Trends and Characteristics of Emergency Department Patients Prescribed Novel Oral Anticoagulants

Outcomes of trauma patients on chronic antithrombotic therapies in a trauma center in a rural state

Objective

The number of trauma patients presenting with chronic antithrombotic therapy is on the rise. The risk of hemorrhage, the leading cause of death in trauma patients, increases for those on such therapy. This study sought to compare the clinical outcomes of patients on warfarin, direct oral anticoagulants (DOAC), or antiplatelet agents.

Methods

A retrospective cohort analysis was conducted on adult patients admitted to a Level 1 trauma center with pre-admission antithrombotic therapy. Patients were divided into those on warfarin, DOACs, and antiplatelet agents. The primary outcomes measured were hospital mortality, total blood products received, hospital length of stay (LOS), and ICU LOS.

Results

738 patients were included in the study: 191 (26 %) warfarin, 260 (35 %) DOACs, and 287 (39 %) antiplatelet. There were no differences in the demographic variables between study groups. The Injury Severity Score (ISS) was similar across the three groups as well as blood product usage, reversal agent usage, and mean hospital stay. Multivariable regression showed patients with pre-admission antiplatelet usage were more likely to have a shorter ICU LOS than those on warfarin (p = 0.048).

Conclusion

Blood product and reversal agent use was similar between patients on warfarin, DOACs, or antiplatelet agents. Patients on antiplatelet agents had a shorter ICU stay than the warfarin group, the only significant difference observed. Our results indicate similar safety profiles of antithrombotic medications in a generic trauma population, likely due to institutional protocols to increase responsiveness and immediate availability of resources when the patient has known anticoagulation.

Temporal trends in admissions for atrial fibrillation and severe bleeding in England: an 18-year longitudinal analysis

Objective. Temporal trends in admissions for atrial fibrillation (AF) and severe bleeding associated with AF vary worldwide. We aimed to explore their temporal trends in England and their relation to the introduction of DOACs in 2014 in the UK. Design. This longitudinal ecological study utilised aggregated data that was extracted from the Hospital Episode Statistics database, which captured annual admissions for AF and severe bleeding associated with AF between 2001 and 2018. Trends in admissions over the study period and across age groups, gender and regions in England were assessed. Results. In total, there were 11,292,177 admissions for AF and 324,851 admissions for severe bleeding associated with AF. There was a steady rise in admissions for AF from 2001 to 2017 (204,808 to 1,109,295; p for trend<.001). A similar trend was observed for severe bleeding (4940 to 30,169; p for trend <.001), but the increase dropped slightly between 2013 and 2014 and continued thereafter. Conclusions. There was a rise in admissions for AF and severe bleeding in England between 2001 and 2018. There is little evidence that the slight drop in admissions for severe bleeding between 2013 and 2014 may have been caused by the introduction of DOACs in 2014. Contributors to these trends need urgent exploration.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury: Approved by ACEP Board of Directors, February 1, 2023 Clinical Policy Endorsed by the Emergency Nurses Association (April 5, 2023)

This 2023 Clinical Policy from the American College of Emergency Physicians is an update of the 2008 “Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following questions: 1) In the adult emergency department patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head computed tomography? 2) In the adult emergency department patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head computed tomography? and 3) In the adult emergency department patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome or to identify patients with delayed sequelae after emergency department discharge? Evidence was graded and recommendations were made based on the strength of the available data. Widespread and consistent implementation of evidence-based clinical recommendations is warranted to improve patient care.

Incidence of Traumatic Delayed Intracranial Hemorrhage Among Patients Using Direct Oral Anticoagulants

BACKGROUND

Emergency department visits due to head injury in the United States have increased significantly over the past decade, and parallel the increasing use of direct oral anticoagulants (DOACs).

OBJECTIVE

We investigated the incidence of delayed intracranial hemorrhage (DICH) in patients with head injury who were taking DOACs.

METHODS

We conducted a single-center retrospective study at a level II trauma center. All patients with head injury and using DOACs with an initial negative head computed tomography (HCT) scan from March 1, 2014 to December 31, 2017 were included. DICH was identified as a positive finding on repeat HCT performed within 24 h. Each case of DICH underwent blinded review by two additional neuroradiologists. Demographic data were collected; independent t-tests were used to compare group means and linear regression for variable correlations.

RESULTS

Two hundred and eighty-seven patients with mean age of 80 years (interquartile range 14 years) met inclusion criteria. Repeat HCT was performed in 224 study participants (78%). Five (1.7%) resulted in DICH, three of which might have been present on initial HCT, with an incidence rate ranging from 0.7% to 1.7%. Only two initial HCTs were read as negative by all three neuroradiologists; 60% disagreed on the initial read. Independent t-test procedures showed an association between DICH and higher Injury Severity Score (ISS).

CONCLUSIONS

We found a DICH incidence rate of 0.7-1.7%. ISS was statistically significant between the two groups. It is possible that in patients with a subjective estimation of low injury severity, a low mechanism of injury and reasonable outpatient follow-up, patients can be discharged home with standard head injury precautions and no repeat HCT, but further prospective studies are needed.

Newer and Better? Comparing Direct Oral Anticoagulants to Warfarin in Patients With Traumatic Intracranial Hemorrhage

BACKGROUND

Direct oral anticoagulants (DOACs) have overtaken warfarin as the preferred anticoagulants for stroke prevention with atrial fibrillation and for treatment of venous thromboembolism. Despite the increased prevalence of DOACs, literature studying their impact on trauma patients with intracranial hemorrhage (ICH) remains limited. Most DOAC reversal agents have only been recently available, and concerns for worse outcomes with DOACs among this population remain. This study aims to assess the outcomes of patients with traumatic ICH taking DOACs compared with those taking warfarin.

METHODS

A retrospective analysis of patients with traumatic ICH over a 5-year period was conducted. Demographics, injury severity, medication, and outcome data were collected for each patient. Patients taking warfarin and DOACs were compared.

RESULTS

736 patients had traumatic ICH over the study period, 75 of which were on either DOACs (25 patients) or warfarin (50 patients). The median age of the anticoagulated patients was 78 years; 52% were female, and 91% presented secondary to a fall. DOACs were reversed at close to half the rate of warfarin (40% vs 77%; P = .032). Despite this, the 2 groups had similar rates of worsening examination, need for operative intervention, and in-hospital mortality. In the follow-up, fewer patients taking DOACs had died at 6-months postinjury compared with those taking warfarin (8% vs 30%; P = .041).

DISCUSSION

Despite DOACs being reversed at nearly half the rate of warfarin, patients presenting with traumatic ICH on warfarin had higher 6-month mortality suggesting a potential survival advantage for DOACs over warfarin in this population.

Expedited surgery in geriatric hip fracture patients taking direct oral anticoagulants is not associated with increased short-term complications or mortality rates

Objectives:

The purpose of this study was to evaluate potential differences in time to surgery, bleeding risk, wound complications, length of stay, transfusion rate, and 30-day mortality between patients anticoagulated with direct oral anticoagulants (DOACs) and those not anticoagulated at the time of evaluation for an acute hip fracture.

Design:

Retrospective chart review Level III Study.

Setting:

One university-based hospital in Rochester, NY.

Patients/Intervention

: Patients 65 years and older undergoing operative treatment of a hip fracture over a 5-year period. Chart review identified patients on DOAC therapy at the time of injury as well as an age and sex-matched control group not on anticoagulation.

Main outcome measurements

: Demographics, procedure type, admission/postoperative laboratory work, perioperative metrics, transfusion metrics, discharge course, reoperation, readmission, wound complications, and 30-day mortality were obtained for comparison.

Results:

Thirty-six hip fractures anticoagulated on DOACs were compared to 108 controls. The DOAC group had delays to operative treatment (27.6 h, SD 16.3 h, 95% CL [22.0–33.1]) vs the control group (19.8 h, SD 10.5 h, 95% CL [17.7–21.8], P = .01). No differences were found in estimated blood loss, procedure time, or change in hemoglobin. Transfusion rates were not significantly different between groups (58.3% DOAC vs 47.2% control, P = .25). No difference in reoperation, readmission, wound complication, deep venous thrombosis rates, or 30-day mortality rates were found.

Conclusion:

Patients presenting on DOAC therapy at the time of hip fracture have a delay to surgery compared with age and sex-matched controls, but no increase in short term complications or mortality rates. Expedited surgery (within 48 h) appeared to be safe and effective treatment for hip fracture patients on DOAC therapies.

Practice Gap in Atrial Fibrillation Oral Anticoagulation Prescribing at Emergency Department Home Discharge

INTRODUCTION

Current U.S. cardiology guidelines recommend oral anticoagulation (OAC) to reduce stroke risk in selected patients with atrial fibrillation (AF), but no formal AF OAC recommendations exist to guide emergency medicine clinicians in the acute care setting. We sought to characterize emergency department (ED) OAC prescribing practices after an ED AF diagnosis.

METHODS

This retrospective study included index visits for OAC-naive patients ≥18 years old who were discharged home from the ED at an urban, academic, tertiary hospital with a primary diagnosis of AF from 2012-2014. Five hypothesis-blinded, chart reviewers abstracted data from patient problem lists and medical history in the electronic health record to assess stroke (CHA₂DS₂-VASc) and bleeding risk (HAS-BLED). The primary outcome was the provision of an OAC prescription at discharge in OAC-naive patients with high stroke risk. Descriptive statistics and multivariable logistic regression assessed associations between OAC prescription and patient characteristics.

RESULTS

We included 138 patient visits in our analysis, of whom 39.9% (n = 55) were low stroke risk (CHA₂DS₂-VASc = 0 in males and 1 in females), 15.9% (n = 22) were intermediate risk (CHA₂DS₂-VASc = 1 in males), and 44.2% (n = 61) were high risk (CHA₂DS₂-VASc ≥ 2). Of patients with high stroke risk and low-to-intermediate bleeding risk (n = 57), 80.7% were not prescribed an OAC at discharge. Cardiology consultation and female gender, but not stroke risk (CHA₂DS₂-VASc score), were predictors of an ED provider prescribing an OAC to an OAC-naive AF patient at ED discharge.

CONCLUSION

The majority of OAC-eligible patients were discharged home without an OAC prescription. In OAC-naive patients discharged home from the ED, cardiology consultation and female gender were associated with OAC prescription. Our findings suggest that access to expert opinion may improve provider comfort with OAC prescribing and highlight the need for improved guidelines specific to ED-management of AF.

Oral Anticoagulation in Patients in the Emergency Department: High Rates of Off-Label Doses, No Difference in Bleeding Rates

BACKGROUND

Empirically, a significant proportion of patients using direct oral anticoagulation (DOAC) take off-label reduced doses. We aimed to investigate the prevalence, indications, dosages, and bleeding complications of oral anticoagulants on admission to the emergency department.

METHODS

In this retrospective analysis, patients presenting to our emergency department between January 1 and December 31, 2018, with therapeutic oral anticoagulation were included (ie, vitamin-K antagonists, rivaroxaban, apixaban, edoxaban, and dabigatran). A detailed chart review was performed for each case concerning characteristics, indication, and bleeding complications.

RESULTS

A total of 19,662 consecutive cases in the emergency department were reported: 1721 (9%) had therapeutic oral anticoagulation. Vitamin-K antagonists (41%), rivaroxaban (36%), and apixaban (19%) were the most common. Stroke prophylaxis in patients with atrial fibrillation (63.2%) and venous thromboembolism (24.1%) were the most common indications. In 27 cases (1.6%), no indication could be identified; further, 32% of patients were classified to have either off-label doses of DOACs or an international normalized ratio (INR) out of range (in vitamin-K antagonists), whereas 20% were classified as off-label underdosed and 12% as overdosed. No difference in the likelihood of bleeding on admission could be found between the respective drugs. Only concomitant use of aspirin was significantly associated with presence and higher severity of bleeding.

CONCLUSIONS

Vitamin-K antagonists are still the most widely used drug followed by rivaroxaban. A significant proportion of patients are being prescribed off label-doses. While no difference was found for the respective anticoagulants with respect to bleeding, concomitant aspirin use was a significant predictor for bleeding in our collective.

Patients on NOACs in the Emergency Room

PURPOSE OF REVIEW

Despite the increasing use of NOACs, there is still uncertainty on how to treat NOAC patients presenting with neurological emergencies. Initial assessment of coagulation status is challenging but essential in these patients to provide best-possible treatment in case of ischemic or hemorrhagic stroke. Meanwhile, anticoagulation reversal strategies have been suggested; yet, the optimal management is still unestablished. The current review aims to provide up-to-date information on (i) how to identify patients with NOAC intake, (ii) which therapies are feasible in the setting of ischemic and hemorrhagic stroke as well as traumatic intracranial hemorrhage, and (iii) how to proceed with patients requiring emergency lumbar puncture.

RECENT FINDINGS

Despite several expert opinions, there is still an ongoing debate which NOAC patients presenting with ischemic stroke may benefit from recanalizing strategies and whether these treatment approaches can be performed safely. Results from two phase IV trials investigating the efficacy of NOAC-specific reversal agents in case of major bleeding seem promising with regard to hemostatic parameters, but these antidotes have not been verified to clinically benefit patients, and approval by authorities in parts is still pending. Specific reversal agents are on the way and will provide new treatment options in patients with NOAC-related ischemic and hemorrhagic stroke. Up to now, the decision which patients should undergo recanalizing treatment for ischemic stroke, or which specific pharmacological reversal treatment in hemorrhagic stroke should be initiated, has to be made cautiously on an individual basis after assessing hemostatic parameters.

Cost-effectiveness of rivaroxaban versus warfarin for treatment of nonvalvular atrial fibrillation in patients with worsening renal function

BACKGROUND

Nonvalvular atrial fibrillation (NVAF) is highly prevalent and increases the risks of cardiovascular events. In a recent subgroup analysis, treatment response was shown to vary for patients exhibiting worsening renal function (WRF) on-treatment. It is important to understand the cost-effectiveness of novel oral anticoagulant (NOAC) use in this population.

METHODS

A cost-effectiveness analysis (CEA) was conducted using a Markov model to determine whether NOAC rivaroxaban treatment is cost-effective relative to warfarin in NVAF patients with on-treatment WRF. Input parameters were sourced from clinical literature including a multicenter clinical trial and subgroup analysis. We studied elderly US male patients at increased risk for stroke (CHADS₂ score ≥ 2) undergoing treatment for NVAF and exhibiting WRF. Main outcome measures included total healthcare costs in 2017 US dollars (societal perspective), total quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICER), and incremental net monetary benefits (INMB) per-patient.

RESULTS

The remaining lifetime use of rivaroxaban is associated with 5.69 QALYs at a cost of $66,075 per patient, while warfarin produced 5.22 QALYs with costs of $78,504 per patient. At a willingness-to-pay (WTP) of $150,000 per QALY, incremental net monetary benefits (INMB) per patient are $83,590. In our population, treatment with warfarin was dominated by rivaroxaban in 99.4% of 10,000 simulations.

CONCLUSIONS

Rivaroxaban is likely a dominant treatment over warfarin in elderly US male NVAF patients exhibiting WRF, providing increased QALYs at a decreased overall cost. Application of these findings may require healthcare providers to predict which patients are likely to exhibit WRF.

Outcomes after Falls Continue to Worsen Despite Trauma and Geriatric Care Advancements

The most common mechanism of traumatic injury is ground-level fall. The objective of this study was to understand how patients sustaining falls and their outcomes have evolved. An institutional trauma database was used to identify adult patients who suffered a fall and were admitted to a Level I trauma center during two distinct time periods: 1998 to 2003 (past) and 2008 to 2013 (current). Data on anticoagulant use and comorbidities was gathered by retrospective chart review of patients treated during 2003 and 2013. Univariable analyses and multivariable regression were used to evaluate demographics and outcomes. A total of 6116 patients were identified, with a 24 per cent increase in number of falls between groups. Current fall patients are older (70 vs 66 years, P < 0.001), more often admitted to intensive care (28 vs 12%, P < 0.001), have longer lengths of stay (5 vs 4 days, P < 0.001), are frequently discharged to skilled nursing facilities (24 vs 8%, P < 0.001), and have higher mortality (5 vs 3%, P = 0.002). The adjusted odds of mortality for patients treated during 2003 and 2013 was associated with age, gender, injury severity score, and Glasgow Coma Scale score. Current fall patients use more health care resources and have worse outcomes, despite advances in trauma and geriatric care.

Hospital admissions for bleeding events associated with treatment with apixaban, dabigatran and rivaroxaban

Objectives

To analyse the hospital admissions for bleeding events associated with treatment with direct oral anticoagulants (DOACs). To describe the characteristics and outcomes of those patients.

Methods

A retrospective observational study was carried out in the framework of an integral risk management plan of drugs and proactive pharmacovigilance of hospital admissions for bleeding associated with apixaban, dabigatran and rivaroxaban from April 2015 through December 2016. Cases were identified using the information management tool of Orion Clinic (hospital electronic medical history) and by reviewing the hospital discharge reports. Various biometric, clinical and pharmacotherapeutic variables of each patient were registered.

Results

37 hospitalisation episodes for DOAC-induced bleeding in 32 patients (15 received rivaroxaban, 9 apixaban and 8 dabigatran) were detected, representing an incidence rate of 3.44 per 100 person-years (95% CI 2.35 to 4.86). The most common bleeding site was gastrointestinal (27 cases, 73.0%). Intracranial bleeding was rare (three cases, 8.1%). Four patients (12.5%) were receiving DOACs at full doses and had a 'dose reduction indication'. The mean (SD) length of stay was 8.4 (5.2) days. Three patients (8.1%) died during the hospitalisation. Among bleeding episodes without fatal outcome, DOACs were stopped in 14 cases, continued in 14 cases, switched for another DOAC in two cases and the dose was reduced in four cases.

Conclusions

DOACs are associated with serious bleeding events that require hospitalisation. The risk/benefit ratio assessment considering patient preferences and an individualised follow-up, especially in patients who are elderly, polymedicated or have impaired renal function, can help to reinforce the safe use of DOACs.

Risk of Intracranial Hemorrhage in Ground-level Fall With Antiplatelet or Anticoagulant Agents

OBJECTIVES

Anticoagulant and antiplatelet medications are known to increase the risk and severity of traumatic intracranial hemorrhage (tICH), even with minor head trauma. Most studies on bleeding propensity with head trauma are retrospective, are based on trauma registries, or include heterogeneous mechanisms of injury. The goal of this study was to determine the rate of tICH from only a common low-acuity mechanism of injury, that of a ground-level fall, in patients taking one or more of the following antiplatelet or anticoagulant medications: aspirin, warfarin, prasugrel, ticagrelor, dabigatran, rivaroxaban, apixaban, or enoxaparin.

METHODS

This was a prospective cohort study conducted at a Level I tertiary care trauma center of consecutive patients meeting the inclusion criteria of a ground-level fall with head trauma as affirmed by the treating clinician, a computed tomography (CT) head obtained, and taking and one of the above antiplatelet or anticoagulants. Patients were identified prospectively through electronic screening with confirmatory chart review. Emergency department charts were abstracted without subsequent knowledge of the hospital course. Patients transferred with a known abnormal CT head were excluded. Primary outcome was rate of tICH on initial CT head. Rates with 95% confidence intervals (CIs) were compared.

RESULTS

Over 30 months, we enrolled 939 subjects. The mean ± SD age was 78.3 ± 11.9 years and 44.6% were male. There were a total of 33 patients with tICH (3.5%, 95% CI = 2.5%-4.9%). Antiplatelets had a rate of tICH of 4.3% (95% CI = 3.0%-6.2%) compared to anticoagulants with a rate of 1.7% (95% CI = 0.4%-4.5%). Aspirin without other agents had an tICH rate of 4.6% (95% CI = 3.2%-6.6%); of these, 81.5% were taking low-dose 81 mg aspirin. Two patients received a craniotomy (one taking aspirin, one taking warfarin). There were four deaths (three taking aspirin, one taking warfarin). Most (72.7%) subjects with tICH were discharged home or to a rehabilitation facility. There were no tICH in 31 subjects taking a direct oral anticoagulant. CIs were overlapping for the groups.

CONCLUSION

There is a low incidence of clinically significant tICH with a ground-level fall in head trauma in patients taking an anticoagulant or antiplatelet medication. There was no statistical difference in rate of tICH between antiplatelet and anticoagulants, which is unanticipated and counterintuitive as most literature and teaching suggests a higher rate with anticoagulants. A larger data set is needed to determine if small differences between the groups exist.

Recent Advances in the Acute Management of Intracerebral Hemorrhage

Primary intracerebral hemorrhage (ICH) is a common, devastating disease that lacks an effective specific treatment. Mortality is high, functional outcomes are poor, and these have not substantially changed for decades. There is, therefore, considerable opportunity for advancement in the management of ICH. In recent years, a significant amount of research has begun to address this gap. This article is aimed at updating neurologists on the most clinically relevant contemporary research.

Bleeding-related admissions in patients with atrial fibrillation receiving antithrombotic therapy: results from the Tasmanian Atrial Fibrillation (TAF) study

PURPOSE

Limited data are available from the Australian setting regarding bleeding in patients with atrial fibrillation (AF) receiving antithrombotic therapy. We aimed to investigate the incidence of hospital admissions due to bleeding and factors associated with bleeding in patients with AF who received antithrombotic therapy.

METHODS

A retrospective cohort study was conducted involving all patients with AF admitted to the Royal Hobart Hospital, Tasmania, Australia, between January 2011 and July 2015. Bleeding rates were calculated per 100 patient-years (PY) of follow-up, and multivariable modelling was used to identify predictors of bleeding.

RESULTS

Of 2202 patients receiving antithrombotic therapy, 113 presented to the hospital with a major or minor bleeding event. These patients were older, had higher stroke and bleeding risk scores and were more often treated with warfarin and multiple antithrombotic therapies than patients who did not experience bleeding. The combined incidence of major and minor bleeding was significantly higher in warfarin- versus direct-acting oral anticoagulants (DOAC)- and antiplatelet-treated patients (4.1 vs 3.0 vs 1.2 per 100 PY, respectively; p = 0.002). Similarly, the rate of major bleeding was higher in patients who received warfarin than in the DOAC and antiplatelet cohorts (2.4 vs 0.4 vs 0.6 per 100 PY, respectively; p = 0.001). In multivariate analysis, increasing age, prior bleeding, warfarin and multiple antithrombotic therapies were independently associated with bleeding.

CONCLUSION

The overall rate of bleeding in this cohort was low relative to similar observational studies. The rate of major bleeding was higher in patients prescribed warfarin compared to DOACs, with a similar rate of major bleeding for DOACs and antiplatelet agents. Our findings suggest potential to strategies to reduce bleeding include using DOACs in preference to warfarin, and avoiding multiple antithrombotic therapies in patients with AF.