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Resumption of Oral Anticoagulation Post-Traumatic Injury
Study Questions:
How do patients in whom oral anticoagulation (OAC; for atrial fibrillation [AF]) is resumed following traumatic injury fare, as compared to those in whom it is withheld?
Methods:
This observational study included Danish patients (N = 4,541) with AF who were hospitalized for traumatic injury that resulted in discontinuation of OAC. Traumatic injury included brain injury, hip fracture, and torso/abdominal injury. Outcomes included all-cause mortality, ischemic stroke, major bleeding, and recurrent traumatic injury. Resumption of OAC was assumed if a prescription for an OAC was filled within 90 days from date of discharge.
Results:
Vitamin K antagonists (VKAs; median age = 80 years, CHA2DS2-VASc = 4, HAS-BLED = 2) and novel oral anticoagulants (NOACs; median age = 81 years, CHA2DS2-VASc = 4, HAS-BLED = 2) were resumed in 60.6% and 16.7% of patients, respectively. OAC was not continued in the remaining 22.7% of patients (median age = 81 years, CHA2DS2-VASc = 4, HAS-BLED = 3). Among patients in whom OAC was not resumed, there was a higher prevalence of traumatic brain injury, prior bleeding, concomitant use of antiplatelet agents, and benzodiazepines. Resumption of OAC was associated with a lower risk of mortality, ischemic stroke, and higher risk of major bleeding, and similar risk of recurrent traumatic injury.
Conclusions:
The authors concluded that resumption of OAC after traumatic injury in patients with AF is associated with a lower risk of mortality and stroke. They go on to question the withholding of OAC in all such patients.
Perspective:
Clinicians may be hesitant to restart OAC in elderly patients following traumatic injuries, especially those resulting in intracranial bleeding. Prior retrospective studies have suggested that the benefits of resuming OAC outweigh the risk of bleeding. Although the current study reinforces this view, significant limitations must be recognized; namely, that it was not based on randomized data. Also, it is possible that patients in the non-resumption group were more frail (these data are not available), and had more significant comorbidities (as suggested by the demographic data), which may also help explain their worse outcomes. Ultimately, the physician caring for such patients has to carefully weigh the risks and benefits, in presenting his/her recommendations to the patient and the family.
Keywords: Abdominal Injuries, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Brain Injuries, Geriatrics, Hemorrhage, Hip Fractures, Intracranial Hemorrhage, Traumatic, Intracranial Hemorrhages, Platelet Aggregation Inhibitors, Risk Assessment, Stroke, Vitamin K
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