Key result
Pre-admission anticoagulation is linked to ~49% higher in-hospital mortality in ICU major bleeding.
Why the study?
A growing number of patients admitted to the ICU with major bleeding are on oral or parenteral anticoagulation, but its impact on patient outcomes and the comparative effects of warfarin versus DOACs remain unknown.
Does pre-admission anticoagulation therapy increase in-hospital mortality and resource utilization in critically ill patients admitted to the ICU with major bleeding?
Cohort (n=1,598)
Yes
Does pre-admission anticoagulation therapy increase in-hospital mortality and resource utilization in critically ill patients admitted to the ICU with major bleeding?
Pre-admission anticoagulation in ICU patients with major bleeding is associated with significantly higher in-hospital mortality, longer hospital stays, and increased healthcare costs, with warfarin associated with longer stays and higher costs than direct oral anticoagulants.
Answers are grounded in this paper and cite their sources.
Anticoagulation-associated major bleeding tied to higher ICU mortality; leaves open whether specific reversal strategies improve outcomes in trials.
OBJECTIVES Patients with major bleeding are commonly admitted to the ICU. A growing number are on either oral or parenteral anticoagulation, but the impact of anticoagulation on patient outcomes is unknown. We sought to examine this association between anticoagulation therapy and mortality, as well as the independent effects of warfarin compared to direct oral anticoagulants. DESIGN Analysis of a prospectively collected registry (2011-2017) of consecutive ICU patients admitted with major bleeding (as defined by International Society on Thrombosis and Haemostasis clinical criteria). SETTING Two hospitals within a single tertiary care level hospital system. PATIENTS We analyzed 1,598 patients identified with major bleeding, of which 245 (15.3%) had been using anticoagulation at the time of ICU admission. Of patients on anticoagulation, 149 were using warfarin, and 60 were using a direct oral anticoagulant. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model. Patients with anticoagulation-associated major bleeding had higher in-hospital mortality (adjusted odds ratio, 1.49; 95% CI, 1.16-1.92). Among survivors, anticoagulation use was associated with longer median hospital length of stay, and higher mean costs. No differences in hospital mortality were seen between warfarin- and direct oral anticoagulant-associated major bleeding. Patients with warfarin-associated major bleeding had longer median length of stay (11 vs 6 d; p = 0.02), and higher total costs than patients with direct oral anticoagulant-associated major bleeding. CONCLUSIONS Among ICU patients admitted with major bleeding, pre-admission anticoagulation use was associated with increased hospital mortality, prolonged length of stay, and higher costs among survivors. As compared to direct oral anticoagulants, patients with warfarin-associated major bleeding had increased length of stay and costs. These findings have important implications in the care of ICU patients with major bleeding.
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Fernando et al. (2019) conducted a cohort in Major bleeding in critically ill ICU patients (n=1,598). Pre-admission oral or parenteral anticoagulation (including warfarin and direct oral anticoagulants) vs. No pre-admission anticoagulation (and warfarin vs direct oral anticoagulants) was evaluated on In-hospital mortality (OR 1.49, 95% CI 1.16-1.92). Pre-admission anticoagulation use in ICU patients with major bleeding was associated with higher in-hospital mortality (adjusted OR 1.49; 95% CI 1.16-1.92).
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