Novel oral anticoagulants and trauma

Kobayashi, Leslie; Barmparas, Galinos; Bosarge, Patrick L.; Brown, Carlos V R; Bukur, Marko; Carrick, Matthew M.; Catalano, Richard D.; Holly-Nicolas, Jan; Inaba, Kenji; Kaminski, Stephen; Klein, Amanda; Kopelman, Tammy R.; Ley, Eric J.; Martínez, E. Márquez; Moore, Forrest O.; Murry, Jason; Nirula, Raminder; Paul, Douglas B.; Quick, Jacob; Rivera, O. Conde; Schreiber, Martin A.; Coimbra, Raúl

doi:10.1097/ta.0000000000001414

Cited by 80 publications

(54 citation statements)

References 42 publications

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“…The univariate and multivariate analyses did not reveal any higher risk for ICH and progression of intracranial bleeding in patients on DOACs compared to VKAs (19% in each group). Interestingly, this study discovered that aspirin intake was associated with the highest rate of ICH diagnosed upon admission [ 24 ].…”

Section: Discussionmentioning

confidence: 99%

“…This is comparable to the report of Wood et al, where 60% of patients on VKA and only 19% of DOAC patients received reversal agents [ 13 ]. In a multicentre study published by Kobayashi et al, the anticoagulant effect of warfarin was reversed in only 47% compared with 13% of the DOAC patients ( p < 0.001) [ 24 ]. Barletta et al reported similar rates of pharmacological reversal (48.1% [warfarin] vs. 13.8% [DOAC], p > 0.001) but, despite this, mortality was comparable between warfarin and DOAC patients (5.9% vs. 4.3%, p = 0.789) [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

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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%

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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“…The safety of these DOACs in the trauma population has recently been assessed. DOACs have a considerably lower rate of the development of intracranial hemorrhage compared to warfarin (24% vs. 31%) [ 33 ]. While there has likely been benefit, the DOACs have few established protocols for reversal of anticoagulation, although work continues to be done in this area [ 33 – 36 ].…”

Section: Discussionmentioning

confidence: 99%

Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall

et al. 2018

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BackgroundFalls are a common cause of hospitalization, morbidity, and mortality among the elderly in the United States. Evidence-based imaging recommendations for evaluation of delayed intracranial hemorrhage (DICH) are not generally agreed upon. The purpose of this project was to evaluate the incidence of DICH detected by head computer tomography (CT) among an elderly population on pre-injury anticoagulant or antiplatelet (ACAP) therapy.MethodsData from a Level 1 Trauma Center trauma registry was used to assess the incidence of DICH in an elderly population of patients (≥65 years) who sustained a minor fall while on pre-injury ACAP medications. Counts and percentages are reported.ResultsData on 1076 elderly trauma patients were downloaded, of which 838 sustained a minor fall and 513 were found to be using a pre-injury ACAP medication. One patient (0.46%) with a DICH was identified out of 218 patients who received a routine repeat head CT. Aspirin and warfarin were the most common pre-injury ACAP medications and 19.27% (42/218) of patients were found to be using multiple ACAP medications.ConclusionsUniversal screening protocols promote immediate-term patient safety, but do so at a great expense with respect to health expenditures and increased radiation exposure. This analysis highlights the need for an effective risk assessment tool for DICH that would reduce the burden of unnecessary screenings while still identifying life-threatening intracranial hemorrhages in affected patients.

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“…Data previously presented. 22 For Renal Failure and Cirrhosis both the number of patients as well as percent (in parentheses) of the population with the comorbidity are presented. Values in bold signify number of patients and percent of population in parentheses.…”

Section: Resultsmentioning

confidence: 99%

“…Data used for this study were collected during a prospective observational study occurring between June 30, 2013 and July 1, 2015 across 16 level 1 trauma centers via the American Association for the Surgery of Trauma-Multi-institutional Trials Committee (AAST-MITC). 22 This is a post-hoc analysis of patients admitted on dabigatran, rivaroxaban, or apixaban. Minors (age <18), patients who were pregnant, and prisoners were excluded.…”

Section: Methodsmentioning

confidence: 99%

Laboratory measures of coagulation among trauma patients on NOAs: results of the AAST-MIT

Kobayashi

Brito

Barmparas

et al. 2018

Trauma Surg Acute Care Open

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BackgroundWarfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG).MethodsThis was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman’s rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups.Results182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1–1.4) and rivaroxaban (median 1.3, IQR 1.1–1.6) compared with apixaban (median 1.1, IQR 1.0–1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8–46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal.DiscussionNeither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs.Level of evidenceLevel IV.

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Novel oral anticoagulants and trauma

Abstract: Prognostic/epidemiologic study, level III.

Cited by 80 publications

References 42 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

Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall

Laboratory measures of coagulation among trauma patients on NOAs: results of the AAST-MIT

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