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

Leslie Kobayashi, Galinos Barmparas, Patrick Bosarge, Carlos V. Brown, Marko Bukur, Matthew M. Carrick, Richard D. Catalano, Jan Holly-Nicolas, Kenji Inaba, Stephen Kaminski, Amanda L. Klein, Tammy Kopelman, Eric J. Ley, Ericca M. Martinez, Forrest O. Moore, Jason Murry, Raminder Nirula, Douglas Paul, Jacob Quick, Omar RiveraMartin Schreiber, Raul Coimbra, AAST Multicenter Prospective Observational Study of Trauma Patients on Novel Oral Anticoagulants Study Group

Research output: Contribution to journalArticle

16 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

Kobayashi, L., Barmparas, G., Bosarge, P., Brown, C. V., Bukur, M., Carrick, M. M., ... 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, 82(5), 827-835. https://doi.org/10.1097/TA.0000000000001414

Novel oral anticoagulants and trauma : The results of a prospective American association for the surgery of trauma multi-institutional trial. / Kobayashi, Leslie; Barmparas, Galinos; Bosarge, Patrick; Brown, Carlos V.; Bukur, Marko; Carrick, Matthew M.; Catalano, Richard D.; Holly-Nicolas, Jan; Inaba, Kenji; Kaminski, Stephen; Klein, Amanda L.; Kopelman, Tammy; Ley, Eric J.; Martinez, Ericca M.; Moore, Forrest O.; Murry, Jason; Nirula, Raminder; Paul, Douglas; Quick, Jacob; Rivera, Omar; Schreiber, Martin; Coimbra, Raul; 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

Kobayashi, L, Barmparas, G, Bosarge, P, Brown, CV, Bukur, M, Carrick, MM, Catalano, RD, Holly-Nicolas, J, Inaba, K, Kaminski, S, Klein, AL, Kopelman, T, Ley, EJ, Martinez, EM, Moore, FO, Murry, J, Nirula, R, Paul, D, Quick, J, Rivera, O, Schreiber, M, Coimbra, R & 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
Kobayashi, Leslie ; Barmparas, Galinos ; Bosarge, Patrick ; Brown, Carlos V. ; Bukur, Marko ; Carrick, Matthew M. ; Catalano, Richard D. ; Holly-Nicolas, Jan ; Inaba, Kenji ; Kaminski, Stephen ; Klein, Amanda L. ; Kopelman, Tammy ; Ley, Eric J. ; Martinez, Ericca M. ; Moore, Forrest O. ; Murry, Jason ; Nirula, Raminder ; Paul, Douglas ; Quick, Jacob ; Rivera, Omar ; Schreiber, Martin ; Coimbra, Raul ; 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.
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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 = "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 and {AAST Multicenter Prospective Observational Study of Trauma Patients on Novel Oral Anticoagulants Study Group}",
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T1 - Novel oral anticoagulants and trauma

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

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

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

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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