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7th January 2022
The incidence of intrathoracic bleeding seen in an emergency department (ED) after elderly patients sustain a rib fracture due to a fall, is similar whether patients have been prescribed a direct oral anticoagulant (DOAC) or a vitamin K antagonist (VKA) such as warfarin. This was the conclusion of a study undertaken by researchers from the Department of Emergency Medicine, Hospital of Merano, Verona, Italy.
Falls are the leading cause of ED presentations in people aged 60 years and older, accounting for almost 50% of all incident injury presentations. Thoracic trauma which is associated with blunt or penetrating injury is a major cause of hospitalisation throughout the world and accounts for 10–15% of all traumas with 23.9% of these patients experiencing one or two rib fractures.
The incidence of intrathoracic bleeding after rib fractures remains uncertain and the extent to which any bleeding is associated with the type of anticoagulation taken is also unclear. For the present study, the researchers wanted to examine whether preinjury treatment with either VKAs or DOACs had an effect on the incidence of complications, such as bleeding, among elderly patients who experienced blunt thoracic trauma after a fall. They undertook a retrospective, observational study and included patients aged 75 years and older receiving oral anti-coagulants and who were found to have sustained at least one rib fracture due to a blunt chest trauma during their ED evaluation. Patients who trauma was caused by a car accident, who had a penetrating chest trauma, experienced severe changes in consciousness or who were haemodynamically unstable were excluded. Eligible patients were then divided into two groups: those taking a DOAC and those prescribed a VKA and both clinical and demographic data was collected for all patients. Regression analysis was used to determine which, if any clinical of demographic factors were associated with the risk of bleeding.
Over a 2-year period, 342 patients with a median age of 84 years (gender not reported) met the eligibility criteria for inclusion, of whom, 38.9% were treated with DOACs. There were a total of 24 (7%) of patients who presented with intrathoracic bleeding of which 17 (5%) required a surgical intervention or died because of their bleeding.
Overall, 4.5% of patients taking a DOAC developed intra-thoracic bleeding after rib fractures compared to 8.6% of those taking a VKA (p = 0.19). In addition, 4.5% of DOAC and 4.3% of VKA patients required surgery or died due to their bleed (p = 0.98).
Using regression analysis, the authors reported that the most significant factors associated with a bleed were age (p = 0.045), the presence of chronic heart failure (p = 0.046), chronic renal failure (p = 0.012), the number of rib fractures (p < 0.001), a high injury severity score (p < 0.001) and dangerous trauma dynamics (p < 0.001). Furthermore, none of these factors were affected by the type of anticoagulant taken.
Commenting on these results, the authors suggested that DOACs and VKAs presented a comparable risk for intra-thoracic bleeding, concluding that the risk of bleeding in the elderly prescribed anticoagulants and sustaining a non-severe trauma appeared to be low.
Turcato G et al. Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients Emergency Care Journal 2021
4th January 2022
The use of low dose aspirin as a primary prevention strategy was found in nearly half of patients aged 70 years of age and older despite current recommendations against its use in this age group. This was an important finding of an analysis by researchers from the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Diseases, Baltimore, US.
Low dose aspirin (LDA) has antithrombotic effects and has been used to reduce the incidence of cardiovascular events such as a myocardial infarction as both a primary and secondary preventative strategy. However, in recent years, the value of LDA for primary prevention, especially in those aged 70 years and older has been questioned, given the increased incidence of major haemorrhage. US guidance in 2019 from the American College of Cardiology and American Heart Association, states that ‘Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD (atherosclerotic cardiovascular disease) among adults>70 years of age.’ Similarly, the European Society of Cardiology also do not recommend aspirin use in those 70 years of age and older who are free from cardiovascular disease.
Given this clear recommendation against the use of LDA in the elderly, for the present study, the US researchers examined trends in the use of aspirin over the past two decades (1998 to 2019) in both primary and secondary prevention and to determine the factors associated with use in both scenarios. Data were obtained from the Behavioural Risk Factor Surveillance (BRFSS), which represents a nationally representative telephone survey of adults across the US. The researchers focused on adults aged 40 years and over to examine trends in aspirin use and individuals were given a score of 0 to 5, based on the presence of cardiovascular risk factors.
Low dose aspirin use increased between 1998 and 2009 from 29% to 37.5% but then decreased from 35.6% (2011) to 33.5% in 2019.
In 2019, 54,388 participants aged 40 years and older responded to questions on aspirin use in BRFSS and overall, 33.5% of them were using the drug. Among those without cardiovascular disease, LDA use was reported by 27.5% for primary prevention and 69.7% for secondary prevention. However, 45.6% of adults > 70 years of age reported using aspirin as a primary preventative strategy. In addition, 12.6% of aspirin users had a score of 0 (i.e., no cardiovascular risk factors).
Among those without any cardiovascular risk factors, males had a higher odds of primary prevention LDA use (adjusted odds ratio, aOR = 1.60, 95% CI 1.12 – 2.27) as did adults aged 70 years and older (aOR = 3.22, 95% CI 2.27 – 4.55) compared to those aged 40 to 69 years. A further factor associated with a higher odds of aspirin use for primary prevention was healthcare coverage (aOR = 2.28).
The authors concluded that despite declines in overall aspirin use, a significant proportion of elderly patients were prescribed the drug and that given the potential risks, clinicians should discuss these risks with a view to discontinuing the drug.
Boakye E et al. Aspirin for cardiovascular disease prevention among adults in the United States: Trends, prevalence, and participant characteristics associated with use. Am J Prev Cardiol 2021