比较直接口服抗凝剂和维生素 K 拮抗剂在老年和非老年创伤患者结局中的应用。
Comparison of direct oral anticoagulant and vitamin K antagonists on outcomes among elderly and nonelderly trauma patients.
机构信息
From the Department of Emergency Medicine (T.N., F.X.G., C.W.C.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Emergency and Critical Care Medicine (T.N.), Hyogo Emergency Medical Center, Hyogo; Department of Emergency and Critical Care Medicine (T.N., H.N., A.N.), Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan; and Department of Surgery (J.B.B.), Division of Trauma and General Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
出版信息
J Trauma Acute Care Surg. 2020 Sep;89(3):514-522. doi: 10.1097/TA.0000000000002823.
BACKGROUND
Direct oral anticoagulants (DOACs) are widely used among patients requiring anticoagulant therapy. These drugs are associated with a lower risk of bleeding than vitamin K antagonists (VKAs). However, the outcomes of elderly trauma patients receiving DOACs are not well known.
METHODS
We reviewed data from trauma patients at our level I trauma center (University of Pittsburgh Medical Center, Presbyterian Hospital) seen from January 2011 to July 2018. We identified trauma patients taking DOACs or VKAs and compared these cohorts using 1:1 propensity score-matching based on patient characteristics, antiplatelet use, comorbidities, and laboratory values. The primary outcome was in-hospital mortality. Secondary outcomes included the proportion of patients discharged to skilled nursing facility/rehabilitation facility discharge or to home, and transfusion volume.
RESULTS
Of 32,272 trauma patients screened, 530 were taking DOACs and 1,702 were taking VKAs. We matched 668 patients in a 1:1 ratio (DOACs group, 334 vs. VKAs group, 334). The DOACs group had similar mortality (4.8% vs. 1.6%; odds ratio (OR), 3.0; 95% confidence interval (CI), 0.31-28.8; p = 0.31) among patients younger than 65 years, but mortality differed (3.0% vs. 6.6%; OR, 0.41; 95% CI, 0.17-0.99; p = 0.048) among patients older than 65 years. The proportion of patients discharged to skilled nursing facility/rehabilitation facility (50.0% vs. 50.6%; OR, 0.98; 95% CI, 0.72-1.32; p = 0.88) and to home (40.4% vs. 38.6%; OR, 1.08; 95% CI, 0.79-1.47; p = 0.64) were similar. Patients in the DOACs group received fewer fresh frozen plasma (p = 0.032), but packed red blood cells (p = 0.86) and prothrombin complex concentrate (p = 0.48) were similar.
CONCLUSION
In this matched cohort of anticoagulated trauma patients, DOACs were associated with the decreased in-hospital mortality and decreased administration of fresh frozen plasma compared with VKAs among trauma patients 65 years or older taking anticoagulant therapy.
LEVEL OF EVIDENCE
Prognostic/Epidemiological, level III.
背景
直接口服抗凝剂（DOACs）在需要抗凝治疗的患者中广泛使用。这些药物与维生素 K 拮抗剂（VKAs）相比出血风险较低。然而，接受 DOACs 治疗的老年创伤患者的结局尚不清楚。
方法
我们回顾了 2011 年 1 月至 2018 年 7 月在我们的一级创伤中心（匹兹堡大学医学中心长老会医院）就诊的创伤患者的数据。我们确定了正在服用 DOACs 或 VKAs 的创伤患者，并根据患者特征、抗血小板药物使用、合并症和实验室值，使用 1:1 倾向评分匹配比较这些队列。主要结局为院内死亡率。次要结局包括入住熟练护理设施/康复设施出院或回家的患者比例，以及输血量。
结果
在筛选的 32272 名创伤患者中，有 530 名患者正在服用 DOACs，1702 名患者正在服用 VKAs。我们以 1:1 的比例匹配了 668 名患者（DOACs 组 334 名，VKAs 组 334 名）。在年龄小于 65 岁的患者中，DOACs 组的死亡率相似（4.8%比 1.6%；比值比（OR），3.0；95%置信区间（CI），0.31-28.8；p=0.31），但在年龄大于 65 岁的患者中，死亡率不同（3.0%比 6.6%；OR，0.41；95%CI，0.17-0.99；p=0.048）。入住熟练护理设施/康复设施（50.0%比 50.6%；OR，0.98；95%CI，0.72-1.32；p=0.88）和回家（40.4%比 38.6%；OR，1.08；95%CI，0.79-1.47；p=0.64）的患者比例相似。DOACs 组患者接受的新鲜冷冻血浆较少（p=0.032），但接受的浓缩凝血酶原复合物（p=0.48）和浓缩红细胞（p=0.86）相似。
结论
在这项接受抗凝治疗的创伤患者匹配队列中，与 VKAs 相比，年龄在 65 岁或以上的接受抗凝治疗的创伤患者中，DOACs 与住院死亡率降低和新鲜冷冻血浆使用减少相关。
证据水平
预后/流行病学，III 级。
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