From the Department of Surgery (Ta.S.I., R.P., D.C.C., R.C.), University of California-San Diego, San Diego, California; and Indiana University (Th.S.I.), Indianapolis, Indiana.
J Trauma Acute Care Surg. 2014 Mar;76(3):642-9; discussion 649-50. doi: 10.1097/TA.0000000000000138.
Elderly patients with atrial fibrillation or flutter who experience ground-level falls are at risk for lethal head injuries. Patients on oral anticoagulation (OAC) for thromboprophylaxis may be at higher risk for these head injuries. Trauma surgeons treating these patients face a difficult choice: (1) continue OAC to minimize stroke risk while increasing the risk of a lethal head injury or (2) discontinue OAC to avoid intracranial hemorrhage while increasing the risk of stroke. To inform this choice, we conducted a retrospective cohort study to assess long-term outcomes and risk factors for mortality after presentation with a ground-level fall among patients with and without OAC.
Retrospective analysis of the longitudinal version of the California Office of Statewide Planning and Development database was performed for years 1995 to 2009. Elderly anticoagulated patients (age > 65 years) with known atrial fibrillation or flutter who fell were stratified by CHA2DS2-VASc score and compared with a nonanticoagulated control cohort. Multivariable logistic regression including patient demographics, stroke risk, injury severity, and hospital type identified risk factors for mortality.
A total of 377,873 patient records met the inclusion criteria, 42,913 on OAC and 334,960 controls. The mean age was 82.4 and 80.6 years, respectively. Most were female, with CHA2DS2-VASc scores between 3 and 5. Mortality among OAC patients after a first fall was 6%, compared with 3.1% among non-OAC patients. Patients dying with a head injury constituted 31.6% of deaths within OAC patients compared with 23.8% among controls. Risk of eventual death with head injury exceeded annualized stroke risk for patients with CHA2DS2-VASc scores of 0 to 2. Predictors for mortality with head injury on the first admission included male sex, Asian ethnicity, a history of stroke, and trauma center admission.
Elderly patients on OAC for atrial fibrillation and/or flutter who fall have a greater risk for mortality compared with controls. Patients with low CHA2DS2-VASc scores (0-3) at high risk for falls with identified risk factors should speak to their prescribing physicians regarding the risk/benefits of continued use of OAC.
Epidemiologic/prognostic study, level III.
患有房颤或房扑的老年患者在地面跌倒时，存在致命性头部受伤的风险。接受口服抗凝剂（OAC）进行血栓预防的患者可能面临更高的头部受伤风险。治疗这些患者的创伤外科医生面临着一个艰难的选择：（1）继续 OAC 以最大程度地降低中风风险，同时增加致命性头部受伤的风险，或（2）停止 OAC 以避免颅内出血，同时增加中风的风险。为了做出这一选择，我们进行了一项回顾性队列研究，以评估有和没有 OAC 的患者在地面跌倒后出现长期结果和死亡率的危险因素。
对 1995 年至 2009 年期间加州全州规划和发展数据库的纵向版本进行回顾性分析。根据 CHA2DS2-VASc 评分，将已知患有房颤或房扑且年龄大于 65 岁的老年抗凝患者分为接受 OAC 治疗的患者和未接受 OAC 治疗的对照组，并进行比较。多变量逻辑回归包括患者人口统计学、中风风险、损伤严重程度和医院类型，以确定死亡率的危险因素。
共有 377873 份患者记录符合纳入标准，其中 42913 份在 OAC 治疗下，334960 份为对照组。平均年龄分别为 82.4 岁和 80.6 岁。大多数是女性，CHA2DS2-VASc 评分为 3 至 5。首次跌倒后 OAC 患者的死亡率为 6%，而非 OAC 患者为 3.1%。在接受 OAC 治疗的患者中，因头部受伤而死亡的患者占 OAC 患者死亡人数的 31.6%，而对照组为 23.8%。对于 CHA2DS2-VASc 评分为 0 至 2 的患者，因头部受伤而死亡的风险超过了年度中风风险。首次入院时因头部受伤导致死亡的预测因素包括男性、亚洲种族、中风史和创伤中心入院。
因房颤和/或房扑而接受 OAC 治疗的老年跌倒患者的死亡率高于对照组。对于 CHA2DS2-VASc 评分较低（0-3）且有跌倒高风险且存在已知危险因素的患者，应与其处方医生讨论继续使用 OAC 的风险/获益。
流行病学/预后研究，III 级。
