Outcomes of Geriatric Trauma Patients on Preinjury Anticoagulation: A Multicenter Study

Abstract

Outpatient anticoagulation in the geriatric trauma patient is a challenging clinical problem. The aim of this study is to determine clinical outcomes associated with class of preinjury anticoagulants (PA) used by this population. This is a multicenter retrospective cohort study among four Level II trauma centers. A total of 1642 patients were evaluated; 684 patients were on anticoagulation and 958 patients were not. Patients on PA were compared with those who were not. Drug classes were divided into thromboxane A2 inhibitors, vitamin K factor-dependent inhibitors, antithrombin III activation, platelet P2Y12 inhibitors, and thrombin inhibitors. Multivariate regression was used to adjust for age, gender, race, mechanism of injury, and Injury Severity Score. No single or combination of anticoagulation agents had a significant association with mortality; however, there were positive trends toward increased mortality were noted for all antiplatelet groups involving thromboxane A2 inhibitors and platelet P2Y12 inhibitors classes. The likelihood of complications was significantly higher with platelet P2Y12 inhibitors adjusted odds ratio (aOR) 2.39 [95% confidence interval (CI) 1.32, 4.3]. The likelihood of blood transfusion was increased with vitamin K inhibitors aOR 2.89 (95% CI 1.3, 6.5), P2Y12 inhibitors aOR 2.76 (95% CI 1.12, 6.76), and combined thromboxane A2 and P2Y12 inhibitors aOR 2.89 (95% CI 1.13, 7.46). P2Y12 inhibitors were also more likely associated with traumatic brain injury aOR 2.16 (95% CI 1.01, 4.6). All classes of PA were associated with solid organ injury. There were no significant differences in the use of antiplatelet agents between patients with major indications for PA and those without major indications. Geriatric trauma patients on outpatient anticoagulants have a higher likelihood of developing complications, packed red blood cell transfusions, traumatic brain injury, and solid organ injury. Attention should be paid to patients on platelet P2Y12 inhibitors, vitamin K inhibitors, and thromboxane A2 inhibitor agents combined with platelet P2Y12 inhibitors. Opportunities exist to address the use of antiplatelet agents among patients without major indications to improve patient outcomes.

A Comparison of Scoring Systems for Predicting Short‐ and Long‐term Survival After Trauma in Older Adults

“…Even with the availability of both preinjury and hospital data, we were unable to generate a risk indicator that provided both high sensitivity and specificity in predicting mortality. Many variables typically considered in “high‐risk” patients (e.g., anticoagulant use, skilled nursing facility residence prior to trauma and specific anatomic injuries) were not predictive of mortality in this analysis …”

The Impact of Anticoagulation on Trauma Outcomes

“…This agrees with previous studies, like Fortuna et al, who showed age was a significant predictor of mortality in blunt head injury. 2,5,14,16 Discharge to Facility…”

“…1 It is believed that novel oral anticoagulants (NOACs) hold a lower risk of adverse events compared with vitamin K antagonists. [2][3][4][5][6] In Ang's study on geriatric trauma, NOACs tended to have the least number of complications, while platelet P2Y12 inhibitors stood out with the most adverse events and the highest risk of intracranial hemorrhage (ICH). 5 To counteract the risk of bleeding, reversal agents are available for most anticoagulants.…”

“…[2][3][4][5][6] In Ang's study on geriatric trauma, NOACs tended to have the least number of complications, while platelet P2Y12 inhibitors stood out with the most adverse events and the highest risk of intracranial hemorrhage (ICH). 5 To counteract the risk of bleeding, reversal agents are available for most anticoagulants. However, reversal agents for NOACs like factor Xa inhibitors, direct thrombin inhibitors, and fibrinolytics are new, very expensive, and not readily accessible at many hospitals, 7 justifying a deeper look into how these agents are affecting patients with a traumatic injury.…”

Aspirin Does Not Increase the Need for Hemostatic Interventions in Blunt Liver and Spleen Injuries.

“…Comparisons between patients with and without aspirin in spleen injury and the results after propensity score matching. or the need for blood transfusions (15)(16)(17)25). Regarding chest trauma, one series demonstrated that antiplatelet or anticoagulation drugs did not increase the complications of hemothorax in blunt chest wall trauma.…”