Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma

Feeney, James M.; Neulander, Matthew; DiFiori, Monica; Kis, Lilla; Shapiro, David S.; Jayaraman, Vijay; Marshall, William T.; Montgomery, Stephanie C.

doi:10.1016/j.injury.2016.08.016

Cited by 40 publications

(18 citation statements)

References 11 publications

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“…In line with our findings, Feeney et al also reported a higher mortality in 162 TBI patients with concomitant VKA intake than in DOAC patients. In the VKA group, the need for surgical interventions (26.7% vs. 8.2%, p = 0.023) and mortality (20.9% vs. 4.9%, p < 0.008) were significantly higher than in the DOAC group [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old

Prexl

Bruckbauer

Voelckel

et al. 2018

Scand J Trauma Resusc Emerg Med

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BackgroundTraumatic brain injury (TBI) is the leading cause of death among trauma patients. Patients under antithrombotic therapy (ATT) carry an increased risk for intracranial haematoma (ICH) formation. There is a paucity of data about the role of direct oral anticoagulants (DOACs) among TBI patients.MethodsIn this retrospective study, we investigated all TBI patients ≥60-years-old who were admitted to the intensive care unit (ICU) from January 2014 until May 2017. Patients were grouped into those receiving vitamin K antagonists (VKA), platelet inhibitors (PI), DOACs and no antithrombotic therapy (no-ATT).ResultsOne-hundred-eighty-six, predominantly male (52.7%) TBI patients with a median age of 79 years (range: 70–85 years) were enrolled in the study. Glasgow Coma Scale and S-100β were not different among the groups. Patients on VKA and DOACs had a higher Charlson Comorbidity Index compared to the PI group and no-ATT group (p = 0.0021). The VKA group received reversal agents significantly more often than the other groups (p < 0.0001). Haematoma progression in the follow-up cranial computed tomography (CCT) was lowest in the DOAC group. The number of CCT and surgical interventions were low with no differences between the groups. No relevant differences in ICU and hospital length of stay were observed. Mortality in the VKA group was significantly higher compared to DOAC, PI and no-ATT group (p = 0.047).DiscussionData from huge registry studies displayed higher efficacy and lower fatal bleeding rates for DOACs compared to VKAs. The current study revealed comparable results. Despite the fact that TBI patients on VKAs received reversal agents more often than patients on DOACs (84.4% vs. 24.2%, p < 0.001), mortality rate was significantly higher in the VKA group (p = 0.047).ConclusionIn patients ≥60 years suffering from TBI, anticoagulation with DOACs appears to be safer than with VKA. Anti-thrombotic therapy with VKA resulted in a worse outcome compared to DOACs and PI. Further studies are warranted to confirm this finding.

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Section: Discussionmentioning

confidence: 99%

The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old

Prexl

Bruckbauer

Voelckel

et al. 2018

Scand J Trauma Resusc Emerg Med

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“…One theory is the increasing use of the new oral anticoagulants, which are challenging to reverse. Recent studies, however, suggest that these medications are actually improving outcomes in injured trauma patients . Perhaps this mortality increase is simply a reflection of an aging U.S. population with increasing comorbidities .…”

Section: Discussionmentioning

confidence: 99%

The Epidemiology of Emergency Department Trauma Discharges in the United States

DiMaggio

Avraham

Lee

et al. 2017

Academic Emergency Medicine

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Objective Injury related morbidity and mortality is an important emergency medicine and public health challenge in the United States (US). Here we describe the epidemiology of traumatic injury presenting to US emergency departments, define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries. Methods We conducted a secondary retrospective, repeated cross-sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all-payer emergency department survey database in the US. Main outcomes and measures were survey-adjusted counts, proportions, means, and rates with associated standard errors, and 95% confidence intervals. We plotted annual age-stratified emergency department discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level 1 or 2 trauma center care with injury fatality using a multi-variable survey-adjusted logistic regression analysis that controlled for age, gender, injury severity, comorbid diagnoses, and teaching hospital status. Results There were 181,194,431 (standard error, se = 4234) traumatic injury discharges from US emergency departments between 2006 and 2012. There was an average year-to-year decrease of 143 (95% CI -184.3, -68.5) visits per 100,000 US population during the study period. The all-age, all-cause case-fatality rate for traumatic injuries across US emergency departments during the study period was 0.17% (se = 0.001). The case-fatality rate for the most severely injured averaged 4.8% (se = 0.001), and severely injured patients were nearly four times as likely to be seen in Level 1 or 2 trauma centers (relative risk = 3.9 (95% CI 3.7, 4.1)). The unadjusted risk ratio, based on group counts, for the association of Level 1 or 2 trauma centers with mortality was RR = 4.9 (95% CI 4.5, 5.3), however, after accounting for gender, age, injury severity and comorbidities, Level 1 or 2 trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 (0.79, 1.18)). There were notable changes at the extremes of age in types and causes of emergency department discharges for traumatic injury between 2009 and 2012. Age-stratified rates of diagnoses of traumatic brain injury increased 29.5% (se = 2.6) for adults older than 85, and increased 44.9% (se = 1.3) for children younger than 18. Firearm related injuries increased 31.7% (se = 0.2) in children five years and younger. The total inflation-adjusted cost of emergency department injury care in the US between 2006 and 2012 was $99.75 billion (se = 0.03). Conclusions Emergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the US. Level 1 or 2 trauma centers remain a bulwark against the tide of severe trauma in the US. But, the types and caus...

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“…A study of 162 patients on preinjury anticoagulant therapy with blunt traumatic injuries and an AIS head score of < 4 found a significantly lower mortality in patients taking DOACs (4.9%) as compared to warfarin (20.8%). 27 Similiarly, a study looking at 186 older adults with TBI on preinjury anticoagulants and found an increased in-hospital mortality with warfarin as compared to DOACs despite adequate reversal agent administration in the warfarin group. 28 Our study, as well as those previously reported, should serve as hypothesis generating for a larger analysis directly comparing preinjury warfarin to DOAC.…”

Section: Author Manuscriptmentioning

confidence: 99%

Effect of Preinjury Oral Anticoagulants on Outcomes Following Traumatic Brain Injury from Falls in Older Adults

et al. 2020

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Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma

Cited by 40 publications

References 11 publications

The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old

The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old

The Epidemiology of Emergency Department Trauma Discharges in the United States

Effect of Preinjury Oral Anticoagulants on Outcomes Following Traumatic Brain Injury from Falls in Older Adults

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