Kobayashi L, Barmparas G, Bosarge P, et al. J Trauma Acute Care Surg. 2017; 82: 827-835.
Study Question: Are trauma patients treated with novel oral anticoagulants (NOAs) at higher risk for intracranial hemorrhage (ICH), ICH progression, and death when compared to trauma patients on oral antithrombotics (OATs), including warfarin and antiplatelet agents?
Study Description: This was a prospective observational study of trauma patients on aspirin, clopidogrel, warfarin, dabigatran, rivaroxaban, or apixaban at 16 Level 1 trauma centers. The primary outcome was mortality.
Results: A total of 1847 patients, 182 in the NOA group and 1665 in the OAT group, were included. Patients in the NOA group were more likely to have a history of cardiac arrhythmia and to present with shock. There were no differences between groups regarding overall mortality (7% NOA vs. 7% OAT, p = 0.758) or mortality in ICH (12% NOA vs. 15% OAT, p = 0.607). These observations remained non-significant after multivariate analysis correcting for numerous factors, including age, mechanism of injury, Glasgow Coma Scale, Injury Severity Scale, ICH progression, reversal of anticoagulation, transfusion, and surgical intervention.
Conclusion(s): The use of NOAs does not increase the risk of death, ICH, or ICH progression in trauma patients.
Perspective: The use of NOAs is increasing as these agents are now recommended first line for treatment of venous thromboembolism and for stroke prevention in atrial fibrillation. The results of this study suggest NOA agents may have a decreased risk for ICH in the setting of trauma when compared to OAT therapy. No differences in mortality were observed between groups; however, this study was underpowered and is therefore at risk for type II error. The observed trend towards reduced risk of ICH in trauma is intriguing and requires further investigation as a primary outcome.