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Intrathoracic bleeding incidence after rib fracture similar for DOACs and VKAs

Intrathoracic bleeding incidence among elderly patients with rib fractures is not influenced by the type of pre-injury anticoagulant therapy

The level of intrathoracic bleeding in elderly patients who sustain a rib fracture due to a fall, is similar irrespective of whether they have been prescribed a direct oral anticoagulant (DOAC) or a vitamin K antagonist (VKA) such as warfarin. This was the finding of a study undertaken by researchers from the Department of Emergency Medicine, Hospital of Merano, Verona, Italy.

Falls are a major cause of presentations in emergency departments among people aged 60 years and older, accounting for almost 50% of all incident injuries seen. Thoracic trauma which is associated with blunt or penetrating injury accounts for 10–15% of all traumas with 23.9% of these patients experiencing one or two rib fractures.

However, the incidence of intrathoracic bleeding after rib fractures remains uncertain as does the extent to which any such bleeding is influenced by the type of anticoagulation prescribed. For the present study, the researchers examined whether pre-injury treatment with either VKAs or DAOCs had an effect on the incidence of complications, such as bleeding, among elderly patients who experienced blunt thoracic trauma after a fall.

They performed a retrospective, observational study and included patients aged 75 years and older who were receiving oral anti-coagulants prior to their fall and who were found to have sustained at least one rib fracture due to a blunt chest trauma during their evaluation at an emergency department. Patients whose trauma was caused by a car accident, who had a penetrating chest trauma, experienced severe changes in consciousness or who were haemodynamically unstable were excluded. Included patients were then dichotomised into two groups: those taking a DOAC and those prescribed a VKA and both clinical and demographic data was collected for all patients. Regression analysis was used to determine which, if any clinical of demographic factors were associated with the risk of bleeding.


Over a 2-year period, 342 patients with a median age of 84 years (gender not reported) met the eligibility criteria for inclusion, of whom, 38.9% were treated with DOACs. There were a total of 24 (7%) of patients who presented with intrathoracic bleeding of which 17 (5%) required a surgical intervention or died because of their bleeding.

Overall, 4.5% of patients taking a DOAC developed intra-thoracic bleeding after rib fractures compared to 8.6% of those taking a VKA (p = 0.19). In addition, 4.5% of DOAC and 4.3% of VKA patients required surgery or died due to their bleed (p = 0.98).

Using regression analysis, the authors reported that the most significant factors associated with a bleed were age (p = 0.045), the presence of chronic heart failure (p = 0.046), chronic renal failure (p = 0.012), the number of rib fractures (p < 0.001), a high injury severity score (p < 0.001) and dangerous trauma dynamics (p < 0.001). Furthermore, none of these factors were affected by the type of anticoagulant taken.

Commenting on these results, the authors suggested that DOACs and VKAs presented a comparable risk for intra-thoracic bleeding and concluded that the risk of bleeding in the elderly prescribed anticoagulants and sustaining a non-severe trauma appeared to be low.


Turcato G et al. Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients Emergency Care Journal 2021

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