Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome

OBJECTIVEIsolated acute subdural hematoma (aSDH) is increasing in older populations and so is the use of oral anticoagulant therapy (OAT). The dramatic increase of OAT—with direct oral anticoagulants (DOACs) as well as with conventional anticoagulants—is leading to changes in the care of patients who present with aSDH while receiving OAT. The purpose of this study was to determine the management and outcome of patients being treated with OAT at the time of aSDH presentation.METHODSIn this single-center, retrospective study, the authors analyzed 116 consecutive cases involving patients with aSDH treated from January 2007 to June 2016. The following parameters were assessed: patient characteristics, admission status, anticoagulation status, perioperative management, comorbidities, clinical course, and outcome as determined at discharge and through 6 months of follow-up. Oral anticoagulants were classified as thrombocyte inhibitors, vitamin K antagonists, and DOACs. Patients were stratified based on which type of medication they were taking, and subgroup analyses were performed. Predictors of unfavorable outcome at discharge and follow-up were identified.RESULTSOf 116 patients, 74 (64%) had been following an OAT regimen at presentation with aSDH. The patients who were taking oral anticoagulants (OAT group) were significantly older (OR 12.5), more often comatose 24 hours postoperatively (OR 2.4), and more often had ≥ 4 comorbidities (OR 3.2) than patients who were not taking oral anticoagulants (no-OAT group). Accordingly, the rate of unfavorable outcome was significantly higher in patients in the OAT group, both at discharge (OR 2.3) and at follow-up (OR 2.2). Of the patients in the OAT group, 37.8% were taking a thrombocyte inhibitor, 54.1% a vitamin K antagonist, and 8.1% DOACs. In all cases, OAT was stopped on discovery of aSDH. For reversal of anticoagulation, patients who were taking a thrombocyte inhibitor received desmopressin 0.4 μg/kg, 1–2 g tranexamic acid, and preoperative transfusion with 2 units of platelets. Patients following other oral anticoagulant regimens received 50 IU/kg of prothrombin complex concentrates and 10 mg of vitamin K. There was no significant difference in the rebleeding rate between the OAT and no-OAT groups. The in-hospital mortality rate was significantly higher for patients who were taking a thrombocyte inhibitor (OR 3.3), whereas patients who were taking a vitamin K antagonist had a significantly higher 6-month mortality rate (OR 2.7). Patients taking DOACs showed a tendency toward unfavorable outcome, with higher mortality rates than patients on conventional OAT or patients in the vitamin K antagonist subgroup. Independent predictors for unfavorable outcome at discharge were comatose status 24 hours after surgery (OR 93.2), rebleeding (OR 9.8), respiratory disease (OR 4.1), and infection (OR 11.1) (Nagelkerke R2 = 0.684). Independent predictors for unfavorable outcome at follow-up were comatose status 24 hours after surgery (OR 12.7), rebleeding (OR 3.1), age ≥ 70 years (OR 3.1), and 6 or more comorbidities (OR 3.1, Nagelkerke R2 = 0.466). OAT itself was not an independent predictor for worse outcome.CONCLUSIONSAn OAT regimen at the time of presentation with aSDH is associated with increased mortality rates and unfavorable outcome at discharge and follow-up. Thrombocyte inhibitor treatment was associated with increased short-term mortality, whereas vitamin K antagonist treatment was associated with increased long-term mortality. In particular, patients on DOACs were seriously affected, showing more unfavorable outcomes at discharge as well as at follow-up. The suggested medical treatment for aSDH in both OAT and no-OAT patients seems to be effective and reasonable, with comparable rebleeding and favorable outcome rates in the 2 groups. In addition, prior OAT is not a predictor for aSDH outcome.

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Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients

Emergency Care Journal ◽

10.4081/ecj.2021.10284 ◽

2021 ◽

Vol 17 (4) ◽

Author(s):

Gianni Turcato ◽

Arian Zaboli ◽

Andrea Tenci ◽

Giorgio Ricci ◽

Massimo Zannoni ◽

...

Keyword(s):

Anticoagulant Therapy ◽

Vitamin K ◽

Oral Anticoagulant ◽

Oral Anticoagulant Therapy ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Traumatic Bleeding ◽

Post Traumatic

Closed chest traumas are frequent consequences of falls in the elderly. The presence of concomitant oral anticoagulant therapy can increase the risk of post-traumatic bleeding even in cases of trauma with non-severe dynamics. There is limited information about the differences between vitamin K antagonists and direct oral anticoagulants in the risk of post-traumatic bleeding. To assess differences in the risk of developing intra-thoracic hemorrhages after chest trauma with at least one rib fracture caused by an accidental fall in patients over 75 years of age taking oral anticoagulant therapy. This study involved data from four emergency departments over two years. All patients on oral anticoagulant therapy and over 75 years of age who reported a closed thoracic trauma with at least one rib fracture were retrospectively evaluated. Patients were divided into two study groups according their anticoagulant therapy. Of the 342 patients included in the study, 38.9% (133/342) were treated with direct oral anticoagulants and 61.1% (209/342) were treated with vitamin K antagonist. A total of 7% (24/342) of patients presented intrathoracic bleeding, while 5% (17/342) required surgery or died as a result for the trauma. Posttraumatic intrathoracic bleeding occurred in 4.5% (6/133) of patients receiving direct oral anticoagulants and 8.6% (18/209) of patients receiving vitamin K antagonist. Logistic regression analysis, revealed no difference in the risk of intrathoracic haemorrhages between the two studied groups. Direct oral anticoagulants therapy presents a risk of post-traumatic intrathoracic haemorrhage comparable to that of vitamin K antagonist therapy.

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Analysis of Recurrent Stroke Volume Between VKA (Vitamin K Antagonist) and Three NOACs (Non-Vitamin K Antagonist Oral Anticoagulants) Under Oral Anticoagulant Therapy

International Journal of Pharmaceutical Sciences Research ◽

10.15344/2394-1502/2016/116 ◽

2016 ◽

Vol 3 (1) ◽

Cited By ~ 1

Author(s):

Hiroaki Oguro ◽

Ryo Mizuhara ◽

Satoshi Abe ◽

Hiroyuki Takayoshi ◽

Shingo Mitaki ◽

...

Keyword(s):

Stroke Volume ◽

Anticoagulant Therapy ◽

Vitamin K ◽

Oral Anticoagulant ◽

Recurrent Stroke ◽

Oral Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Vitamin K Antagonist

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Recommendations on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation (Based on 2018 European Heart Rhythm Association Practical Guide)

Kardiologiia ◽

10.18087/cardio.2019.5.2633 ◽

2019 ◽

Vol 59 (5) ◽

pp. 68-79

Author(s):

L. V. Popova ◽

T. B. Kondratieva ◽

M. B. Aksenova ◽

T. V. Khlevchuk ◽

M. Z. Kanevskaya

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Randomized Clinical Trials ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Heart Rhythm ◽

Vitamin K Antagonist ◽

Advanced Liver Disease ◽

Clinical Variants

Non-vitamin K antagonist oral anticoagulants (NOACs) – direct oral anticoagulants – are getting the ever-broadening use in clinical practice. However, many problems related to optimal use of NOACs in specific clinical situations remain unresolved. European Heart Rhythm Association in April 2018 issued the renovated recommendations on the use of NOACs in patients with atrial fibrillation. The authors of recommendations presented some specific clinical variants for which they formulated practical advices based on the evidence obtained in randomized clinical trials. They also outlined the indications for use of NOACs, formulated practical start-program and scheme of subsequent follow-up management of patients taking NOACs. Recommendations contain information on pharmacokinetics of NOACs and their interactions with other drugs, consideration of feasibility of NOACs use in patients with chronic renal insufficiency or advanced liver disease. Many other practical problems are covered as well.

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Régi és új orális antikoagulánsok hazai alkalmazása pitvarfibrillációban

Orvosi Hetilap ◽

10.1556/650.2017.30802 ◽

2017 ◽

Vol 158 (39) ◽

pp. 1545-1549

Author(s):

János Tomcsányi ◽

Balázs Salfer ◽

Bence Nagy

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Oral Anticoagulant ◽

Oral Anticoagulant Therapy ◽

Real Life ◽

Vitamin K Antagonist ◽

Anticoagulant Treatment ◽

Oral Anticoagulant Treatment ◽

New Oral Anticoagulant ◽

Method Analysis

Abstract: Introduction: Despite a progress in the management of patients with atrial fibrillation this arrhythmia is one of the major causes of stroke, heart failure, sudden death and cardiovascular morbidity. Oral anticoagulation with vitamin K antagonist or non-vitamin K antagonist markedly reduces stroke and mortality in atrial fibrillation patients. Aim: To estimate the real-life vitamin K antagonist and non-vitamin K antagonist oral anticoagulant treatment in past years in Hungary. Method: Analysis of the National Health Insurance Administation database for atrial fibrillation (BNO: I48) between 2010–2015. We assumed that AF patient would turn to health care provides at least once either as inpatients or outpatients in a 5-year period. The patient was accepted as adherent after 6 months therapy and at least 80% oral anticoagulant prescription. Results: The prevalence of AF in Hungary is 3%. The mortality rate of AF 7%–10% per year. The adherence of the old oral anticoagulant treatment was 55%, but it was 69% among patient treated by “new” oral anticoagulant treatment. However, one third of the patients are not treated by effective old or new oral anticoagulant treatment. Conclusions: We need more effort to improve the effective and high adherence oral anticoagulant therapy in our country. Orv Hetil. 2017; 158(39): 1545–1549.

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Stroke Prevention in Atrial Fibrillation

Circulation ◽

10.1161/circulationaha.120.049768 ◽

2020 ◽

Vol 142 (24) ◽

pp. 2371-2388

Author(s):

Aristeidis H Katsanos ◽

Hooman Kamel ◽

Jeff S. Healey ◽

Robert G. Hart

Keyword(s):

Atrial Fibrillation ◽

Clinical Trials ◽

High Risk ◽

Vitamin K ◽

Stroke Prevention ◽

Oral Anticoagulant ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Bleeding Complications ◽

Secondary Stroke Prevention

Ischemic strokes related to atrial fibrillation are highly prevalent, presenting with severe neurologic syndromes and associated with high risk of recurrence. Although advances have been made in both primary and secondary stroke prevention for patients with atrial fibrillation, the long-term risks for stroke recurrence and bleeding complications from antithrombotic treatment remain substantial. We summarize the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focus on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials. Non–vitamin K antagonist oral anticoagulants have been proven to be safer and equally effective compared with warfarin in stroke prevention for patients with nonvalvular atrial fibrillation. Non–vitamin K antagonist oral anticoagulants are being investigated for the treatment of patients with atrial fibrillation and rheumatic heart disease, for the treatment of patients with recent embolic stroke of undetermined source and indirect evidence of cardiac embolism, and in the prevention of vascular-mediated cognitive decline in patients with atrial fibrillation. Multiple clinical trials are assessing the optimal timing of non–vitamin K antagonist oral anticoagulant initiation after a recent ischemic stroke and the benefit:harm ratio of non–vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation and history of previous intracranial bleeding. Ongoing trials are addressing the usefulness of left atrial appendage occlusion in both primary and secondary stroke prevention for patients with atrial fibrillation, including those with high risk of bleeding. The additive value of prolonged cardiac monitoring for subclinical atrial fibrillation detection through smartphone applications or implantable cardiac devices, together with the optimal medical management of individuals with covert paroxysmal atrial fibrillation, is a topic of intensive research interest. Colchicine treatment and factor XIa inhibition constitute 2 novel pharmacologic approaches that might provide future treatment options in the secondary prevention of cardioembolic stroke attributable to atrial fibrillation.

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