Key result
DOACs are linked to ~35% lower intracranial bleeding risk versus VKAs in impaired kidney function.
Why the study?
Acute deterioration of renal function frequently occurs at emergency department presentation and increases bleeding risk on oral anticoagulation, but whether outcomes and bleeding characteristics differ between direct oral anticoagulants and vitamin-K antagonists remained unclear.
Do bleeding characteristics, required therapies, and clinical outcomes differ between DOACs and VKAs in patients with impaired kidney function presenting to the emergency department with acute hemorrhage?
Cohort (n=577)
No
Do bleeding characteristics, required therapies, and clinical outcomes differ between DOACs and VKAs in patients with impaired kidney function presenting to the emergency department with acute hemorrhage?
Absolute Event Rate: 14.6% vs 22.4%
p-value: p=0.036
In patients with impaired kidney function presenting with acute hemorrhage, DOAC use is associated with fewer intracranial bleeds and interventional therapies but more emergency endoscopies compared to VKA use.
Hypothesis-generating for fewer intracranial bleeds with DOACs; should not yet change anticoagulant selection in renal impairment.
BACKGROUND: Up to a fourth of patients at emergency department (ED) presentation suffer from acute deterioration of renal function, which is an important risk factor for bleeding events in patients on oral anticoagulation therapy. We hypothesized that outcomes of patients, bleeding characteristics, therapy, and outcome differ between direct oral anticoagulants (DOACs) and vitamin-K antagonists (VKAs). METHODS: All anticoagulated patients older than 17 years with an impaired kidney function treated for an acute haemorrhage in a large Swiss university ED from 01.06.2012 to 01.07.2017 were included in this retrospective cohort study. Patient, treatment, and bleeding characteristics as well as outcomes (length of stay ED, intensive care unit and in-hospital admission, ED resource consumption, in-hospital mortality) were compared between patients on DOAC or VKA anticoagulant. RESULTS: In total, 158 patients on DOAC and 419 patients on VKA with acute bleeding and impaired renal function were included. The renal function in patients on VKA was significantly worse compared to patients on DOAC (VKA: median 141 μmol/L vs. DOAC 132 μmol/L, p = 0.002). Patients on DOAC presented with a smaller number of intracranial bleeding compared to VKA (14.6% DOAC vs. 22.4% VKA, p = 0.036). DOAC patients needed more emergency endoscopies (15.8% DOAC vs, 9.1% VKA, p = 0.020) but less interventional emergency therapies to stop the bleeding (13.9% DOAC vs. 22.2% VKA, p = 0.027). Investigated outcomes did not differ significantly between the two groups. CONCLUSIONS: DOAC patients were found to have a smaller proportional incidence of intracranial bleedings, needed more emergency endoscopies but less often interventional therapy compared to patients on VKA. Adapted treatment algorithms are a potential target to improve care in patients with DOAC.
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Müller et al. (2021) conducted a cohort in Acute hemorrhage with impaired kidney function on oral anticoagulation (n=577). Direct oral anticoagulants (DOACs) vs. Vitamin-K antagonists (VKAs) was evaluated on Incidence of intracranial bleeding (p=0.036). In patients with impaired kidney function presenting with acute hemorrhage, DOAC therapy was associated with a significantly lower incidence of intracranial bleeding compared to VKA therapy (14.6% vs 22.4%).
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