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Abstract：
BACKGROUND: Compliance with perioperative anticoagulation guidelines is essential to minimize bleeding and thromboembolic risks in patients undergoing surgery. Compared to vitamin-K antagonists (VKAs), perioperative management of direct oral anticoagulants (DOACs) contains fewer steps. Therefore, we hypothesized that noncompliance with guidelines in VKA users is higher than in DOAC users. The primary aim of our study was to investigate the difference in noncompliance to perioperative anticoagulant management guidelines between elderly patients using VKAs versus those using DOACs. The secondary aim was to determine the difference in occurrence of conflicting information communicated to the patients and the difference in incidence of coagulation-related adverse events.
METHODS: This retrospective non-controlled observational cohort study examined elderly patients undergoing elective orthopedic surgery in a teaching hospital in the Netherlands. All patients undergoing elective orthopedic surgery between 1 May 2016 and 1 January 2020, aged 70 years and over, using VKAs or DOACs were selected. Nonelective surgeries were excluded. The primary outcome was the noncompliance to perioperative anticoagulant management guidelines. Secondary outcomes were missing or conflicting information on anticoagulation management communicated to the patient and coagulation-related adverse events. For continuous data, the unpaired T-test was used and for categorical data, the chi-square test.
RESULTS: In patients using VKAs, noncompliance to one of the steps of perioperative anticoagulation management was 81%, compared to 55% in patients using DOACs (p < 0.001). In most cases, VKAs or DOACs were interrupted for longer than recommended. In 13% of patients using a VKA with perioperative bridging, bridging was not conducted as recommended in the guidelines. In 13% of patients using a DOAC, a low-molecular-weight heparin (LMWH) was prescribed while a DOAC had already been restarted postoperatively. VKA users received conflicting information about perioperative anticoagulation management more often than DOAC users (33% versus 20%; p < 0.001). No difference was seen in postoperative coagulation-related complications.
CONCLUSIONS: Guidelines compliance in DOAC users is higher than in VKA users. Clinical decision support to help in selecting the right interruption interval in DOAC users, simplified standardized perioperative management, good coordination of instructions given to patients, and familiarity with updated guidelines are important in reducing noncompliance.
METHODS: This retrospective non-controlled observational cohort study examined elderly patients undergoing elective orthopedic surgery in a teaching hospital in the Netherlands. All patients undergoing elective orthopedic surgery between 1 May 2016 and 1 January 2020, aged 70 years and over, using VKAs or DOACs were selected. Nonelective surgeries were excluded. The primary outcome was the noncompliance to perioperative anticoagulant management guidelines. Secondary outcomes were missing or conflicting information on anticoagulation management communicated to the patient and coagulation-related adverse events. For continuous data, the unpaired T-test was used and for categorical data, the chi-square test.
RESULTS: In patients using VKAs, noncompliance to one of the steps of perioperative anticoagulation management was 81%, compared to 55% in patients using DOACs (p < 0.001). In most cases, VKAs or DOACs were interrupted for longer than recommended. In 13% of patients using a VKA with perioperative bridging, bridging was not conducted as recommended in the guidelines. In 13% of patients using a DOAC, a low-molecular-weight heparin (LMWH) was prescribed while a DOAC had already been restarted postoperatively. VKA users received conflicting information about perioperative anticoagulation management more often than DOAC users (33% versus 20%; p < 0.001). No difference was seen in postoperative coagulation-related complications.
CONCLUSIONS: Guidelines compliance in DOAC users is higher than in VKA users. Clinical decision support to help in selecting the right interruption interval in DOAC users, simplified standardized perioperative management, good coordination of instructions given to patients, and familiarity with updated guidelines are important in reducing noncompliance.
摘要：
背景：遵守围手术期抗凝指南对于减少手术患者的出血和血栓栓塞风险至关重要。与维生素K拮抗剂（VKAs）相比，直接口服抗凝药(DOACs)的围手术期处理步骤较少.因此,我们假设VKA用户不符合指南的情况高于DOAC用户。我们研究的主要目的是调查使用VKAs的老年患者与使用DOAC的老年患者在不遵守围手术期抗凝管理指南方面的差异。次要目的是确定传达给患者的冲突信息的发生率差异以及凝血相关不良事件的发生率差异。
方法：这项回顾性非对照观察性队列研究调查了在荷兰一家教学医院接受择期骨科手术的老年患者。2016年5月1日至2020年1月1日期间接受择期骨科手术的所有患者，年龄70岁及以上，选择使用VKAs或DOAC。非选择性手术被排除。主要结果是不符合围手术期抗凝治疗指南。次要结局是与患者沟通的抗凝管理信息缺失或冲突以及凝血相关不良事件。对于连续数据，使用不成对T检验，对于分类数据，卡方检验。
结果：在使用VKAs的患者中，对围手术期抗凝管理步骤之一的不依从性为81%,相比之下，使用DOAC的患者为55%(p<0.001)。在大多数情况下,VKAs或DOAC中断的时间比建议的时间长。在13％的患者使用VKA围手术期桥接，没有按照指南中的建议进行桥接.13%的患者使用DOAC,在DOAC已经在术后重新开始的情况下,使用低分子量肝素(LMWH).与DOAC用户相比，VKA用户更经常收到关于围手术期抗凝管理的相互矛盾的信息(33%对20%;p<0.001)。术后凝血相关并发症无差异。
结论：DOAC用户的指南合规性高于VKA用户。临床决策支持有助于在DOAC用户中选择正确的中断间隔，简化的标准化围手术期管理，给患者的指导协调良好，和熟悉更新的指导方针是重要的，以减少不遵守。
方法：这项回顾性非对照观察性队列研究调查了在荷兰一家教学医院接受择期骨科手术的老年患者。2016年5月1日至2020年1月1日期间接受择期骨科手术的所有患者，年龄70岁及以上，选择使用VKAs或DOAC。非选择性手术被排除。主要结果是不符合围手术期抗凝治疗指南。次要结局是与患者沟通的抗凝管理信息缺失或冲突以及凝血相关不良事件。对于连续数据，使用不成对T检验，对于分类数据，卡方检验。
结果：在使用VKAs的患者中，对围手术期抗凝管理步骤之一的不依从性为81%,相比之下，使用DOAC的患者为55%(p<0.001)。在大多数情况下,VKAs或DOAC中断的时间比建议的时间长。在13％的患者使用VKA围手术期桥接，没有按照指南中的建议进行桥接.13%的患者使用DOAC,在DOAC已经在术后重新开始的情况下,使用低分子量肝素(LMWH).与DOAC用户相比，VKA用户更经常收到关于围手术期抗凝管理的相互矛盾的信息(33%对20%;p<0.001)。术后凝血相关并发症无差异。
结论：DOAC用户的指南合规性高于VKA用户。临床决策支持有助于在DOAC用户中选择正确的中断间隔，简化的标准化围手术期管理，给患者的指导协调良好，和熟悉更新的指导方针是重要的，以减少不遵守。
