老年创伤性脑损伤患者中，伤前抗凝药物和处方抗血小板药物对预后的影响。

The impact of preinjury anticoagulants and prescription antiplatelet agents on outcomes in older patients with traumatic brain injury.

机构信息

From the Trauma Service, Scripps Mercy Hospital, San Diego, California.

出版信息

J Trauma Acute Care Surg. 2014 Feb;76(2):431-6. doi: 10.1097/TA.0000000000000107.

DOI:10.1097/TA.0000000000000107

PMID:24458049

Abstract

BACKGROUND

Anticoagulants and prescription antiplatelet (ACAP) agents widely used by older adults have the potential to adversely affect traumatic brain injury (TBI) outcomes. We hypothesized that TBI patients on preinjury ACAP agents would have worse outcomes than non-ACAP patients.

METHODS

This was a 5.5-year retrospective review of patients 55 years and older admitted to a Level I trauma center with blunt force TBI. Patients were categorized as ACAP (warfarin, clopidogrel, dipyridamole/aspirin, enoxaparin, subcutaneous heparin, or multiple agents) or non-ACAP. ACAP patients were further stratified by class of agent (anticoagulant or antiplatelet). Initial and subsequent head computerized tomographic results were examined for type and progression of TBI. Patient preadmission living status and discharge destination were identified. Primary outcome was in-hospital mortality. Secondary outcomes were progression of initial TBI, development of new intracranial hemorrhage (remote from initial), and the need for an increased level of care at discharge.

RESULTS

A total of 353 patients met inclusion criteria: 273 non-ACAP (77%) and 80 ACAP (23%). Upon exclusion of three patients taking a combination of agents, 350 were available for advanced analyses. ACAP status was significantly related to in-hospital mortality. After adjustment for patient and injury characteristics, anticoagulant users were more likely than non-ACAP patients to show progression of initial hemorrhage and develop a new hemorrhagic focus. However, compared with non-ACAP users, antiplatelet users were more likely to die in the hospital. Among survivors to discharge, anticoagulant users were more likely to be discharged to a care facility, but this finding was not robust to adjustment.

CONCLUSION

Older TBI patients on preinjury ACAP agents experience a comparatively higher rate of inpatient mortality and other adverse outcomes caused by the effects of antiplatelet agents. Our findings should inform decision making regarding prognosis and caution against grouping anticoagulant and antiplatelet users together in considering outcomes.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

摘要

背景

老年人广泛使用的抗凝药物和处方抗血小板药物（ACAP）有可能对创伤性脑损伤（TBI）的结果产生不利影响。我们假设，在受伤前使用 ACAP 药物的 TBI 患者的预后比非 ACAP 患者差。

方法

这是一项为期 5.5 年的回顾性研究，对象为 55 岁及以上在一级创伤中心因钝力性 TBI 入院的患者。患者分为 ACAP（华法林、氯吡格雷、双嘧达莫/阿司匹林、依诺肝素、皮下肝素或多种药物）或非 ACAP。ACAP 患者进一步根据药物类别（抗凝剂或抗血小板药物）进行分层。检查初始和后续头部计算机断层扫描结果，以确定 TBI 的类型和进展。确定患者入院前的居住状况和出院去向。主要结局是住院死亡率。次要结局是初始 TBI 的进展、新颅内出血（与初始出血部位不同）的发生以及出院时需要增加护理水平。

结果

共有 353 名患者符合纳入标准：273 名非 ACAP（77%）和 80 名 ACAP（23%）。排除服用多种药物的 3 名患者后，350 名患者可进行进一步分析。ACAP 状态与住院死亡率显著相关。在调整了患者和损伤特征后，抗凝剂使用者比非 ACAP 患者更有可能出现初始出血进展和发生新的出血灶。然而，与非 ACAP 使用者相比，抗血小板使用者更有可能在医院死亡。在出院幸存者中，抗凝剂使用者更有可能被送往护理机构，但这一发现在调整后并不稳健。