Injuries in patients who are on oral anticoagulants
and antiplatelet drugs
In
the recent past increasing number of cardiovascular patients (atrial
fibrillation, DVT, post interventions) are put on oral anticoagulants and
antiplatelet drugs after a life or limb threatening cardiovascular event. Therapeutic advancements are increasing probably
the need for these special classes of drugs in our patients. We are concerned
about the risk of bleeding in such patients.
Spontaneous bleeding is one and prolonged and profuse bleeding from
trauma is the other which we may have address in some of these patients. We
have already noted the increased risk of puncture site complications (bleeding,
pseudo-aneurysm) after angiogram or angioplasty in those receiving the triple
antiplatelet therapy in the cardiac patients.
The patients are leading active lives and traveling like any person
after recovering from cardiovascular events and there is a probability that
they may be prone for injuries.
If
a patient who is on oral anticoagulants or antiplatelet drugs sustain injuries
there can be more bleeding and some times it can be life threatening. Bleeding
in to the closed cavities such as intracranial, intra thoracic and
retroperitoneal can continue for longer periods under the influence of the
drugs. Recently DJ Bonville et al from
Albany retrospectively reviewed (3,436) the impact of pre-injury warfarin and
antiplatelet drugs (456) on the outcomes of trauma patients from 2004 – 2007 at
a New York state level-1 trauma center.
Patients on Warfarin were 3.1 times more likely die after adjusting for
potential confounders. Aspirin and clopidogrel were not associated with
increased mortality. But these drugs were associated with increased risk of
Intra cranial hemorrhage (ICH). But
among the ICH patients increased mortality was associated with warfarin. (Surgery
2011;150: 861-8)
In
many countries and in India the aging population is going increase in the
coming years. In USA people above 65 years are 13% and they are going to become
20% in 2050. Some of these are going to
receive these medications. Many studies
in the past linked the mortality and morbidity of trauma patients to the use of
anticoagulants. In one retrospective study Dossett et al reviewed one million trauma patients
admitted in 402 centers. In this group 36,270 patients were taking warfarin. Among these taking warfarin 9.3% died and
only 4.3% died in the group not taking warfarin. (Arch Surg 2011;146:565-70).
Initiation
of oral anticoagulation after giving heparin for 5 days in DVT patients is
practiced in many hospitals. The tablet warfarin action is monitored by testing
the INR frequently and maintained between 2-3. It is difficult for the patients
who are not living close to the towns to get the reliable INR tests. The Indian
diet may be also interfering with action of the drugs. Anticoagulation clinics
are not present in states like Andhra Pradesh in India. There is a need for the
development of web sites to guide these patients about the drug interactions
and precautions to be taken while taking the medication. It will be very
convenient for the patients if is possible to provide the free testing
facilities at the pharmacies supplying (selling) the medications. These
patients can carry a card which can be flashed in case of emergency such as
trauma to help the treating doctors to take necessary precautions and reverse
the effects of anticoagulation (warfarin effect). Correction with Fresh frozen
plasma, Injection Vitamin K and Factor
VIIa are used for reversing the warfarin effect.
