Skip to main content


Log in

The impact of pre-injury direct oral anticoagulants compared to warfarin in geriatric G-60 trauma patients

  • Original Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript



Pre-injury oral anticoagulants are associated with worse outcomes in geriatric (G-60) trauma patients, but there are limited data comparing warfarin with direct oral anticoagulants (DOAC). We sought to compare outcomes in G-60 trauma patients taking pre-injury DOACs vs. warfarin.


All trauma patients, age ≥60 who were admitted to the hospital and taking an oral anticoagulant pre-injury were retrospectively identified. Patients were excluded if their reason for admission was a suicide attempt or penetrating extremity injury. Outcome measures included blood transfusions, hospital LOS, and mortality. A second analysis was performed, whereby patients were matched using ISS and age.


There were 3,941 patients identified; 331 had documentation of anticoagulant use, pre-injury (warfarin, n = 237; DOAC, n = 94). Demographics were similar, but ISS [9 (4–13) vs. 8 (4–9), p = .027], initial INR [2.2 (1.8–2.9) vs. 1.2 (1.1–1.5), p < .001], and the use of pharmacologic reversal agents (48 vs. 14%, p < .001) were higher in the warfarin group. There was no difference in the use of blood transfusions (24 vs. 17%, p = .164) or mortality (5.9 vs. 4.3%, p = .789) between warfarin and DOAC groups, respectively. However, LOS was longer in the warfarin group [5 (3–7.5) vs. 4 (2–6.3) days, p = .02]. Matched analysis showed no difference in blood transfusions (23 vs. 17%, p = .276), mortality (2.1 vs. 4.3%, p = .682) or LOS [5 (3–7) vs. 4 (2–6.3) days, p = .158] between warfarin and DOAC groups, respectively.


Pre-injury DOACs are not associated with worse clinical outcomes compared to warfarin in G-60 trauma patients. Higher use of pharmacologic reversal agents with warfarin may be related to differences in mechanism of action and effect on INR.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others


  1. IMS Institute for Healthcare Informatics, Medicines Use and Spending Shifts. A review of the Use of Medicines in the U.S. in 2014. http://www.imshealthcom/files/web/IMSH%20Institute/Reports/Medicines_Use_and_Spending_Shifts/Medicine-Spending-and-Growth_1995-2014pdf. Accessed October 2016.

  2. Bonville DJ, Ata A, Jahraus CB, Arnold-Lloyd T, Salem L, Rosati C, Stain SC. Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients. Surgery. 2011;150:861–8.

    Article  PubMed  Google Scholar 

  3. Collins CE, Witkowski ER, Flahive JM, Anderson FA Jr, Santry HP. Effect of preinjury warfarin use on outcomes after head trauma in Medicare beneficiaries. Am J Surg. 2014;208(544–549):e541.

    Google Scholar 

  4. Dossett LA, Riesel JN, Griffin MR, Cotton BA. Prevalence and implications of preinjury warfarin use: an analysis of the National Trauma Databank. Arch Surg. 2011;146:565–70.

    Article  PubMed  Google Scholar 

  5. Grandhi R, Harrison G, Voronovich Z, Bauer J, Chen SH, Nicholas D, Alarcon LH, Okonkwo DO. Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients. J Trauma Acute Care Surg. 2015;78:614–21.

    Article  CAS  PubMed  Google Scholar 

  6. Lecky FE, Omar M, Bouamra O, Jenks T, Edwards A, Battle CE, Evans PA. The effect of preinjury warfarin use on mortality rates in trauma patients: a European multicentre study. Emerg Med J. 2015;32:916–20.

    Article  PubMed  Google Scholar 

  7. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients. J Trauma. 2007;63:525–30.

    Article  CAS  PubMed  Google Scholar 

  8. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981–92.

    Article  CAS  PubMed  Google Scholar 

  9. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Paolini JF, Berkowitz SD, Fox KA, Califf RM. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883–91.

    Article  CAS  PubMed  Google Scholar 

  10. Barnes GD, Lucas E, Alexander GC, Goldberger ZD. National Trends in Ambulatory Oral Anticoagulant Use. Am J Med. 2015;128(1300–1305):e1302.

    Google Scholar 

  11. von Heymann C, Rosenthal C, Kaufner L, Sander M. Management of direct oral anticoagulants-associated bleeding in the trauma patient. Curr Opin Anaesthesiol. 2016;29:220–8.

    Article  Google Scholar 

  12. Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System (WISQARS). http://www.cdcgov/injury/images/lc-charts/leading_causes_of_injury_deaths_violence_2014_1040w760hgif. Accessed October 2016.

  13. Ganetsky M. Trends and Characteristics of Emergency Department Patients Prescribed Novel Oral Anticoagulants. J Emerg Med. 2015;49:693–7.

    Article  PubMed  Google Scholar 

  14. Adelborg K, Grove EL, Sundboll J, Laursen M, Schmidt M. Sixteen-year nationwide trends in antithrombotic drug use in Denmark and its correlation with landmark studies. Heart; 2016

  15. Hanemaaijer S, Sodihardjo F, Horikx A, Wensing M, De Smet PA, Bouvy ML, Teichert M. Trends in antithrombotic drug use and adherence to non-vitamin K oral anticoagulants in the Netherlands. Int J Clin Pharm. 2015;37:1128–35.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Weitz JI, Semchuk W, Turpie AG, Fisher WD, Kong C, Ciaccia A, Cairns JA. Trends in Prescribing Oral Anticoagulants in Canada, 2008–2014. Clin Ther. 2015;37(2506–2514):e2504.

    Google Scholar 

  17. Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma. 2005;59:1131–7. (discussion 1137–1139).

    Article  CAS  PubMed  Google Scholar 

  18. Frontera JA, Lewin JJ 3rd, Rabinstein AA, Aisiku IP, Alexandrov AW, Cook AM, del Zoppo GJ, Kumar MA, Peerschke EI, Stiefel MF, Teitelbaum JS, Wartenberg KE, Zerfoss CL. Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the neurocritical care society and society of critical care medicine. Neurocrit Care. 2016;24:6–46.

    Article  CAS  PubMed  Google Scholar 

  19. Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EA, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Feeney JM, Santone E, DiFiori M, Kis L, Jayaraman V, Montgomery SC. Compared to warfarin, direct oral anticoagulants are associated with lower mortality in patients with blunt traumatic intracranial hemorrhage: a TQIP study. J Trauma Acute Care Surg. 2016;81:843–8.

    Article  CAS  PubMed  Google Scholar 

  21. Maung AA, Bhattacharya B, Schuster KM, Davis KA. Trauma patients on new oral anticoagulation agents have lower mortality than those on warfarin. J Trauma Acute Care Surg. 2016;81:652–7.

    Article  CAS  PubMed  Google Scholar 

  22. Pozzessere A, Grotts J, Kaminski S. Dabigatran use does not increase intracranial hemorrhage in traumatic geriatric falls when compared with warfarin. Am Surg. 2015;81:1039–42.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to A. J. Mangram.

Ethics declarations

Conflict of interest


Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Barletta, J.F., Hall, S., Sucher, J.F. et al. The impact of pre-injury direct oral anticoagulants compared to warfarin in geriatric G-60 trauma patients. Eur J Trauma Emerg Surg 43, 445–449 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: