Warfarin has been the oral anticoagulant of choice for the treatment of thromboembolic disease. However, upwards of 50% of all new anticoagulant prescriptions are now for direct oral anticoagulants (DOAC). Despite this, outcome data evaluating preinjury anticoagulants remains scarce following traumatic brain injury (TBI). Our study objective is to determine the effects of preinjury anticoagulation on outcomes in older adults with TBI.
Patient data was obtained from 29 level 1 and 2 trauma centers from 2012 to June 30, 2018. Overall, 8312 patients who were aged65 years or older, suffering a ground level fall, and with an Abbreviated Injury Scale score (AIS)-head of ≥ 3 were identified. Patients were excluded if they presented with no signs of life or a traumatic mechanism besides ground level fall. Statistical comparisons were made using multivariable analyses with anticoagulant/antiplatelet use as the independent variable.
Of the total patients with TBI, 3293 were on antiplatelet agents (AP), 669 on warfarin, 414 on warfarin + AP, 188 on DOACs, 116 on DOAC + AP, and 3632 on no anticoagulant. There were 185 (27.7%) patients on warfarin and 43 (22.9%) on a DOAC with a combined outcome of mortality or hospice as compared to 575 (15.8%) in the no anticoagulant group (p<0.001). After adjusting for patient factors, there was an increased risk of mortality or hospice in the warfarin (OR 1.60; 95% CI 1.27 – 2.01) and DOAC group (OR 1.67; 95% CI 1.07 – 2.59) as compared to no anticoagulant. Warfarin+AP was associated with an increased risk of mortality or hospice (OR 1.61; 95% CI 1.18-2.21) that was not seen with DOAC+AP (OR 0.93; 95% CI 0.46-1.87) as compared to no anticoagulant.
In older adults with TBI, preinjury treatment with warfarin or DOACs resulted in an increased risk of mortality or hospice whereas preinjury AP therapy did not increase risk. Future studies are needed with larger sample sizes to directly compare TBI outcomes associated with preinjury warfarin versus DOAC use.

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