Benefits and risks of anticoagulation resumption following traumatic brain injury.
Benefits and risks of anticoagulation resumption following traumatic brain injury.
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DOI：
10.1001/jamainternmed.2014.2534
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发表时间：
2014-08
影响因子：
39
通讯作者：
Zuckerman IH
中科院分区：
文献类型：
--
作者：
Albrecht JS;Liu X;Baumgarten M;Langenberg P;Rattinger GB;Smith GS;Gambert SR;Gottlieb SS;Zuckerman IH
创伤性脑损伤后与抗凝治疗相关的出血风险增加，为老年患者的医疗管理带来了严重的困境：创伤性脑损伤后是否应该恢复抗凝治疗，如果是，何时恢复？评估创伤性脑损伤后恢复华法林治疗相关血栓形成和出血事件的风险。回顾性分析2006年至2009年期间因创伤性脑损伤住院的65岁以上医疗保险受益人的行政索赔数据，这些受益人在受伤前一个月接受华法林治疗（n = 10 782）。创伤性脑损伤住院后出院后每30天内的warranty使用情况。主要结局是创伤性脑损伤住院后出院后的出血和血栓形成事件。使用国际疾病分类第九次修订版临床修改代码在住院索赔中定义出血事件，包括出血性卒中、上消化道出血、肾上腺出血和其他出血。血栓形成事件包括缺血性卒中、肺栓塞、深静脉血栓形成和心肌梗死。出血性或缺血性卒中的复合终点是次要结局。创伤性脑损伤的医疗保险受益人主要是女性（64%）和白色（92%），平均（SD）年龄为81.3（7.3）岁，82%患有房颤。在出院后的12个月内，55%的患者在1天或30天以上的时间内接受华法林治疗。我们研究了华法林使用对后续阶段结局的滞后效应。既往使用华法林与血栓事件风险降低（相对风险[RR]，0.77 [95% CI，0.67-0.88]）和出血事件风险增加（RR，1.51 [95% CI，1.29-1.78]）相关。既往使用华法林与出血性或缺血性卒中风险降低相关（RR，0.83 [95% CI，0.72-0.96]）。本研究的结果表明，尽管出血风险增加，但就卒中风险降低而言，大多数接受抗凝治疗的患者在因创伤性脑损伤住院后出院后恢复华法林治疗后仍有净获益。
The increased risk of hemorrhage associated with anticoagulant therapy following traumatic brain injury creates a serious dilemma for medical management of older patients: Should anticoagulant therapy be resumed after traumatic brain injury, and if so, when? To estimate the risk of thrombotic and hemorrhagic events associated with warfarin therapy resumption following traumatic brain injury. Retrospective analysis of administrative claims data for Medicare beneficiaries aged at least 65 years hospitalized for traumatic brain injury during 2006 through 2009 who received warfarin in the month prior to injury (n = 10 782). Warfarin use in each 30-day period following discharge after hospitalization for traumatic brain injury. The primary outcomes were hemorrhagic and thrombotic events following discharge after hospitalization for traumatic brain injury. Hemorrhagic events were defined on inpatient claims using International Classification of Diseases, Ninth Revision, Clinical Modification codes and included hemorrhagic stroke, upper gastrointestinal bleeding, adrenal hemorrhage, and other hemorrhage. Thrombotic events included ischemic stroke, pulmonary embolism, deep venous thrombosis, and myocardial infarction. A composite of hemorrhagic or ischemic stroke was a secondary outcome. Medicare beneficiaries with traumatic brain injury were predominantly female (64%) and white (92%), with a mean (SD) age of 81.3 (7.3) years, and 82% had atrial fibrillation. Over the 12 months following hospital discharge, 55% received warfarin during 1 or more 30-day periods. We examined the lagged effect of warfarin use on outcomes in the following period. Warfarin use in the prior period was associated with decreased risk of thrombotic events (relative risk [RR], 0.77 [95% CI, 0.67-0.88]) and increased risk of hemorrhagic events (RR, 1.51 [95% CI, 1.29-1.78]). Warfarin use in the prior period was associated with decreased risk of hemorrhagic or ischemic stroke (RR, 0.83 [95% CI, 0.72-0.96]). Results from this study suggest that despite increased risk of hemorrhage, there is a net benefit for most patients receiving anticoagulation therapy, in terms of a reduction in risk of stroke, from warfarin therapy resumption following discharge after hospitalization for traumatic brain injury.