Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures

doi:10.1016/S0016-5107(02)70402-1

Gastrointestinal Endoscopy

Volume 55, Issue 7, June 2002, Pages 775-779

https://doi.org/10.1016/S0016-5107(02)70402-1 Get rights and content

Abstract

This is one of a series of statements discussing the practice of gastrointestinal endoscopy in common clinical situations. It is intended to aid endoscopists in determining the appropriate use of endoscopic procedures in conjunction with anticoagulation and/or antiplatelet therapy. Guidelines for the appropriate practice of endoscopy are based on critical review of the available data and expert consensus. Controlled clinical studies would be beneficial to clarify some aspects of this statement and revision might be necessary as new data appear. Clinical consideration may justify a course of action at variance from these specific recommendations.

Introduction

Anticoagulation therapy with warfarin is used to reduce the risk of thromboembolic events in patients with certain cardiovascular conditions, deep vein thrombosis (DVT), and hypercoagulable states. Anticoagulation therapy complicates the management of gastrointestinal bleeding. Interruption of anticoagulation therapy may be desirable for some patients undergoing endoscopic procedures. When preparing for an endoscopic procedure on an anticoagulated patient considerations include (1) the risk of complications of the underlying gastrointestinal disorder related directly to anticoagulation therapy; (2) bleeding related to an endoscopic intervention carried out in the setting of anticoagulation; and (3) a thromboembolic event related to interruption of anticoagulation therapy. Additional considerations include the utilization of resources for hospitalization, parenteral anticoagulation therapy, and laboratory tests used to monitor and document adjustment of anticoagulation therapy.

This guideline addresses the management of patients undergoing endoscopic procedures who are on either anticoagulation therapy or aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDS). First, the endoscopic management of acute gastrointestinal bleeding in therapeutically anticoagulated patients is discussed. Second, the risk of bleeding related to endoscopic interventions is considered. Third, the risk of thromboembolic events associated with interrupting anticoagulation therapy is discussed. Management schemes for patients on long-term anticoagulation therapy are proposed. Last, the risk of bleeding related to the use of aspirin or other NSAIDS in the periendoscopic period is reviewed and recommendations for management are provided.

Section snippets

Acute gastrointestinal hemorrhage in the anticoagulated patient

The most common site of significant bleeding in patients receiving oral anticoagulation therapy is the gastrointestinal tract.¹ A history of prior gastrointestinal bleeding, but not a history of peptic ulcer disease alone, is associated with an increased risk of major gastrointestinal hemorrhage during warfarin therapy (30% at 3 years versus 5% in those with no prior bleeding history).² The risk of gastrointestinal bleeding is also increased when the international normalized ratio (INR) is

Recommendations

The decision to reverse anticoagulation, risking thromboembolic consequences, must be weighed against the risk of continued bleeding by maintaining the anticoagulated state. The degree of reversal of anticoagulation should be individualized. A supratherapeutic INR may be treated with fresh frozen plasma. In one series, correction of the INR to 1.5 to 2.5 allowed successful endoscopic diagnosis and therapy at rates comparable with those achieved in nonanticoagulated patients.³ In contrast to the

Procedure risks

Endoscopic procedures vary in their potential to produce significant or uncontrolled bleeding. Low-risk procedures include diagnostic esophagogastroduodenoscopy (EGD), flexible sigmoidoscopy and colonoscopy with or without biopsy, diagnostic endoscopic retrograde cholangiopancreatography (ERCP), and biliary stent insertion without endoscopic sphincterotomy, endosonography (EUS), and push enteroscopy. High-risk procedures include those associated with an increased risk of bleeding such as

References (29)

EM Mathus-Vliegen et al.
Nd:YAG laser photocoagulation in colorectal adenoma. Evaluation of its safety, usefulness and efficacy
Gastroenterology
(1986)
P Rutgeerts et al.
Pallia five Nd:YAG laser therapy for cancer of the esophagus and gastroesophageal junction: impact on quality of remaining life
Gastrointest Endosc
(1988)
PB Cotton et al.
Endoscopic sphincterotomy complications and their mangement: An attempt at consensus
Gastrointest Endosc
(1991)
Research Committee of the British Thoracic Society
Optimum duration of anticoagulation for deep-vein thrombosis and pulmonary embolism
Lancet
(1992)
ML Shiffman et al.
Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDs
Gastrointest Endosc
(1994)
CP Choudari et al.
Acute gastrointestinal haemorrhage in patients treated with anticoagulant drugs
Gut
(1995)
CS Landefield et al.
Anticoagulant related bleeding: clinical epidemiology, prediction and prevention
Am J Med
(1993)
CP Choudari et al.
Acute gastrointestinal haemorrhage in anticoagulated patients: diagnosis and response to Endoscopic treatment
Gut
(1994)
JA Madura et al.
The mangement of patients on chronic coumadin therapy undergoing subsequent surgical procedures
Am Surg
(1994)
SK Kuwada et al.
Gostout CJ. The role of withdrawing chronic anticoagulation because of acute GI bleeding
Am J Gastroenterol
(1996)

J Waye

Colonoscopy

CA Cancer J Clin

(1992)

SG Remine et al.

Endoscopic gastric polypectomy

May Clin Proc

(1981)

SC Cannegieter et al.

Thromboembolic and bleeding complications in patients with mechanical heart valve prosthesis

Circulation

(1994)

RD Stein et al.

Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves

Chest

(1992)

Cited by (307)

Endoscopic Evaluation and Management of Pancreaticobiliary Disease
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
The diagnostic and therapeutic armamentarium available to practitioners managing pancreaticobiliary disease has expanded significantly in the past two decades. The rapid and dramatic increase in novel endoscopic technology has permitted less invasive diagnostic and therapeutic maneuvers in the pancreatic and bile ducts that had previously required open surgical and percutaneous techniques. Advances in radiographic technology have mirrored the endoscopic evolution, and although it has effectively transitioned the role of endoscopic retrograde cholangiopancreatography (ERCP) to a modality primarily for pancreatobiliary therapeutics, technologic advances, including confocal laser endomicroscopy, direct cholangioscopy, and pancreatoscopy, have been built on the scaffold of ERCP. Endoscopic ultrasound (EUS) provides continuous, real-time images of the intramural gastrointestinal tract and organs and adjacent structures that otherwise would not be visible. The advent of echoendoscopes containing an elevator and therapeutic channel allowed for the passage of aspiration needles, guidewires, and stents under direct endosonographic visualization effectively increasing the therapeutic role and indications for EUS. This chapter discusses ERCP and EUS techniques that can aid in the management of pancreaticobiliary disease.
2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force
2017, Journal of the American College of Cardiology
One-Year Survival is Not Affected by Gastrointestinal Bleeding After Percutaneous Coronary Interventions
2017, American Journal of the Medical Sciences
Percutaneous coronary intervention (PCI) has been the main therapy in acute coronary syndromes, and early antithrombotic agents as well as 1-year dual antiplatelet therapy are required for adjuvant therapy. However, the development of post-PCI gastrointestinal (GI) bleeding may increase all-cause mortality. We compared the characteristics and outcomes of patients with GI bleeding within 1 year after PCI to those who did not develop bleeding.
A retrospective cohort study was conducted using data from 384 PCI procedures performed between January 2011 and December 2013 at our hospital. End points were identified after 30 days, 90 days and 1 year postprocedure for evidence of GI bleeding or new onset anemia. Variables were compared between patients with and without GI bleeding using t test and Fisher exact test. Kaplan-Meier curve was constructed for estimating bleeding-free survival probability.
In a more than 1-year follow-up period, there were 39 cases (10.2%, 95% CI: 0.073-0.136) of documented GI bleeds. Females were found to have a significantly higher frequency of GI bleeding than males (16.8% vs. 8.0%, P = 0.018), and Hispanics more than non-Hispanics (11.7% vs. 1.7%, P = 0.017). All patients with GI bleeding survived at 1 year.
In our study of a predominantly Hispanic population, a high incidence of GI bleeding after PCI occurred. However, there was no association between the incidence of GI bleeding and all-cause mortality, whether PCI was performed in the setting of acute coronary syndrome or as an elective procedure. There is a need to conduct a larger prospective study to validate the findings of our study.
Managing antithrombotic agents during endoscopy
2016, Best Practice and Research: Clinical Gastroenterology
How much does the specialist know about cardiogastroenterology?
2018, Revista de Gastroenterologia de Mexico
La enfermedad cardiovascular (ECV) es un problema creciente de salud pública. El 40% de la población general en 2030 presentará ECV y como consecuencia requerirá terapia antitrombótica (TAA). La cardiogastroenterología (CGE) es una nueva área de conocimiento que evalúa los efectos y complicaciones gastrointestinales de la TAA. Nuestro objetivo fue evaluar mediante una encuesta validada el conocimiento en prescripción, farmacología, riesgos y complicaciones gastrointestinales de la TAA en un grupo de especialistas y residentes de gastroenterología (RG) y medicina interna (RMI).
Se aplicó una encuesta validada de 30 preguntas en un grupo de especialistas y RMI y RG. La encuesta incluyó preguntas de indicaciones, farmacología, evaluación de riesgo de hemorragia gastrointestinal, riesgo trombótico y el uso de TAA durante procedimientos endoscópicos. Se definió conocimiento suficiente como ≥ 18 (> 60%) aciertos.
La encuesta fue contestada por 194 médicos: 82 (42%) RMI y RG y 112 (58%) especialistas. Solo 40 (20.6%) tuvieron conocimiento suficiente en CGE. Los residentes tuvieron un mayor número de aciertos que los especialistas (53% vs. 36%, p < 0.0001). Los RG tuvieron más aciertos que los RMI, RG e internistas (70% vs. 53%, 40% y 46%, respectivamente, p < 0.001). Solo los residentes tuvieron conocimiento suficiente en farmacología y uso de la TAA en endoscopia (p < 0.0001). Todos los grupos tuvieron conocimiento insuficiente en evaluación de riesgo trombótico-hemorrágico.
Existe conocimiento insuficiente sobre CGE en este grupo de residentes y especialistas. Se requieren programas de educación médica acerca del uso apropiado de la TAA.
Cardiovascular disease is a growing public health problem. Forty percent of the general population will suffer from the disease by 2030, consequently requiring antithrombotic therapy. Cardiogastroenterology is a new area of knowledge that evaluates the gastrointestinal effects and complications of antithrombotic therapy. Our aim was to evaluate, through a validated questionnaire, the knowledge held by a group of specialists and residents in the areas of gastroenterology and internal medicine, about pharmacology and drug prescription, as well as gastrointestinal risks and complications, in relation to antithrombotic therapy.
A validated questionnaire composed of 30 items was applied to a group of specialists and residents in the areas of gastroenterology and internal medicine. The questions were on indications, pharmacology, evaluation of risks for gastrointestinal bleeding and thromboembolic events, and use of antithrombotic therapy during endoscopic procedures. Sufficient knowledge was defined as 18 or more (≥ 60%) correct answers.
The questionnaire was answered by 194 physicians: 82 (42%) internal medicine residents and gastroenterology residents and 112 (58%) specialists. Only 40 (20.6%) of the participants had sufficient knowledge of cardiogastroenterology. Residents had a higher number of correct answers than specialists (53 vs. 36%, P<.0001). The gastroenterology residents had more correct answers than the internal medicine residents, gastroenterologists, and internists (70 vs. 53, 40, and 46%, respectively, P<.001). Only residents had sufficient knowledge regarding pharmacology and the use of antithrombotic therapy in endoscopy (P<.0001). All groups had insufficient knowledge in evaluating the risk for gastrointestinal bleeding and thrombosis.
Knowledge of cardiogastroenterology was insufficient in the group of residents and specialists surveyed. There is a need for medical education programs on the appropriate use of antithrombotic therapy.
Feasibility and Efficacy of Gastric Underwater Endoscopic Mucosal Resection
2024, Diagnostics

View all citing articles on Scopus

View full text

GuidelinesGuideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures

Abstract

Introduction

Section snippets

Acute gastrointestinal hemorrhage in the anticoagulated patient

Recommendations

Procedure risks

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Lancet

Gastrointest Endosc

Acute gastrointestinal haemorrhage in patients treated with anticoagulant drugs

Gut

Anticoagulant related bleeding: clinical epidemiology, prediction and prevention

Am J Med

Acute gastrointestinal haemorrhage in anticoagulated patients: diagnosis and response to Endoscopic treatment

Gut

The mangement of patients on chronic coumadin therapy undergoing subsequent surgical procedures

Am Surg

Gostout CJ. The role of withdrawing chronic anticoagulation because of acute GI bleeding

Am J Gastroenterol

Colonoscopy

CA Cancer J Clin

Endoscopic gastric polypectomy

May Clin Proc

Thromboembolic and bleeding complications in patients with mechanical heart valve prosthesis

Circulation

Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves

Chest

Guidelines
Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures