The Novel Oral Anticoagulants (NOACs) have Worse Outcomes Compared to Warfarin in Patients with Intracranial Hemorrhage after TBI

Introduction Novel-oral-anticoagulants(NOACs) use is increasing in trauma patients. The reversal of these agents after hemorrhage is still evolving. The aim of our study was to evaluate outcomes after traumatic brain injury in patients on NOACs. Methods 3-year (2014-2016) analysis of our prospectively maintained TBI database. We included all TBI patients with intracranial-hemorrhage (ICH) on anticoagulants. Patients were stratified into two groups; those on NOACs and on Warfarin, and were matched in a 1:2 ratio using propensity score matching for demographics, injury and vital parameters, type, and size of ICH. Outcome measures were progression of ICH, mortality, SNF disposition, and hospital and ICU length of stay (LOS). Results We analyzed 1459 TBI patients, of which 210 patients were matched (NAOCs: 70, Warfarin: 140). Matched groups were similar in age (p=0.21), mechanism of injury (p=0.61), GCS (p=0.54), ISS (p=0.62), and type and size of ICH (p=0.09). Patients on pre-injury NOACs had higher rate of progression (p=0.03), neurosurgical intervention (p=0.04), mortality (p=0.04), and longer ICU LOS (p=0.04) compared to patients on warfarin. However, there was no difference in hospital-LOS (p=0.22) and SNF disposition (p=0. 14). On sub-analysis of severe-TBI patients (GCS≤8), rate of progression (p=0.59), neurosurgical intervention (p=0.62) or mortality (p=0.81) was similar in both groups. Conclusions The use of NOACs generally carry a high risk of bleeding and can be detrimental in head injuries with ICH. NOACs use is associated with increased risk of progression of ICH, neurosurgical intervention and mortality after a mild and moderate TBI. Primary care physicians and cardiologists need to reconsider the data on the need for anticoagulation and the type of agent used and weigh it against the risk of bleeding. In addition, development of reversal agents for the NOACs and implementation of a strict protocol for the reversal of these agents may lead to improved outcomes. Level of Evidence Level III, Therapeutic studies Oral presentation for the Earl Young Resident Research Competition at the 48th Annual Meeting of Western Trauma Association, February 25th -March 2nd 2018, British Columbia, Canada. There are no identifiable conflicts of interests to report. The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript. Address for correspondence: Bellal Joseph, MD, University of Arizona, Department of Surgery, Division of Trauma, Critical Care, and Emergency Surgery. 1501 N. Campbell Ave, Room.5411, P.O. Box 245063, Tucson, AZ 85727. E-mail: bjoseph@surgery.arizona.edu © 2018 Lippincott Williams & Wilkins, Inc.

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