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AHEAD Study: an observational study of the management of anticoagulated patients who suffer head injury
  1. Suzanne Mason1,
  2. Maxine Kuczawski1,
  3. M Dawn Teare1,
  4. Matt Stevenson1,
  5. Steve Goodacre1,
  6. Shammi Ramlakhan2,
  7. Francis Morris2,
  8. Joanne Rothwell1
  1. 1School of Health and Related Research, University of Sheffield, Sheffield, UK
  2. 2Emergency Department, Northern General Hospital, Sheffield, UK
  1. Correspondence to Professor Suzanne Mason; s.mason{at}sheffield.ac.uk

Abstract

Objectives Management of anticoagulated patients after head injury is unclear due to lack of robust evidence. This study aimed to determine the adverse outcome rate in these patients and identify risk factors associated with poor outcome.

Design Multicentre, observational study using routine patient records.

Setting 33 emergency departments in England and Scotland.

Participants 3566 adults (aged ≥16 years) who had suffered blunt head injury and were currently taking warfarin.

Main outcome measures Primary outcome measure was rate of adverse outcome defined as death or neurosurgery following initial injury, clinically significant CT scan finding or reattendance with related complication within 10 weeks of initial hospital attendance. Secondary objectives included identifying risk factors for adverse outcome using univariable and multivariable analyses.

Results Clinical data available for 3534/3566 patients (99.1%), median age 79 years; mean initial international normalised ratio (INR) 2.67 (SD 1.34); 81.2% Glasgow Coma Scale (GCS) 15: 59.8% received a CT scan with significant head injury-related finding in 5.4% (n=208); 0.5% underwent neurosurgery; 1.2% patients suffered a head injury-related death. Overall adverse outcome rate was 5.9% (95% CI 5.2% to 6.7%). Patients with GCS=15 and no associated symptoms had lowest risk of adverse outcome (risk 2.7%; 95% CI 2.1 to 3.6). Patients with GCS=15 multivariable analysis (using imputation) found risk of adverse outcome to increase when reporting at least one associated symptom: vomiting (relative risk (RR) 1.8; 95% CI 1.0 to 3.4), amnesia (RR 3.5; 95% CI 2.1 to 5.7), headache (RR 1.3; 95% CI 0.8 to 2.2), loss of consciousness (RR 1.75; 95% CI 1.0 to 3.0). INR measurement did not predict adverse outcome in patients with GCS=15 (RR 1.1; 95% CI 1.0 to 1.2).

Conclusions In alert warfarinised patients following head injury, the presence of symptoms is associated with greater risk of adverse outcome. Those with GCS=15 and no symptoms are a substantial group and have a low risk of adverse outcome.

Trial registration number NCT02461498.

  • Warfarin

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Footnotes

  • Contributors All authors made substantial contributions to the conception and design (SM, SG, SR, FM), acquisition of the data (MK), or analysis and interpretation (MDT, MK, MS, SG, SM, JR). MK drafted the article and all other authors revised it critically for important intellectual content. SM is the guarantor. All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding This paper presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme grant reference number PB-PG-0808-17148.

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Ethics approval NRES Committee Yorkshire and The Humber—Sheffield: 11/H1308/13.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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