Novel oral anticoagulants and trauma: The results of a prospective American association for the surgery of trauma multi-institutional trial

AAST Multicenter Prospective Observational Study of Trauma Patients on Novel Oral Anticoagulants Study Group

    Research output: Contribution to journalArticle

    19 Citations (Scopus)

    Abstract

    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 patientswere enrolled between July 2013 and June 2015. Mean agewas 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.

    Original languageEnglish (US)
    Pages (from-to)827-835
    Number of pages9
    JournalJournal of Trauma and Acute Care Surgery
    Volume82
    Issue number5
    DOIs
    StatePublished - 2017

    Fingerprint

    Intracranial Hemorrhages
    Anticoagulants
    Wounds and Injuries
    Warfarin
    Injury Severity Score
    clopidogrel
    Platelet Aggregation Inhibitors
    Aspirin
    Multivariate Analysis
    Confidence Intervals
    Vital Signs
    Trauma Centers
    Incidence
    Proxy
    Comorbidity
    Demography
    Mortality

    Keywords

    • Anticoagulation
    • Injury
    • Oral anticoagulants
    • Trauma

    ASJC Scopus subject areas

    • Surgery
    • Critical Care and Intensive Care Medicine

    Cite this

    Novel oral anticoagulants and trauma : The results of a prospective American association for the surgery of trauma multi-institutional trial. / AAST Multicenter Prospective Observational Study of Trauma Patients on Novel Oral Anticoagulants Study Group.

    In: Journal of Trauma and Acute Care Surgery, Vol. 82, No. 5, 2017, p. 827-835.

    Research output: Contribution to journalArticle

    AAST Multicenter Prospective Observational Study of Trauma Patients on Novel Oral Anticoagulants Study Group 2017, 'Novel oral anticoagulants and trauma: The results of a prospective American association for the surgery of trauma multi-institutional trial', Journal of Trauma and Acute Care Surgery, vol. 82, no. 5, pp. 827-835. https://doi.org/10.1097/TA.0000000000001414
    AAST Multicenter Prospective Observational Study of Trauma Patients on Novel Oral Anticoagulants Study Group. / Novel oral anticoagulants and trauma : The results of a prospective American association for the surgery of trauma multi-institutional trial. In: Journal of Trauma and Acute Care Surgery. 2017 ; Vol. 82, No. 5. pp. 827-835.
    @article{2cebe4a0d2694916975e1be8e304190f,
    title = "Novel oral anticoagulants and trauma: The results of a prospective American association for the surgery of trauma multi-institutional trial",
    abstract = "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 patientswere enrolled between July 2013 and June 2015. Mean agewas 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.",
    keywords = "Anticoagulation, Injury, Oral anticoagulants, Trauma",
    author = "{AAST Multicenter Prospective Observational Study of Trauma Patients on Novel Oral Anticoagulants Study Group} and Leslie Kobayashi and Galinos Barmparas and Patrick Bosarge and Brown, {Carlos V.} and Marko Bukur and Carrick, {Matthew M.} and Catalano, {Richard D.} and Jan Holly-Nicolas and Kenji Inaba and Stephen Kaminski and Klein, {Amanda L.} and Tammy Kopelman and Ley, {Eric J.} and Martinez, {Ericca M.} and Moore, {Forrest O.} and Jason Murry and Raminder Nirula and Douglas Paul and Jacob Quick and Omar Rivera and Martin Schreiber and Raul Coimbra",
    year = "2017",
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    language = "English (US)",
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    TY - JOUR

    T1 - Novel oral anticoagulants and trauma

    T2 - The results of a prospective American association for the surgery of trauma multi-institutional trial

    AU - AAST Multicenter Prospective Observational Study of Trauma Patients on Novel Oral Anticoagulants Study Group

    AU - Kobayashi, Leslie

    AU - Barmparas, Galinos

    AU - Bosarge, Patrick

    AU - Brown, Carlos V.

    AU - Bukur, Marko

    AU - Carrick, Matthew M.

    AU - Catalano, Richard D.

    AU - Holly-Nicolas, Jan

    AU - Inaba, Kenji

    AU - Kaminski, Stephen

    AU - Klein, Amanda L.

    AU - Kopelman, Tammy

    AU - Ley, Eric J.

    AU - Martinez, Ericca M.

    AU - Moore, Forrest O.

    AU - Murry, Jason

    AU - Nirula, Raminder

    AU - Paul, Douglas

    AU - Quick, Jacob

    AU - Rivera, Omar

    AU - Schreiber, Martin

    AU - Coimbra, Raul

    PY - 2017

    Y1 - 2017

    N2 - 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 patientswere enrolled between July 2013 and June 2015. Mean agewas 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.

    AB - 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 patientswere enrolled between July 2013 and June 2015. Mean agewas 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.

    KW - Anticoagulation

    KW - Injury

    KW - Oral anticoagulants

    KW - Trauma

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