Oral anticoagulant reversal and mortality in trauma patients: a multicentre propensity score–matched cohort study

TL;DR

This study finds that preinjury use of oral anticoagulants increases trauma mortality, but following guidelines to reverse their effects can significantly reduce this risk without causing more blood clots.

Contribution

The study demonstrates that guideline-concordant reversal of oral anticoagulants reduces trauma mortality without increasing thrombotic risk, emphasizing the need for systematic implementation of reversal strategies.

Findings

Preinjury oral anticoagulant therapy is independently associated with increased trauma mortality, particularly with vitamin K antagonists.

Guideline-concordant reversal of anticoagulants significantly reduces mortality at both day 1 and day 7 post-trauma.

There is no significant association between anticoagulant reversal and thrombotic complications.

Abstract

Oral anticoagulant (OAC) therapy increases bleeding risk but its impact on trauma outcomes and the benefit of reversal remains uncertain. This study aimed to evaluate 1/the effect of preinjury OAC therapy on trauma mortality and 2/the protective role of OAC reversal and its associated thrombotic risk.

We conducted an observational study using a prospective multicenter trauma registry between January 2012 and December 2023. OAC-treated patients were matched with non-OAC-treated patients using a propensity score. Univariable and multivariable logistic regressions assessed associations between OAC therapy and day 1 and day 7 mortality. The effect of guideline-concordant OAC reversal was evaluated. Thrombotic complications were recorded.

Of the 27,426 trauma patients, 3% were OAC-treated. They were older, had more comorbidities, and experienced higher mortality. After matching (n = 2196), OAC therapy remained independently associated with increased mortality (day 1: OR 2·21, 95% CI [1·41–3·43]; day 7: OR 2·06, [1·41–3·00]), with greater risk from vitamin K antagonists (VKA) than direct oral anticoagulants (DOAC). Guideline-concordant OAC reversal, achieved only in 21% of cases, independently reduced mortality at day 1 (OR 0·10, 95% CI [0·03–0·31], p < 0·01) and day 7 (OR 0·51, 95% CI [0·22–0·97], p < 0·01). No significant association was found between reversal and thrombotic complications.

Preinjury OAC therapy substantially increased trauma mortality, particularly with VKA. Guideline-concordant reversal was associated with reduced mortality in both VKA- and DOAC-treated patients without excess thrombotic risk but remains underused. These findings emphasise the urgent need for systematic implementation of reversal strategies in OAC-treated trauma patients.

The Traumabase registry is funded by several Regional Health Agencies (Agences Régionales de Santé, ARS): ARS Île-de-France, ARS Occitanie, ARS Grand Est, 10.13039/501100014160ARS Hauts-de-France, and ARS Auvergne-Rhône-Alpes. The registry is also funded by the French Road Safety Observatory—Road Safety Delegation Service (Observatoire National Interministériel de la Sécurité Routière—Délégation à la Sécurité Routière).

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