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Original Investigation
August 2014

Benefits and Risks of Anticoagulation Resumption Following Traumatic Brain Injury

Author Affiliations
  • 1Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
  • 2Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
  • 3Division of Pharmacy Practice, Fairleigh Dickinson University School of Pharmacy, Florham Park, New Jersey
  • 4Shock, Trauma and Anesthesiology Research (STAR)–Organized Research Center, National Study Center for Trauma and Emergency Medical Services, University of Maryland, Baltimore
  • 5Department of Medicine, University of Maryland School of Medicine, Baltimore
  • 6IMPAQ International LLC, Columbia, Maryland
JAMA Intern Med. 2014;174(8):1244-1251. doi:10.1001/jamainternmed.2014.2534
Abstract

Importance  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?

Objective  To estimate the risk of thrombotic and hemorrhagic events associated with warfarin therapy resumption following traumatic brain injury.

Design, Setting, and Participants  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).

Intervention  Warfarin use in each 30-day period following discharge after hospitalization for traumatic brain injury.

Main Outcomes and Measures  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.

Results  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]).

Conclusions and Relevance  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.

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