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Powell K, Curtiss W, Sadek E, Hecht J. Is reversal of anticoagulants necessary in neurologically intact traumatic intracranial hemorrhage? Pharmacotherapy 2024; 44:241-248. [PMID: 38140830 DOI: 10.1002/phar.2901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Falls are the leading cause of injury in older individuals, with intracranial hemorrhage (ICH) being a common complication. Anticoagulants, such as vitamin K antagonist and direct oral anticoagulants, are increasingly utilized, and clinicians may question the necessity of reversal in patients with minor ICH, especially in the setting of increased risk of adverse events. This study aimed to identify a population of patients with minor traumatic ICH at low risk for poor-neurologic status where anticoagulant reversal may not improve outcomes. METHODS This retrospective cohort study utilized data accessed from 35 trauma centers from 2018 to 2021. Patients included had a preinjury anticoagulant regimen, ICH due to blunt trauma, Glasgow Coma Scale score of 15, an Abbreviated Injury Scale (AIS) head score from 2 to 4, and an AIS of ≤1 for non-head regions within 24 h of hospital arrival. Patients were excluded if they required an emergent neurosurgical procedure or were on a preinjury purinergic-P2 receptor-12 protein (P2Y12) inhibitor. The primary outcome was the rate of in-hospital mortality or hospice. RESULTS There were 654 patients on preinjury anticoagulation who were included with a minor traumatic ICH without neurologic deficits. Overall, 263 patients were reversed and 391 were not reversed. Twelve (4.6%) patients with in-hospital mortality or hospice were reversed compared with 19 (4.91%) patients who were not reversed (p = 0.861). A composite of hospital complications occurred in 21 (8%) reversed patients and 34 (8.7%) not reversed patients (p = 0.748). The average intensive care unit length of stay was 1.4 ± 3.4 days in the reversed group and 1.1 ± 1.8 days in the not reversed group (p = 0.069). CONCLUSION This study found no difference in hospital outcomes between patients with minor traumatic ICH on oral anticoagulants who were neurologically intact that were reversed versus those who were not reversed. Further studies should continue to define the subset of traumatic ICH patients who may not require reversal of anticoagulation.
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Affiliation(s)
- Kelly Powell
- Trinity Health Ann Arbor, Ypsilanti, Michigan, USA
| | | | - Erin Sadek
- Trinity Health Ann Arbor, Ypsilanti, Michigan, USA
| | - Jason Hecht
- Trinity Health Ann Arbor, Ypsilanti, Michigan, USA
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Barletta JF, Shirah GR, Mangram AJ, Sucher JF, Hostert SA, Bruce K, Springs H, Zach V. Reversal of pre-injury factor-Xa inhibitors with prothrombin complex concentrates in patients following traumatic brain injury. Clin Neurol Neurosurg 2023; 235:108040. [PMID: 37944307 DOI: 10.1016/j.clineuro.2023.108040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION There is substantial debate on the best method to reverse factor Xa-inhibitors in patients following traumatic brain injury (TBI). Prothrombin complex concentrates (PCC) have been used for this indication but their role has been questioned. This study reported failure rates with PCC in patients following TBI and as a secondary objective, compared 4-factor (4 F-PCC) and activated PCC (APCC). MATERIAL AND METHODS Consecutive patients with TBI on factor Xa-inhibitors admitted to one of two trauma centers were retrospectively identified. Patients with penetrating TBI, delays in PCC administration (>6 h), receipt of tranexamic acid, factor VIIa or no follow up CT-scan were excluded. The primary outcome was treatment failure defined as hematoma expansion > 20% from baseline for SDH, EDH or IPH, a new hematoma not present on the initial CT scan or any expansion of a SAH or IVH. Hematoma expansion was further categorized as symptomatic or asymptomatic, designated by a change in the motor GCS score, neurologic exam or change ≥ 3 in NIH Stroke Scale. Multi-variate analysis was performed. RESULTS There were 43 patients with a mean age of 77 ± 13 years with primarily mild TBI (95%) after a ground level fall (79%). The mean dose was 41 ± 12 units/kg. Sixty percent received 4 F-PCC and 40% APCC. The incidence of treatment failure was 28% (12/43). Of the 12 patients with hematoma expansion, only 3 were symptomatic (9.3%). Hematoma expansion with 4 F-PCC and APCC were similar (27% vs. 29%,p = .859). Only sex was associated with hematoma expansion on multivariate analysis [OR (95% CI) = 6.7 (1.1 - 40.9)]. CONCLUSION PCC was an effective option for factor Xa inhibitor reversal following TBI. The relationship between radiographic expansion and clinical expansion was poor.
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Affiliation(s)
- Jeffrey F Barletta
- Midwestern University, College of Pharmacy, Glendale Campus, 19555 N 59th Avenue, Glendale, AZ 85308, USA.
| | - Gina R Shirah
- HonorHealth, John C. Lincoln Medical Center, 250 E Dunlap Ave, Phoenix, AZ 85020, USA
| | - Alicia J Mangram
- HonorHealth, John C. Lincoln Medical Center, 250 E Dunlap Ave, Phoenix, AZ 85020, USA
| | - Joseph F Sucher
- HonorHealth, Deer Valley Medical Center, 19829 N 27th Ave, Phoenix, AZ 85027, USA
| | - Sarah A Hostert
- HonorHealth, Deer Valley Medical Center, 19829 N 27th Ave, Phoenix, AZ 85027, USA
| | - Kimberli Bruce
- HonorHealth, John C. Lincoln Medical Center, 250 E Dunlap Ave, Phoenix, AZ 85020, USA
| | - Hayley Springs
- HonorHealth, John C. Lincoln Medical Center, 250 E Dunlap Ave, Phoenix, AZ 85020, USA
| | - Victor Zach
- Midwestern University, College of Osteopathic Medicine, 19555 59th Ave, Glendale, AZ 85308, USA; A.T. Still College of Osteopathic Medicine, 5850 E Still Cir, Mesa, AZ 85206, USA
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Baker RI, Gilmore G, Chen V, Young L, Merriman E, Curnow J, Joseph J, Tiao JY, Chih J, McRae S, Harper P, Tan CW, Brighton T, Royle G, Hugman A, Hankey GJ, Crowther H, Boey J, Gallus A, Campbell P, Tran H. Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study. Res Pract Thromb Haemost 2023; 7:100196. [PMID: 37601024 PMCID: PMC10439397 DOI: 10.1016/j.rpth.2023.100196] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 04/17/2023] [Accepted: 05/11/2023] [Indexed: 08/22/2023] Open
Abstract
Background Restoring hemostasis in patients on oral anticoagulants presenting with major hemorrhage (MH) or before surgical intervention has changed, with the replacement of vitamin K antagonist (VKA) with direct oral anticoagulants (DOACs). Objectives To observe the difference in urgent hemostatic management between patients on VKA and those on DOACs. Methods A multicenter observational study evaluated the variation in laboratory testing, hemostatic management, mortality, and hospital length of stay (LOS) in patients on VKA or DOACs presenting with MH or urgent hemostatic restoration. Results Of the 1194 patients analyzed, 783 had MH (61% VKA) and 411 required urgent hemostatic restoration before surgery (56% VKA). Compared to the international normalized ratio (97.6%), plasma DOAC levels were measured less frequently (<45%), and the time taken from admission for the coagulation sample to reach the laboratory varied widely (median, 52.3 minutes; IQR, 24.8-206.7). No significant plasma DOAC level (<50 ng/mL) was found in up to 19% of patients. There was a poor relationship between plasma DOAC level and the usage of a hemostatic agent. When compared with patients receiving VKA (96.5%) or dabigatran (93.7%), fewer patients prescribed a factor Xa inhibitor (75.5%) received a prohemostatic reversal agent. The overall 30-day mortality for MH (mean: 17.8%) and length of stay (LOS) (median: 8.7 days) was similar between VKA and DOAC patients. Conclusion In DOAC patients, when compared to those receiving VKA, plasma DOAC levels were measured less frequently than the international normalized ratio and had a poor relationship with administering a hemostatic reversal agent. In addition, following MH, mortality and LOS were similar between VKA and DOAC patients.
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Affiliation(s)
- Ross I. Baker
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia
- Perth Blood Institute, Perth, Australia
- Hollywood Hospital Haemophilia Centre, Perth, Australia
| | - Grace Gilmore
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia
- Perth Blood Institute, Perth, Australia
| | - Vivien Chen
- Concord Repatriation General Hospital, Concord Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia
| | - Laura Young
- Auckland City Hospital, Grafton, Auckland, New Zealand
| | | | | | - Joanne Joseph
- St Vincent’s Hospital and School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales Sydney, Sydney, Australia
| | - Jim Y. Tiao
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia
- Perth Blood Institute, Perth, Australia
| | - Jun Chih
- Curtin School of Population Health, Perth, Australia
| | - Simon McRae
- Perth Blood Institute, Perth, Australia
- Hollywood Hospital Haemophilia Centre, Perth, Australia
| | - Paul Harper
- Palmerston North Hospital, Palmerston North, New Zealand
| | - Chee W. Tan
- Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | | | | | | | - Graeme J. Hankey
- Perron Institute for Neurological and Translational Science and The University of Western Australia, Perth, Australia
| | | | - Jirping Boey
- Flinders Medical Centre, Flinders University, Adelaide, Australia
| | - Alexander Gallus
- Flinders Medical Centre, Flinders University, Adelaide, Australia
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