Antithrombotic Therapy and Mortality Risk in Older Adults with Hip Fractures

Objectives: Antithrombotic therapy, including antiplatelet therapy, direct oral anticoagulants (DOACs), and vitamin K antagonists (VKAs), is increasingly prescribed. These therapies pose complex challenges in patients with hip fracture due to risks of bleeding, risks of thromboembolism, and their potential role as markers of frailty. However, limited real-world evidence exists regarding their risks and benefits in this population. This retrospective cohort study examines the association between antithrombotic therapy and mortality in older patients with hip fracture. Design: Retrospective cohort study. Setting and Participants: Patients with hip fracture admitted to a level 1 trauma center between January 2021 and December 2022. Methods: Data on clinical characteristics, antithrombotic therapy, and outcomes were collected from health records. Mortality was analyzed using Kaplan-Meier curves and Cox proportional hazards regression, adjusting for age, sex, comorbidity, functional status, surgery, kidney function, body mass index, and nursing home residency. Secondary outcomes included transfusion rates and thromboembolic events. Results: Among 526 patients (median age, 82 years; 69% female), 1-year mortality rates were 14.3% for no antithrombotic therapy, 21.0% for antiplatelet therapy, 26.4% for DOACs, and 48.9% for VKAs. At 2 years, mortality rates increased to 20.9%, 30.4%, 32.1%, and 61.7%, respectively (log-rank P < .001). In the fully adjusted model, the mortality risks associated with antiplatelet therapy [hazard ratio (HR), 0.71; 95% CI, 0.45-1.12] and DOACs (HR, 0.99; 95% CI, 0.54-1.81) were no longer significant compared with patients without antithrombotic therapy, whereas VKAs remained significantly associated with increased mortality (HR, 2.17; 95% CI, 1.22-3.83). Secondary outcomes revealed that all antithrombotic therapies were linked to delayed surgery and higher transfusion rates. However, neither delayed surgery nor transfusions independently predicted mortality. Conclusions and Implications: VKA use is associated with significantly higher mortality in older patients with hip fracture and may identify a subset at substantial risk of poor outcomes. These findings underscore the need for careful assessment and management of VKA users and further research to confirm these observations.