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Compared to warfarin, direct oral anticoagulants are associated with lower mortality in patients with blunt traumatic intracranial hemorrhage: A TQIP study

Feeney, James M. MD; Santone, Elizabeth; DiFiori, Monica; Kis, Lilla; Jayaraman, Vijay MD; Montgomery, Stephanie C. MD

Journal of Trauma and Acute Care Surgery: November 2016 - Volume 81 - Issue 5 - p 843–848
doi: 10.1097/TA.0000000000001245
Original Articles
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BACKGROUND Falls represent the leading cause of traumatic brain injury in adults older than 65, with nearly one third experiencing a fall each year. Evidence suggests that up to 0.5% of anticoagulated patients suffer from intracranial hemorrhage (ICH) annually. Direct oral anticoagulants (DOACs) have become an increasingly popular alternative to warfarin for anticoagulation; however, there is a dearth of research regarding the safety of DOACs, in particular on the outcome of traumatic ICH while taking DOACs.

METHODS We queried our Trauma Quality Improvement Project registry for patients who presented with traumatic intracranial hemorrhage during anticoagulant use. Patients were grouped into those prescribed warfarin and patients prescribed DOAC medications. The groups were compared with respect to age, gender, Glasgow Coma Score (GCS) on arrival, Abbreviated Injury Scale (AIS) (head), Injury Severity Score (ISS), mortality, need for operative intervention, hospital and ICU lengths of stay, proportion of patients transfused (and their transfusion requirements), and rates of discharge to skilled nursing facility. Poisson regression was conducted to determine the relationship between mortality and treatment group while controlling for covariates (comorbidities, ISS).

RESULTS There were no differences between DOAC and warfarin groups in terms of age, gender, median ISS, median AIS head, or median admission GCS. Mechanisms of injury, median hospital and ICU lengths of stay, ICU free days, and transfusion requirements were also not significantly different.

DOAC use was associated with significantly lower mortality (4.9% vs. 20.8%; p < 0.008) and a lower rate of operative intervention (8.2% vs. 26.7%; p = 0.023) when compared with warfarin. Excluding patients who died, the observed rate of discharge to skilled nursing facility was lower in the DOAC group (28.8% compared with 39.7%; p = 0.03). Multivariate Poisson regression analysis demonstrated that warfarin use was associated with an increased mortality when controlling for injury severity, and comorbidities.

CONCLUSIONS We report improved mortality and reduced rates of operative intervention in patients with traumatic ICH associated with DOACs compared with a similar group taking warfarin. We also noted an association with decreased rate of discharge to SNF in patients taking DOACs compared with warfarin.

LEVEL OF EVIDENCE Therapeutic study, level IV.

From the Department of Surgery (J.M.F., V.J., S.C.M.), Saint Francis Hospital and Medical Center, Hartford, Connecticut; University of Connecticut School of Medicine (J.M.F., E.S., V.J., S.C.M.), Farmington, Connecticut; and Trinity College (M.D., L.K.), Hartford, Connecticut.

Submitted: February 26, 2016, Revised: July 14, 2016, Accepted: July 18, 2016, Published online: September 3, 2016.

Address for reprints: James M. Feeney, MD, FACS, Saint Francis Hospital and Medical Center, 114 Woodland St., Hartford, CT 06103; email:

© 2016 Lippincott Williams & Wilkins, Inc.