Direct Oral Anticoagulants vs Low-Molecular-Weight Heparin for Thromboprophylaxis in Nonoperative Pelvic Fractures.

Abstract

Patients with pelvic fractures are prone to venous thromboembolic (VTE) complications. Recent literature shows superiority of direct oral anticoagulants (DOACs) over low-molecular-weight heparin (LMWH) for thromboprophylaxis in patients undergoing orthopaedic operations. The aim of our study was to compare in-hospital outcomes for DOACs vs LMWH in patients with nonoperative pelvic fractures. We performed a 2-year (2015 to 2016) analysis of the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database. We included all adult patients with isolated blunt pelvic fractures who were managed nonoperatively and received thromboprophylaxis with either LMWH or DOACs (Factor-Xa inhibitor or direct thrombin inhibitor). Patients were divided into 2 groups based on receipt of DOACs vs LMWH and were propensity-score-matched in a 1:2 ratio to control for possible confounding factors. Primary outcomes were deep venous thrombosis (DVT) and/or pulmonary embolism (PE). Secondary outcomes were pRBC transfusions, intervention for hemorrhage control, and in-hospital mortality after initiation of thromboprophylaxis. We identified 20,692 patients with pelvic fractures. There were 7,312 patients with isolated pelvic fractures included, 852 of whom were matched (DOACs: 284; LMWH: 568). Mean age was 43.2 ± 15 years, median Injury Severity Score was 14 (range 10 to 18). Matched groups were similar in demographics, vital signs, injury parameters, and timing of initiation of thromboprophylaxis. Overall, 5.2% of patients had DVT, 1.4% PE, and 1.3% died. Patients who received DOACs were less likely to develop DVT (1.8% vs 6.9%, p < 0.01) compared with LMWH. There was no difference in PE (p = 0.85) or in-hospital mortality (p = 0.79) between the 2 groups. Similarly, there was no difference in post-prophylaxis blood transfusion, and post-prophylaxis intervention for hemorrhage control. In patients with nonoperative pelvic fractures, DOACs were associated with a reduced rate of DVT vs LMWH without increasing the risk of bleeding complications. No association was found between the type of thromboprophylactic agent and rates of PE or in-hospital mortality.