来决定。
证据等级
预后和流行病学；III 级。
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