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2016 ; 1
(1
): 65-72
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Incidence and Determinants of Traumatic Intracranial Bleeding Among Older
Veterans Receiving Warfarin for Atrial Fibrillation
#MMPMID27437657
Dodson JA
; Petrone A
; Gagnon DR
; Tinetti ME
; Krumholz HM
; Gaziano JM
JAMA Cardiol
2016[Apr]; 1
(1
): 65-72
PMID27437657
show ga
IMPORTANCE: Traumatic intracranial bleeding, which is most commonly attributable
to falls, is a common concern among health care professionals, who are hesitant
to prescribe oral anticoagulants to older adults with atrial fibrillation.
OBJECTIVE: To describe the incidence of and risk factors for traumatic
intracranial bleeding in a large cohort of older adults who were newly prescribed
warfarin sodium. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study at
the US Department of Veterans Affairs (VA). Participants included 31?951 veterans
with atrial fibrillation 75 years or older who were new referrals to VA
anticoagulation clinics (for warfarin therapy) between January 1, 2002, and
December 31, 2012. The dates of the core analysis were March 2014 through May
2015, and subsequent ad hoc analyses were performed through December 2015.
Patients with comorbid conditions requiring warfarin were excluded. MAIN OUTCOMES
AND MEASURES: The primary outcome was hospitalization for traumatic intracranial
bleeding. Secondary outcomes included hospitalization for any intracranial
bleeding or ischemic stroke. We used International Classification of Diseases,
Ninth Revision, Clinical Modification codes to identify the incidence rates of
these outcomes after warfarin initiation using VA administrative data (in-system
hospitalizations) and Medicare fee-for-service claims data (out-of-system
hospitalizations). Clinical characteristics, laboratory results, and pharmacy
data were extracted from the VA electronic medical record. For traumatic
intracranial bleeding, Cox proportional hazards regression was used to determine
predictors of interest selected a priori based on prior known associations.
RESULTS: The study population comprised 31?951 participants. The mean (SD)
patient age was 81.1 (4.1) years, and 98.1% were male. Comorbidities were common,
including hypertension (82.5%), coronary artery disease (42.6%), and diabetes
mellitus (33.8%). During the study period, the incidence rate of hospitalization
for traumatic intracranial bleeding was 4.80 per 1000 person-years. In unadjusted
models, significant predictors of traumatic intracranial bleeding included
dementia, fall within the past year, anemia, depression, abnormal renal or liver
function, anticonvulsant use, labile international normalized ratio, and
antihypertensive use. After adjusting for potential confounders, the remaining
significant predictors for traumatic intracranial bleeding were dementia (hazard
ratio [HR], 1.76; 95% CI, 1.26-2.46), anemia (HR, 1.23; 95% CI, 1.00-1.52),
depression (HR, 1.30; 95% CI, 1.05-1.61), anticonvulsant use (HR, 1.35; 95% CI,
1.04-1.75), and labile international normalized ratio (HR, 1.33; 95% CI,
1.04-1.72). The incidence rates of hospitalization for any intracranial bleeding
and ischemic stroke were 14.58 and 13.44, respectively, per 1000 person-years.
CONCLUSIONS AND RELEVANCE: Among patients 75 years or older with atrial
fibrillation initiating warfarin therapy, the risk factors for traumatic
intracranial bleeding are unique from those for ischemic stroke. The high overall
rate of intracranial bleeding in our sample supports the need to more
systematically evaluate the benefits and harms of warfarin therapy in older
adults.
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