Key result
Trauma patients on novel oral anticoagulants were not at higher risk for intracranial hemorrhage compared to those on traditional agents (24% vs. 31%; IRR 0.78; 95% CI 0.61-1.01; p=0.05).
Why the study?
Do novel oral anticoagulants increase the risk of intracranial hemorrhage, progression of ICH, or death in trauma patients compared to traditional anticoagulants and antiplatelet agents?
Observational (n=1,847)
Yes
Do novel oral anticoagulants increase the risk of intracranial hemorrhage, progression of ICH, or death in trauma patients compared to traditional anticoagulants and antiplatelet agents?
In trauma patients, pre-injury use of novel oral anticoagulants is not associated with a higher risk of intracranial hemorrhage, progression of hemorrhage, or death compared to traditional anticoagulants and antiplatelets.
NOAs were not associated with higher ICH or mortality risk in trauma; leaves open whether outcomes differ from traditional agents in larger trials.
BACKGROUND: The number of anticoagulated trauma patients is increasing. Trauma patients on warfarin have been found to have poor outcomes, particularly after intracranial hemorrhage (ICH). However, the effect of novel oral anticoagulants (NOAs) on trauma outcomes is unknown. We hypothesized that patients on NOAs would have higher rates of ICH, ICH progression, and death compared with patients on traditional anticoagulant and antiplatelet agents. METHODS: This was a prospective observational trial across 16 trauma centers. Inclusion criteria was any trauma patient admitted on aspirin, clopidogrel, warfarin, dabigatran, rivaroxaban, or apixaban. Demographic data, admission vital signs, mechanism of injury, injury severity scores, laboratory values, and interventions were collected. Outcomes included ICH, progression of ICH, and death. RESULTS: A total of 1,847 patients were enrolled between July 2013 and June 2015. Mean age was 74.9 years (SD ± 13.8), 46% were female, 77% were non-Hispanic white. At least one comorbidity was reported in 94% of patients. Blunt trauma accounted for 99% of patients, and the median Injury Severity Score was 9 (interquartile range, 4-14). 50% of patients were on antiplatelet agents, 33% on warfarin, 10% on NOAs, and 7% on combination therapy or subcutaneous agents.Patients taking NOAs were not at higher risk for ICH on univariate (24% vs. 31%) or multivariate analysis (incidence rate ratio, 0.78; confidence interval 0.61-1.01, p = 0.05). Compared with all other agents, patients on aspirin (90%, 81 mg; 10%, 325 mg) had the highest rate (35%) and risk (incidence rate ratio, 1.27; confidence interval, 1.13-1.43; p < 0.001) of ICH. Progression of ICH occurred in 17% of patients and was not different between medication groups. Study mortality was 7% and was not significantly different between groups on univariate or multivariate analysis. CONCLUSION: Patients on NOAs were not at higher risk for ICH, ICH progression, or death. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.
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Kobayashi et al. (2017) conducted an observational in Trauma (n=1,847). Novel oral anticoagulants (NOAs) vs. Traditional anticoagulant and antiplatelet agents was evaluated on Intracranial hemorrhage (ICH) (IRR 0.78, 95% CI 0.61-1.01, p=0.05). Trauma patients on novel oral anticoagulants were not at higher risk for intracranial hemorrhage compared to those on traditional agents (24% vs. 31%; IRR 0.78; 95% CI 0.61-1.01; p=0.05).
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