Oral anticoagulant reversal and mortality in trauma patients: a multicentre propensity score-matched cohort study

Oral anticoagulant (OAC) therapy increases bleeding risk but its impact on trauma outcomes and the benefit of reversal remains uncertain. This study aimed to evaluate 1/the effect of preinjury OAC therapy on trauma mortality and 2/the protective role of OAC reversal and its associated thrombotic risk.

We conducted an observational study using a prospective multicenter trauma registry between January 2012 and December 2023. OAC-treated patients were matched with non-OAC-treated patients using a propensity score. Univariable and multivariable logistic regressions assessed associations between OAC therapy and day 1 and day 7 mortality. The effect of guideline-concordant OAC reversal was evaluated. Thrombotic complications were recorded.

Of the 27,426 trauma patients, 3% were OAC-treated. They were older, had more comorbidities, and experienced higher mortality. After matching (n = 2196), OAC therapy remained independently associated with increased mortality (day 1: OR 2·21, 95% CI [1·41-3·43]; day 7: OR 2·06, [1·41-3·00]), with greater risk from vitamin K antagonists (VKA) than direct oral anticoagulants (DOAC). Guideline-concordant OAC reversal, achieved only in 21% of cases, independently reduced mortality at day 1 (OR 0·10, 95% CI [0·03-0·31], p < 0·01) and day 7 (OR 0·51, 95% CI [0·22-0·97], p < 0·01). No significant association was found between reversal and thrombotic complications.

Preinjury OAC therapy substantially increased trauma mortality, particularly with VKA. Guideline-concordant reversal was associated with reduced mortality in both VKA- and DOAC-treated patients without excess thrombotic risk but remains underused. These findings emphasise the urgent need for systematic implementation of reversal strategies in OAC-treated trauma patients.

The Traumabase registry is funded by several Regional Health Agencies (Agences Régionales de Santé, ARS): ARS Île-de-France, ARS Occitanie, ARS Grand Est, ARS Hauts-de-France, and ARS Auvergne-Rhône-Alpes. The registry is also funded by the French Road Safety Observatory-Road Safety Delegation Service (Observatoire National Interministériel de la Sécurité Routière-Délégation à la Sécurité Routière).