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Peng D, Zhai H. Application of Antithrombotic Drugs in Different Age-Group Patients with Upper Gastrointestinal Bleeding. Gastroenterol Res Pract 2024; 2024:1710708. [PMID: 38606387 PMCID: PMC11008970 DOI: 10.1155/2024/1710708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/02/2024] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
Objective This study aimed at exploring the safety and timing of antithrombotic drugs in different age-group patients with UGIB. Methods An observational study retrospectively based on the single-center database with 713 patients with UGIB. Result Among the 713 patients, 62.13% were elderly patients (aged > 60 years) and the mortality was 2.9%. In elderly patients with UGIB, we found that previous medication history, resumption of medication, and time of resumption did not affect the in-hospital mortality. The resumption of anticoagulants increased the risk of rebleeding. The independent risk factors of mortality were CHF, cirrhosis, creatine kinase, and albumin. The independent risk factors of rebleeding were the application of anticoagulants during hospitalization, variceal bleeding, black stool, red blood cells (lab), platelets (lab), and heart rate. Conclusions In UGIB patients, a history of antiplatelet or antithrombotic drugs and the use of antiplatelet drugs after UGIB did not affect the patient's prognosis. In elderly UGIB patients, although antithrombotic drugs did not increase the risk of death, the increased risk of rebleeding after resumption of use deserved careful treatment. It was safe to recover anticoagulant drugs as soon as possible in young UGIB patients.
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Affiliation(s)
- Ding Peng
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Huihong Zhai
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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2
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Pemmasani G, Ashwath A, Aronow WS, Yandrapalli S, Leighton J, John S. Six-month cardiovascular prognostic impact of type 1 And type 2 myocardial infarction in patients hospitalized for gastrointestinal bleeding. Eur J Intern Med 2023; 116:51-57. [PMID: 37500309 DOI: 10.1016/j.ejim.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 06/25/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Patients with gastrointestinal bleeding (GIB) are at an increased risk of cardiovascular events and myocardial infarction (MI). Myocardial supply-demand mismatch results in type 2 MI(T2MI) and atherosclerotic plaque rupture leads to type 1 MI(T1MI). Data comparing the prognostic impact of these MI types in GIB are sparse. METHODS Patients hospitalized for GIB were identified in the 2019 US Nationwide Readmissions Sample. In this population, we studied the differences in management of T1MI and T2MI, and the association of these MI types with in-hospital mortality and risk for 6-month MI and MI-related mortality. RESULTS Of 444,475 patients admitted for a GIB, 12,860 (2.9%) had an MI (1.7% T2MI, 1.2% T1MI). Patients with T1MI were more likely to receive coronary angiography and revascularization than patients with T2MI. In-hospital mortality occurred in 2.0% patients, at a significantly higher rate in patients with an MI (7.9% vs 1.8%; P < 0.001), and higher with T1MI (11.9%) than T2MI (5.3%; P < 0.001). Among the survivors, 2.2% patient had an MI within 6 months, at a significantly higher rate in patients with index MI (13.1% vs 2.0%, adjusted OR 4.3 95% CI 3.83-4.90; P < 0.001). Mortality during the subsequent MI occurred in 0.3% of all patients (12% with an MI), at a 6-fold higher rate in patients with index MI (1.7% vs 0.3%; adjusted OR 3.69 95% CI 2.75-4.95; P < 0.001). The elevated risks were associated with both MI types. The risks for 6-month MI and related mortality were similar between T1MI and T2MI (6-month AMI: adjusted OR for T2MI = 1.03, 95% 0.83-1.29; fatal MI: adjusted OR for T2MI = 1.5, 95% CI 0.85-2.7). CONCLUSION The occurrence of an MI is associated with a substantially elevated risk for subsequent AMI and related mortality in patients hospitalized for a GIB. This future prognostic impact was similar between T1MI and T2MI.
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Affiliation(s)
- Gayatri Pemmasani
- Department of Medicine, SUNY Upstate Medical University, 750 E Adam St, Syracuse, NY 13202, United States.
| | - Ashwini Ashwath
- Department of Medicine, SUNY Upstate Medical University, 750 E Adam St, Syracuse, NY 13202, United States
| | - Wilbert S Aronow
- Westchester Medical Center and New York Medical College, Valhalla, NY, United States
| | - Srikanth Yandrapalli
- Division of Cardiology, Warren Alpert School of Medicine at Brown University, Providence, RI, United States
| | - Jonathan Leighton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, United States
| | - Savio John
- Division of Gastroenterology, SUNY Upstate Medical University, Syracuse, NY, United States
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Hozman M, Hassouna S, Grochol L, Waldauf P, Hracek T, Pazdiorova BZ, Adamec S, Osmancik P. Previous antithrombotic therapy does not have an impact on the in-hospital mortality of patients with upper gastrointestinal bleeding. Eur Heart J Suppl 2023; 25:E25-E32. [PMID: 37234230 PMCID: PMC10206644 DOI: 10.1093/eurheartjsupp/suad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The association between antithrombotics (ATs) and the risk of gastrointestinal bleeding is well known; however, data regarding the influence of ATs on outcomes are scarce. The goals of this study are: (i) to assess the impact of prior AT therapy on in-hospital and 6-month outcomes and (ii) to determine the re-initiation rate of the ATs after a bleeding event. All patients with upper gastrointestinal bleeding (UGB) who underwent urgent gastroscopy in three centres from 1 January 2019 to 31 December 2019 were retrospectively analysed. Propensity score matching (PSM) was used. Among 333 patients [60% males, mean age 69.2 (±17.3) years], 44% were receiving ATs. In multivariate logistic regression, no association between AT treatment and worse in-hospital outcomes was observed. Development of haemorrhagic shock led to worse survival [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.9-10.2, P < 0.001; after PSM: OR 5.3, 95% CI 1.8-15.7, P = 0.003]. During 6-months follow-up, higher age (OR 1.0, 95% CI 1.0-1.1, P = 0.002), higher comorbidity (OR 1.4, 95% CI 1.2-1.7, P < 0.001), a history of cancer (OR 3.6, 95% CI 1.6-8.1, P < 0.001) and a history of liver cirrhosis (OR 2.2, 95% CI 1.0-4.4, P = 0.029) were associated with higher mortality. After a bleeding episode, ATs were adequately re-initiated in 73.8%. Previous AT therapy does not worsen in-hospital outcomes in after UGB. Development of haemorrhagic shock predicted poor prognosis. Higher 6-month mortality was observed in older patients, patients with more comorbidities, with liver cirrhosis and cancer.
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Affiliation(s)
- Marek Hozman
- Cardiocenter, Hospital Karlovy Vary, 360 01 Karlovy Vary, Czech Republic
| | - Sabri Hassouna
- Cardiocenter, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Ruska 87, 100 00 Prague, Czech Republic
| | - Lukas Grochol
- 2nd Department of Internal Medicine, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady,100 00 Prague, Czech Republic
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | - Tomas Hracek
- Department of General Surgery, 3rd Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | | | - Stanislav Adamec
- Department of Gastroenterology, Hospital Cheb, 350 02 Cheb, Czech Republic
| | - Pavel Osmancik
- Corresponding author. Tel: 00420-721544447, Fax: 00420-267162817,
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4
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Martin AC, Benamouzig R, Gouin-Thibault I, Schmidt J. Management of Gastrointestinal Bleeding and Resumption of Oral Anticoagulant Therapy in Patients with Atrial Fibrillation: A Multidisciplinary Discussion. Am J Cardiovasc Drugs 2023:10.1007/s40256-023-00582-9. [PMID: 37145342 DOI: 10.1007/s40256-023-00582-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 05/06/2023]
Abstract
Direct oral anticoagulants (DOACs) are recommended for the prevention of thromboembolism in patients with atrial fibrillation (AF), and are now preferred over vitamin K antagonists due to their beneficial efficacy and safety profile. However, all oral anticoagulants carry a risk of gastrointestinal (GI) bleeding. Although the risk is well documented and acute bleeding well codified, there is limited high-quality evidence and no guidelines to guide physicians on the optimal management of anticoagulation after a GI bleeding event. The aim of this review is to provide a multidisciplinary critical discussion of the optimal management of GI bleeding in patients with AF receiving oral anticoagulants to help physicians provide individualized treatment for each patient and optimize outcomes. It is important to perform endoscopy when a patient presents with bleeding manifestations or hemodynamic instability to determine the bleed location and severity of bleeding and then perform initial resuscitation. Administration of all anticoagulants and antiplatelets should be stopped and bleeding allowed to resolve with time; however, anticoagulant reversal should be considered for patients who have life-threatening bleeding or when the bleeding is not controlled by the initial resuscitation. Anticoagulation needs to be timely resumed considering that bleeding risk outweighs thrombotic risk when anticoagulation is resumed early after the bleeding event. To prevent further bleeding, physicians should prescribe anticoagulant therapy with the lowest risk of GI bleeding, avoid medications with GI toxicity, and consider the effect of concomitant medications on potentiating the bleeding risk.
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Affiliation(s)
- Anne-Céline Martin
- Advanced Heart Failure Unit, AP-HP, Cardiology Department, European Hospital Georges Pompidou, Paris, France.
- INSERM UMRS_1140, Innovative Therapies in Haemostasis, Université Paris Cité, 75006, Paris, France.
| | - Robert Benamouzig
- Service de Gastroentérologie, Hôpital Avicenne, AP-HP, Université Paris-Nord-La Sorbonne, Bobigny, France
| | - Isabelle Gouin-Thibault
- Laboratory of Hematology, IRSET-INSERM UMRS 1085, Rennes University Hospital, Rennes, France
| | - Jeannot Schmidt
- LaPSCo, Physiological and Psychosocial Stress, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
- Emergency Department, CHU Clermont-Ferrand, University Hospital Gabriel Montpied, Clermont-Ferrand, France
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5
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A. Aulinger B, H. Saner F, Stark K, Mayerle J, M. Lange C. Platelet Aggregation Inhibitors and Anticoagulants in Gastroenterological and Visceral Surgical Procedures. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:851-860. [PMID: 36345703 PMCID: PMC9981979 DOI: 10.3238/arztebl.m2022.0342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 04/22/2022] [Accepted: 09/26/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND The proper management of patients being treated with platelet aggregation inhibitors or anticoagulant drugs is a common clinical problem for both elective and emergency procedures in gastroenterology and visceral surgery. The essential matters that must be kept in mind in this situation are the hemorrhagic risk of the procedure, the indication for anticoagulation, and the pharmacology of anticoagulant drugs and platelet aggregation inhibitors. METHODS This review is based on publications retrieved by a selective search in PubMed and on the guidelines of the relevant specialist societies. RESULTS Nearly all procedures in gastroenterology and visceral surgery can be performed under monotherapy with acetyl - salicylic acid. Other platelet aggregation inhibitors, such as clopidogrel or prasugrel, or anticoagulant drugs generally do not need to paused before diagnostic endoscopic procedures with a low risk of bleeding (<1.5%), but they must be paused before procedures in gastroenterology and visceral surgery where the risk of bleeding is high (≥ 1.5%). Bridging with heparin is reserved for patients with a very high risk of thromboembolism ( ≥ 5%). CONCLUSION Knowledge of the current recommendations on the management of anticoagulants before gastroenterological and visceral surgical procedures gives the clinician a well-founded means of dealing with this complex and common clinical situation.
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Affiliation(s)
| | - Fuat H. Saner
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Germany
| | - Konstantin Stark
- Medizinische Klinik und Poliklinik I, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Julia Mayerle
- Department of Internal Medicine II, LMU University Hospital Munich, Germany
| | - Christian M. Lange
- Department of Internal Medicine II, LMU University Hospital Munich, Germany,*Medizinische Klinik und Poliklinik II, Klinikum der Universität München, Marchioninistrasse 15,D- 81337 Munich, Germany
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6
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Ji R, Wang L, Liu X, Liu Y, Wang D, Wang W, Zhang R, Jiang R, Jia J, Feng H, Ding Z, Ju Y, Lu J, Liu G, Wang Y, Zhao X. A novel risk score to predict deep vein thrombosis after spontaneous intracerebral hemorrhage. Front Neurol 2022; 13:930500. [PMID: 36388194 PMCID: PMC9650187 DOI: 10.3389/fneur.2022.930500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/14/2022] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Studies showed that patients with hemorrhagic stroke are at a higher risk of developing deep vein thrombosis (DVT) than those with ischemic stroke. We aimed to develop a risk score (intracerebral hemorrhage-associated deep vein thrombosis score, ICH-DVT) for predicting in-hospital DVT after ICH. Methods The ICH-DVT was developed based on the Beijing Registration of Intracerebral Hemorrhage, in which eligible patients were randomly divided into derivation (60%) and internal validation cohorts (40%). External validation was performed using the iMCAS study (In-hospital Medical Complication after Acute Stroke). Independent predictors of in-hospital DVT after ICH were obtained using multivariable logistic regression, and β-coefficients were used to generate a scoring system of the ICH-DVT. The area under the receiver operating characteristic curve (AUROC) and the Hosmer–Lemeshow goodness-of-fit test were used to assess model discrimination and calibration, respectively. Results The overall in-hospital DVT after ICH was 6.3%, 6.0%, and 5.7% in the derivation (n = 1,309), internal validation (n = 655), and external validation (n = 314) cohorts, respectively. A 31-point ICH-DVT was developed from the set of independent predictors including age, hematoma volume, subarachnoid extension, pneumonia, gastrointestinal bleeding, and length of hospitalization. The ICH-DVT showed good discrimination (AUROC) in the derivation (0.81; 95%CI = 0.79–0.83), internal validation (0.83, 95%CI = 0.80–0.86), and external validation (0.88; 95%CI = 0.84–0.92) cohorts. The ICH-DVT was well calibrated (Hosmer–Lemeshow test) in the derivation (P = 0.53), internal validation (P = 0.38), and external validation (P = 0.06) cohorts. Conclusion The ICH-DVT is a valid grading scale for predicting in-hospital DVT after ICH. Further studies on the effect of the ICH-DVT on clinical outcomes after ICH are warranted.
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Affiliation(s)
- Ruijun Ji
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Beijing Key Laboratory of Brain Function Reconstruction, Beijing, China
| | - Linlin Wang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinyu Liu
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yanfang Liu
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dandan Wang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wenjuan Wang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Runhua Zhang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruixuan Jiang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiaokun Jia
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Feng
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zeyu Ding
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yi Ju
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingjing Lu
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Gaifen Liu
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Beijing Key Laboratory of Brain Function Reconstruction, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Beijing Key Laboratory of Brain Function Reconstruction, Beijing, China
- *Correspondence: Xingquan Zhao
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7
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Escobar A, Salem AM, Dickson K, Johnson TN, Burk KJ, Bashoura L, Faiz SA. Anticoagulation and bleeding in the cancer patient. Support Care Cancer 2022; 30:8547-8557. [PMID: 35579752 PMCID: PMC9529787 DOI: 10.1007/s00520-022-07136-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Cancer patients have an increased risk of bleeding compared to non-cancer patients with anticoagulant therapy. A bleeding risk assessment before initiation of anticoagulation is recommended. Currently low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are the mainstays of treatment for cancer-associated venous thromboembolism (VTE). Since DOACs are administered orally, they offer some convenience and ease of administration; however, LMWH may be preferred in certain cancers. Given the prevalence of anticoagulant therapies in cancer patients, clinical providers must be able to recognize potentially critical bleeding sites and modalities to reverse major hemorrhage. Reversal agents or antidotes to bleeding may be required when bleeding is persistent or life-threatening. These include vitamin K, fresh frozen plasma (FFP), protamine, prothrombin complex concentrate (PCC) or andexanet alfa, and idarucizumab. Inferior vena cava (IVC) filter insertion can be also considered in those with major bleeding. Evidence for timing and need for re-initiation of anticoagulant therapy after a major bleeding remains sparse, but a multi-disciplinary approach and shared decision-making can be implemented in the interim.
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Affiliation(s)
- Andres Escobar
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Ahmed M Salem
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kodwo Dickson
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tami N Johnson
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathyrn J Burk
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA.
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8
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Ruiz J, López-Vinardell L, Juanes A, Riera-Magallon A, Puig M, Mangues MA. Risk factors for emergency department revisit in elderly patients with gastrointestinal bleeding secondary to anticoagulant therapy. Eur J Hosp Pharm 2022; 29:271-274. [PMID: 33293283 PMCID: PMC9660616 DOI: 10.1136/ejhpharm-2020-002426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/11/2020] [Accepted: 11/17/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To evaluate the frequency of emergency department (ED) revisits among elderly patients with gastrointestinal bleeding secondary to anticoagulant treatment and identify factors associated with an increased risk of ED revisits. METHODS A 3-year retrospective observational study was designed, including elderly patients (≥65 years) with atrial fibrillation and undergoing oral anticoagulation therapy who visited the ED for gastrointestinal bleeding. To evaluate the risk factors for 30-day revisit, a multivariate analysis was designed including comorbidities, concomitant treatment, change in anticoagulant treatment and prescription of direct-acting oral anticoagulants. RESULTS 80 patients were included. At discharge, anticoagulation therapy was modified in 21 (26.2%) patients; and changed from an oral anticoagulant to heparin in 17 (21.2%) patients and to another oral anticoagulant in 4 (5.0%) patients. Anticoagulant treatment was withdrawn in 5 (6.3%) patients at discharge. Eleven (13.7%) patients revisited the ED 30 days after hospital discharge for bleeding episodes. No differences in the frequency of revisit to the ED were observed in the patients who changed their anticoagulant treatment at discharge. In the multivariate analysis, chronic kidney disease was the only factor significantly associated with revisits at 30 days. CONCLUSIONS Elderly patients who experience a first episode of gastrointestinal bleeding have a high risk of revisiting the ED for a bleeding episode, with no particular differences between the types of anticoagulant prescribed at discharge.
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Affiliation(s)
- Jesus Ruiz
- Pharmacy, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
| | | | - Ana Juanes
- Pharmacy, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
| | | | - Mireia Puig
- Emergency Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
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9
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Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 2). JACC. ASIA 2022; 2:519-537. [PMID: 36624790 PMCID: PMC9823285 DOI: 10.1016/j.jacasi.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/29/2022] [Accepted: 06/22/2022] [Indexed: 01/12/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk for stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonistdirect oral anticoagulant agent (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions for which NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the past decade, and a more sophisticated strategy for patients with AF is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. The aim of this statement is to provide possible treatment options in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is part 2 of the statement.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan,Address for correspondence: Dr Chern-En Chiang, General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. @en_chern
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea,Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand,Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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10
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Abdelfattah AH, Talib U, Elkot AN, Dawoud H, Talib A. Acute Non-glue Pulmonary Embolism Following Endoscopic Ultrasound (EUS)-Guided Glue/Coil Treatment for Gastric Varices: A Case Report and Literature Review. Cureus 2022; 14:e27446. [PMID: 36051733 PMCID: PMC9420448 DOI: 10.7759/cureus.27446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2022] [Indexed: 11/05/2022] Open
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11
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Huang G, Tian FY, An W, Ai LS, Yu YB. Effects of antithrombotic therapy on bleeding after endoscopic sphincterotomy: A systematic review and meta-analysis. Endosc Int Open 2022; 10:E865-E873. [PMID: 35692927 PMCID: PMC9187383 DOI: 10.1055/a-1793-9479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 01/31/2022] [Indexed: 10/25/2022] Open
Abstract
Background and study aims Bleeding is a common complication of following endoscopy sphincterotomy (EST), and antithrombotic therapy use during the procedure often increases risk of it. Although several guidelines have been released regarding the use of antithrombotic agents during EST, many issues about it remain controversial. We carried out a systematic review and meta-analysis to evaluate the effect of antithrombotic medication on the risk of EST bleeding. Methods A structured literature search was carried out in Web of Science, EMBASE, PubMed, and Cochrane Library databases. RevMan 5.2 was used for meta-analysis to investigate the rate of post-EST bleeding. Results Seven retrospective articles were included. Compared with patients who had never taken antithrombotic drugs, patients who discontinued antithrombotic drugs 1 day before the procedure had a significantly increased risk of post-EST bleeding (OR, 1.95; 95 %CI, 1.57-2.43), particularly for severe bleeding (OR, 1.83; 95 %CI, 1.44-2.34). In addition, compared with patients who discontinued antithrombotic therapy for at least 1 day, patients who continued taking antithrombotic drugs did have an increased risk of post-EST bleeding (OR, 0.70; 95 %CI, 0.40-1.23). Conclusions The use of antithrombotic drugs may increase the bleeding rate of EST, but discontinuing therapy 1 day before endoscopy does not significantly reduce the bleeding rate.
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Affiliation(s)
- Gang Huang
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Feng-Yu Tian
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Wen An
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Li-Si Ai
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Yan-Bo Yu
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
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12
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Gonai T, Toya Y, Kawasaki K, Yanai S, Akasaka R, Nakamura S, Matsumoto T. Risk factors of re‐bleeding within a year in colonic diverticular bleeding patients. DEN OPEN 2022; 2:e22. [PMID: 35310758 PMCID: PMC8828229 DOI: 10.1002/deo2.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023]
Abstract
Background/Aims Although colonic diverticular bleeding (CDB) is common, few reports have described the effects of antithrombotic agents (ATs) on CDB. This study aimed to clarify the risk factors of re‐bleeding within a year in CDB patients. Methods We retrospectively analyzed the risk of re‐bleeding in CDB patients. Among 324 patients who were hospitalized for acute lower gastrointestinal bleeding at our institution during the period from 2015 to 2019, we used 76 patients who were diagnosed as CDB. Risk factors for re‐bleeding were determined by Cox proportional hazard models. Results Of 76 patients analyzed, 32 were taking ATs, nine of whom were taking multiple agents. Twenty‐six patients re‐bled within a year. Compared with the patients without re‐bleeding, patients with re‐bleeding within a year had been treated by antithrombotic therapy more frequently (62% vs. 32%, p = 0.013). Cox proportional hazard model revealed that treatment with ATs (hazard ratio 3.89, 95% confidence interval 1.53–10.74, p = 0.004) was an independent risk factor for re‐bleeding within a year. Conclusion ATs were found to be an independent risk factor related to re‐bleeding within a year in patients with CDB.
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Affiliation(s)
- Takahiro Gonai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Keisuke Kawasaki
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Shunichi Yanai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Risaburo Akasaka
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Shotaro Nakamura
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine Iwate Medical University Iwate Japan
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13
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Kate V, Sureshkumar S, Gurushankari B, Kalayarasan R. Acute Upper Non-variceal and Lower Gastrointestinal Bleeding. J Gastrointest Surg 2022; 26:932-949. [PMID: 35083723 DOI: 10.1007/s11605-022-05258-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/17/2022] [Indexed: 01/31/2023]
Abstract
Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.
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Affiliation(s)
- Vikram Kate
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
| | - Sathasivam Sureshkumar
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Balakrishnan Gurushankari
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Raja Kalayarasan
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
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14
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Jain H, Singh G, Kaul V, Gambhir HS. Management dilemmas in restarting anticoagulation after gastrointestinal bleeding. Proc (Bayl Univ Med Cent) 2022; 35:322-327. [DOI: 10.1080/08998280.2022.2043707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Hanish Jain
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Garima Singh
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Viren Kaul
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Harvir Singh Gambhir
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
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15
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Gonai T, Toya Y, Kudara N, Abe K, Sawaguchi S, Fujiwara T, Eizuka M, Miura M, Urushikubo J, Yamada S, Yamaguchi S, Asakura K, Orikasa S, Matsumoto T. Risk factors for short-term re-bleeding in patients with colonic diverticular bleeding: a multicenter retrospective study. Scand J Gastroenterol 2022:1-6. [PMID: 35138982 DOI: 10.1080/00365521.2022.2035812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM Few studies have evaluated risk factors for short-term re-bleeding in patients with colonic diverticular bleeding (CDB). We aimed to reveal risk factors for re-bleeding within a month in patients with CDB. METHODS We retrospectively analyzed clinical course of patients with CDB diagnosed at 10 institutions between 2015 and 2019. Risk factors for re-bleeding within a month were assessed by Cox proportional hazards models. RESULTS Among 370 patients, 173 (47%) patients had been under the use of antithrombotic agents (ATs) and 34 (9%) experienced re-bleeding within a month. Multivariate analysis revealed that the use of ATs was an independent risk factor for re-bleeding within a month (HR 2.38, 95% CI 1.10-5.50, p = .028). Furthermore, use of multiple ATs and continuation of ATs were found to be independent risk factors for re-bleeding within a month (HR 3.88, 95% CI 1.49-10.00, p = .007 and HR 3.30, 95% CI 1.23-8.63, p = .019, respectively). Two of 370 patients, who discontinued ATs, developed thromboembolic event. CONCLUSIONS Use of ATs was an independent risk factor for short-term re-bleeding within a month in patients with CDB. This was especially the case for the use of multiple ATs and continuation of ATs. However, discontinuation of ATs may increase the thromboembolic events those patients.
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Affiliation(s)
- Takahiro Gonai
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Shiwa-gun, Japan
- Department of Gastroenterology, Iwate Prefectural Kuji Hospital, Kuji, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Shiwa-gun, Japan
| | - Norihiko Kudara
- Department of Gastroenterology, Iwate Prefectural Ofunato Hospital, Ofunato, Japan
| | - Keinosuke Abe
- Department of Gastroenterology, Iwate Prefectural Miyako Hospital, Miyako, Japan
| | - Sera Sawaguchi
- Department of Gastroenterology, Iwate Prefectural Miyako Hospital, Miyako, Japan
| | - Takao Fujiwara
- Department of Gastroenterology, Morioka Red Cross Hospital, Morioka, Japan
| | - Makoto Eizuka
- Department of Gastroenterology, Hachinohe Red Cross Hospital, Hachinohe, Japan
| | - Manami Miura
- Department of Gastroenterology, Iwate Prefectural Ninohe Hospital, Ninohe, Japan
| | - Jun Urushikubo
- Department of Gastroenterology, Iwate Prefectural Ninohe Hospital, Ninohe, Japan
| | - Shun Yamada
- Department of Gastroenterology, Noshiro Kosei Medical Center, Noshiro, Japan
| | - Satoko Yamaguchi
- Department of Gastroenterology, Kazuno Kosei Hospital, Kazuno, Japan
| | - Kensuke Asakura
- Department of Gastroenterology, Iwate Prefectural Kuji Hospital, Kuji, Japan
| | - Shunsuke Orikasa
- Department of Gastroenterology, Kitakami Saiseikai Hospital, Kitakami, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Shiwa-gun, Japan
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16
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Tapaskar N, Ham SA, Micic D, Sengupta N. Restarting Warfarin vs Direct Oral Anticoagulants After Major Gastrointestinal Bleeding and Associated Outcomes in Atrial Fibrillation: A Cohort Study. Clin Gastroenterol Hepatol 2022; 20:381-389.e9. [PMID: 33227428 DOI: 10.1016/j.cgh.2020.11.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/14/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Limited data exist on the management of anticoagulation after hospitalization for gastrointestinal bleeding (GIB) and the risks of recurrent GIB and thromboembolism in patients who are prescribed warfarin vs direct oral anticoagulants (DOACs). The purpose of this study was to assess the risk of recurrent GIB and thromboembolism with resumption of anticoagulation after GIB. METHODS This was a retrospective analysis of adults with atrial fibrillation prescribed warfarin or DOACs and subsequently hospitalized for GIB. We used claims data from IBM MarketScan Databases from January 2008 through December 2017. Multivariable time-varying regression was used to determine the risks of recurrent GIB and thromboembolism within 6 months of the index hospitalization. RESULTS There were 2991 patients hospitalized for GIB on anticoagulants (warfarin, n = 1872; rivaroxaban, n = 676; dabigatran, n = 293; and apixaban, n = 250). Of warfarin users, 46% (n = 869) resumed warfarin after discharge compared with 43% (n = 483) of DOAC users who resumed DOACs. In the regression analysis modeling time-varying coefficients for anticoagulant use, warfarin resumption was associated with an increased risk of recurrent GIB (hazard ratio [HR], 2.12; 95% CI, 1.43-3.14; P = .0002) compared with no anticoagulant resumption, whereas there was no association with DOAC resumption and recurrent bleeding (HR, 1.43; 95% CI, 0.81-2.52; P = .22). Rivaroxaban was the only individual DOAC that was associated with recurrent GIB (HR, 2.73; 95% CI, 1.43-5.20; P = .002). Both warfarin (HR, 0.61; 95% CI, 0.39-0.96; P = .033) and DOAC (HR, 0.52; 95% CI, 0.28-0.98; P = .044) resumption as a class was associated with a decreased risk of thromboembolism. CONCLUSIONS Either warfarin or DOAC resumption after hospitalization for GIB was associated with a decreased risk of thromboembolism, whereas warfarin and rivaroxaban resumption were associated with an increased risk of recurrent GIB.
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Affiliation(s)
- Natalie Tapaskar
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Sandra A Ham
- Center for Health and the Social Sciences, University of Chicago Medicine, Chicago, Illinois
| | - Dejan Micic
- Section of Gastroenterology Hepatology and Nutrition, University of Chicago Medicine, Chicago, Illinois
| | - Neil Sengupta
- Section of Gastroenterology Hepatology and Nutrition, University of Chicago Medicine, Chicago, Illinois.
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17
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Matsuhashi T, Fukuda S, Mikami T, Tatsuta T, Hikichi T, Nakamura J, Abe Y, Onozato Y, Hatta W, Masamune A, Ohyauchi M, Ito H, Hanabata N, Araki Y, Yanagita T, Imamura H, Tsuji T, Sugawara K, Horikawa Y, Ohara S, Kondo Y, Dohmen T, Iijima K. Effects of anti-thrombotic drugs on all-cause mortality after upper gastrointestinal bleeding in Japan: A multicenter study with 2205 cases. Dig Endosc 2022; 34:113-122. [PMID: 33615547 DOI: 10.1111/den.13961] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/16/2021] [Indexed: 12/13/2022]
Abstract
OBJECTS Although anti-thrombotic use is recognized as a risk factor for upper gastrointestinal bleeding (UGIB), there has been no clear evidence that it worsens the outcomes after the bleeding. The aim of this study is to investigate the effects of anti-thrombotic agents on in-hospital mortality following UGIB. METHODS Information on clinical parameters, including usage of anti-thrombotic agents, was retrospectively collected from consecutive patients with UGIB at 12 high-volume centers in Japan between 2011 and 2018. The all-cause in-hospital mortality rate was evaluated according to the usage of anti-thrombotic agents. RESULTS Clinical data were collected from 2205 patients with endoscopically confirmed UGIB. Six hundred and forty-five (29.3%) patients used anti-thrombotic agents. The all-cause in-hospital mortality rate was 5.7% (125 deaths). After excluding 29 cases in which death occurred due to end-stage malignancy, 96 deaths (bleeding-related, n = 22 ; non-bleeding-related, n = 74) were considered "preventable." Overall, the "preventable" mortality rate in anti-thrombotic users was significantly higher than that in non-users (6.0% vs. 3.7%, P < 0.05). However, the "preventable" mortality of anti-thrombotic users showed a marked improvement over time; although the rate in users remained significantly higher than that in non-users until 2015 (7.3% vs. 4.2%, P < 0.05), after 2016, the difference was no longer statistically significant (4.8% vs. 3.5%). CONCLUSIONS Although the usage of anti-thrombotic agents worsened the outcomes after UGIB, the situation has recently been improving. We speculate that the recent revision of the Japanese guidelines on the management of anti-thrombotic treatment after UGIB may have partly contributed to improving the survival of users of anti-thrombotic agents.
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Affiliation(s)
- Tamotsu Matsuhashi
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Sho Fukuda
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yasuhiko Abe
- Division of Endoscopy, Yamagata University Hospital, Yamagata, Japan
| | - Yusuke Onozato
- Department of Gastroenterology, Faculty of Medicine, Yamagata University Hospital, Yamagata, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Motoki Ohyauchi
- Department of Gastroenterology, Osaki Citizen Hospital, Miyagi, Japan
| | - Hirotaka Ito
- Department of Gastroenterology, Osaki Citizen Hospital, Miyagi, Japan
| | - Norihiro Hanabata
- Department of Gastroenterology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yasumitsu Araki
- Department of Gastroenterology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Takumi Yanagita
- Department of Gastroenterology, Ohta Nishinouchi Hospital, Fukushima, Japan
| | - Hidemichi Imamura
- Department of Gastroenterology, Ohta Nishinouchi Hospital, Fukushima, Japan
| | - Tsuyotoshi Tsuji
- Department of Gastroenterology, Akita City Hospital, Akita, Japan
| | - Kae Sugawara
- Department of Gastroenterology, Akita City Hospital, Akita, Japan
| | - Youhei Horikawa
- Department of Gastroenterology, Hiraka General Hospital, Akita, Japan
| | - Shuichi Ohara
- Department of Gastroenterology, Tohoku Rosai Hospital, Miyagi, Japan
| | - Yutaka Kondo
- Department of Gastroenterology, Tohoku Rosai Hospital, Miyagi, Japan
| | - Takahiro Dohmen
- Department of Gastroenterology, Yuri Kumiai General Hospital, Akita, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
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18
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Hosni M, Rahal M, Tamim H, Daniel F, Al Hashash J, Sharara AI, Soweid A, Shaib YH, Mourad FH, Wehbeh AN, Rockey DC, Barada K. Increased rebleeding and mortality in patients with gastrointestinal bleeding treated with anticoagulant drugs compared to antiplatelet drugs. Eur J Gastroenterol Hepatol 2021; 33:e490-e498. [PMID: 33867445 DOI: 10.1097/meg.0000000000002148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM We determined the effect of antiplatelet and anticoagulant agents on rebleeding and mortality in patients with gastrointestinal bleeding. METHODS This was a prospective study of patients admitted with gastrointestinal bleeding between 2013 and 2018. Outcomes were compared among patients on antiplatelet agents only, anticoagulant drugs only, combination therapy, and none. The association between mortality, rebleeding, and type of antithrombotic medication on admission and discharge was determined using multivariate analysis. RESULTS A total of 509 patients were followed up for a median of 19 months. End of follow-up rebleeding and mortality rates were 19.4% and 23.0%, respectively. Independent predictors of mortality were age [hazard ratio (HR) = 1.025 per year increase, P = 0.002], higher Charlson Comorbidity Index (HR = 1.4, P < 0.0001), severe bleeding (HR = 2.1, P < 0.0001), and being on anticoagulants (HR = 2.3, P = 0.002). Being on antiplatelets was protective against rebleeding (HR = 0.6, P = 0.047). Those on anticoagulants were more likely to die (HR = 2.5, P < 0.0001) and to rebleed (HR = 2.1, P = 0.01) than those on antiplatelets. Antithrombotic drug discontinuation upon discharge was associated with increased mortality in patients with cardiovascular disease. CONCLUSION In gastrointestinal bleeding, rebleeding and mortality were associated with being on anticoagulant drugs, while being on antiplatelet agents was protective against rebleeding. Discontinuation of antithrombotics upon discharge increased the risk of death. The findings inform risk stratification and decisions regarding continuation or discontinuation of antithrombotics.
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Affiliation(s)
| | | | - Hani Tamim
- Biostatistics Support Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | | | | | | | | | | | | | | | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
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Thrombotic events and rebleeding after hemorrhage in patients taking direct oral anticoagulants for non-valvular atrial fibrillation. PLoS One 2021; 16:e0260585. [PMID: 34843582 PMCID: PMC8629319 DOI: 10.1371/journal.pone.0260585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 11/13/2021] [Indexed: 11/19/2022] Open
Abstract
Several direct oral anticoagulants have been developed to prevent cardiogenic thrombosis in patients with atrial fibrillation, on the other hand, have the complication of bleeding. Since clinical course after bleeding with direct oral anticoagulant remains unclear, the present retrospective cohort study was to clarify the course after hemorrhage among patients receiving direct oral anticoagulants. Among all 2005 patients prescribed dabigatran, rivaroxaban, apixaban, or edoxaban between April 2011 and June 2017, subjects comprised 96 patients with non-valvular atrial fibrillation who experienced relevant bleeding during direct oral anticoagulant therapy (Bleeding Academic Research Consortium type 2 or above). The clinical course after hemorrhage was reviewed to examine whether rebleeding or thrombotic events occurred up to the end of December 2019. Gastrointestinal bleeding was the most frequent cause of initial bleeding (57 patients, 59%). Rebleeding occurred in 11 patients (4.5%/year), with gastrointestinal bleeding in 10 and subarachnoid hemorrhage in 1. All rebleeding occurred in patients who resumed anticoagulation therapy. Another significant factor related with rebleeding included past history of gastrointestinal bleeding. On the other hand, major adverse cardiac and cerebrovascular events occurred in 6 patients older than 75 years old or more (2.5%/year), with systemic thrombosis in 4 and cardiac death in 2. All 4 patients with systemic thrombosis withheld anticoagulants after index bleeding, although only 10 patients withheld anticoagulation therapy. Rebleeding should be taken care of when anticoagulants are resumed after bleeding, particularly among patients who initially experienced gastrointestinal bleeding. Systemic thrombosis occurred at a high rate when anticoagulant therapy was withheld after bleeding.
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20
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Milling TJ, Refaai MA, Sengupta N. Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines. Dig Dis Sci 2021; 66:3698-3714. [PMID: 33403486 PMCID: PMC9245141 DOI: 10.1007/s10620-020-06728-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa). AIM To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed. METHODS This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data. RESULTS GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio > 2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications. CONCLUSIONS The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.
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Affiliation(s)
- Truman J. Milling
- Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX, USA
| | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Neil Sengupta
- Section of Gastroenterology Hepatology and Nutrition, The University of Chicago, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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21
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Xu Y, Siegal DM. Anticoagulant-associated gastrointestinal bleeding: Framework for decisions about whether, when and how to resume anticoagulants. J Thromb Haemost 2021; 19:2383-2393. [PMID: 34273241 DOI: 10.1111/jth.15466] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 11/27/2022]
Abstract
Gastrointestinal (GI) bleeding is the most frequent single site of oral anticoagulant (OAC)-associated major bleeding. Patients with major GI bleeding experience morbidity and a substantial risk of short-term all-cause mortality up to 10%. While OACs are frequently discontinued during acute bleeding, there is substantial uncertainty about whether, when, and how OACs should be resumed after bleeding has resolved. Limited evidence suggests a lower risk of thromboembolism and death, and a higher risk of recurrent bleeding with OAC resumption. However, the absolute risks and optimal timing of anticoagulation remain uncertain based on these observational studies at risk of bias, particularly due to baseline confounding. In addition to an individualized approach to determining the benefits and harms of treatment decisions informed by the best available evidence about thrombosis and recurrent bleeding, discussions should meaningfully incorporate patient values and preferences. The objective of this review is to provide a framework for decision-making by summarizing the epidemiology and clinical outcomes of OAC-associated GI bleeding, providing an approach for assessment and risk stratification for OAC resumption and its timing, and outlining strategies for the prevention of recurrent GI bleeding.
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Affiliation(s)
- Yan Xu
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Deborah M Siegal
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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23
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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Triantafyllou K, Gkolfakis P, Gralnek IM, Oakland K, Manes G, Radaelli F, Awadie H, Camus Duboc M, Christodoulou D, Fedorov E, Guy RJ, Hollenbach M, Ibrahim M, Neeman Z, Regge D, Rodriguez de Santiago E, Tham TC, Thelin-Schmidt P, van Hooft JE. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:850-868. [PMID: 34062566 DOI: 10.1055/a-1496-8969] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.
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Affiliation(s)
- Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare, London, UK
| | - Gianpiero Manes
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese and Rho, Milan, Italy
| | | | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Marine Camus Duboc
- Gastroenterology Department, Saint-Antoine Hospital, APHP Sorbonne University, Paris, France
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital & Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Evgeny Fedorov
- Department of Gastroenterology, Moscow University Hospital, Pirogov Russia National Research Medical University, Moscow, Russia
| | - Richard J Guy
- Department of Emergency General Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Daniele Regge
- Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Peter Thelin-Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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25
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Bingzheng X, Jingnan R, Ligang B, Jianping C. The effects of anticoagulant therapy re-initiation after gastrointestinal bleeding: A systematic review and meta-analysis. J Clin Pharm Ther 2021; 46:1509-1518. [PMID: 34101229 DOI: 10.1111/jcpt.13442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/21/2021] [Accepted: 05/11/2021] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Long-term anticoagulant/antithrombotic therapy is widely used for the management of thromboembolic conditions. Gastrointestinal bleeding is a common collateral manifestation of anticoagulant/antithrombotic therapy that complicates its administration. The continuation or discontinuation of anticoagulant/antithrombotic therapy after an episode of gastrointestinal bleeding has been a matter of debate. Despite recent positive reports from retrospective cohort studies suggesting a reduction in morbidity- and mortality-related outcomes with continued administration of anticoagulant/antithrombotic agents (even after gastrointestinal bleeding), no consensus or comparisons about the efficacies of continued or discontinued antithrombotic administration exist. Therefore, we developed this current state-of-evidence analysis evaluating the comparative effects of continuation and discontinuation of anticoagulant/antithrombotic drugs after gastrointestinal bleeding on the overall incidences of gastrointestinal bleeding, thromboembolic events and mortality events. METHODS We performed a systematic academic literature search according to the PRISMA guidelines across five databases: Web of Science, Embase, CENTRAL, Scopus and MEDLINE. Moreover, we conducted a random effect meta-analysis to compare the effects of continuation and discontinuation of anticoagulant/antithrombotic drugs after an event of gastrointestinal bleeding on the overall incidences of gastrointestinal bleeding, thromboembolic events and mortality events. RESULTS We found seven eligible studies (from 1397 candidates) with 2532 participants (mean age, 73.1 ± 4.1 years). Our meta-analysis revealed lower odds of thromboembolic events (OR, -0.21), mortality outcomes (OR, -0.39) and an increase in the incidence of gastrointestinal bleeding (OR, 2.4) in the group with continued anticoagulant/antithrombotic therapy than in the group discontinuing the therapy. WHAT IS NEW AND CONCLUSION We provide an updated evidence on the comparative effects between continuation and discontinuation of anticoagulant/antithrombotic drugs after gastrointestinal bleeding events based on the overall incidences of gastrointestinal bleeding, thromboembolic events and mortality events. This study reports confirm an overall lower incidence of thromboembolic events and mortality outcomes for the continuation group than for the discontinuation group.
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Affiliation(s)
- Xu Bingzheng
- Department of Emergency, Dongyang people's Hospital of Zhejiang Province, Dongyang, China
| | - Ren Jingnan
- Department of Emergency, Dongyang people's Hospital of Zhejiang Province, Dongyang, China
| | - Bao Ligang
- Department of Emergency, Dongyang people's Hospital of Zhejiang Province, Dongyang, China
| | - Chen Jianping
- Department of Emergency, Dongyang people's Hospital of Zhejiang Province, Dongyang, China
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Abstract
Incidence and prevalence of atrial fibrillation (AF) and chronic kidney disease are increasing, and the two conditions commonly coexist. Renal impairment further increases the risk of ischemic stroke and systemic thromboembolism in patients with AF but also paradoxically predisposes to bleeding. Renal function should be monitored closely in patients with AF requiring oral anticoagulation therapy, particularly those receiving direct oral anticoagulants. Vitamin K antagonists can be used as part of a dose-adjusted anticoagulation regimen in patients with mild to moderate renal dysfunction. Dialysis-dependent patients taking vitamin K antagonists are at increased risk of sustaining major hemorrhage.
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Affiliation(s)
- Maria Stefil
- Department of Cardiology, Royal Liverpool Hospital, Prescot Street, Liverpool, L7 8XP, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
| | - Katarzyna Nabrdalik
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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27
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Tapaskar N, Pang A, Werner DA, Sengupta N. Resuming Anticoagulation Following Hospitalization for Gastrointestinal Bleeding Is Associated with Reduced Thromboembolic Events and Improved Mortality: Results from a Systematic Review and Meta-Analysis. Dig Dis Sci 2021; 66:554-566. [PMID: 32279174 DOI: 10.1007/s10620-020-06248-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/31/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Systemic anticoagulants are widely prescribed for prevention and treatment of thromboembolism, but are commonly complicated by gastrointestinal bleeding (GIB). Limited data exist on the management of anticoagulation after hospitalization for GIB and the subsequent risks of recurrent GIB, thromboembolism, and mortality. METHODS We performed a systematic review and meta-analysis of studies to determine risk of recurrent GIB, thromboembolism, and mortality after resuming anticoagulation following GIB. PubMed, EMBASE, and Scopus were searched for randomized controlled trials and cohort studies in patients with atrial fibrillation, venous thromboembolism, or valvular heart disease who received long-term warfarin or direct oral anticoagulants before experiencing GIB. Studies were included if data were available on anticoagulation management and outcomes of recurrent GIB, thromboembolism, and mortality following GIB. RESULTS A total of 5354 studies were reviewed of which 10 were included in the meta-analysis. There were 2080 patients who resumed anticoagulation and 2296 patients who discontinued anticoagulation post-index GIB. Resumption of anticoagulation was associated with a significant increase in recurrent GIB (OR 1.646, 95% CI 1.035-2.617, p = 0.035). There was a significant decrease in thromboembolic events in patients who resumed anticoagulation compared to those who did not (OR 0.340, 95% CI 0.178-0.652, p = 0.001, I2 = 62.7%). Resumption of anticoagulation was associated with a significant reduction in all-cause mortality (OR 0.499, 95% CI 0.419-0.595, p < 0.0001). CONCLUSION While resumption of anticoagulation following index GIB was associated with a significant increase in recurrent GIB, it was also associated with a significant decrease in thromboembolic events and all-cause mortality.
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Affiliation(s)
- Natalie Tapaskar
- Department of Medicine, University of Chicago Medicine, Chicago, USA
| | - Alice Pang
- Department of Medicine, New York University Langone Health, 550 First Avenue, New York, NY, 10022, USA
| | - Debra A Werner
- The John Crerar Library, University of Chicago, 5730 S Ellis Ave, Chicago, IL, 60637, USA
| | - Neil Sengupta
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, 5841 S Maryland Avenue, MC 4076, Chicago, IL, 60637, USA.
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Zhou E, Lord A, Boehme A, Henninger N, de Havenon A, Vahidy F, Ishida K, Torres J, Mistry EA, Mac Grory B, Sheth KN, Gurol ME, Furie K, Elkind MSV, Yaghi S. Risk of Ischemic Stroke in Patients With Atrial Fibrillation After Extracranial Hemorrhage. Stroke 2020; 51:3592-3599. [PMID: 33028172 DOI: 10.1161/strokeaha.120.029959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Anticoagulation therapy not only reduces the risk of ischemic stroke in atrial fibrillation (AF) but also predisposes patients to hemorrhagic complications. There is limited knowledge on the risk of first-ever ischemic stroke in patients with AF after extracranial hemorrhage (ECH). METHODS We conducted a retrospective study using the California State Inpatient Database including all nonfederal hospital admissions in California from 2005 to 2011. The exposure variable was hospitalization with a diagnosis of ECH with a previous diagnosis of AF. The outcome variable was a subsequent hospitalization with acute ischemic stroke. We excluded patients with stroke before or at the time of ECH diagnosis. We calculated adjusted hazard ratios for ischemic stroke during follow-up and at 6-month intervals using Cox regression models adjusted for pertinent demographics and comorbidities. In subgroup analyses, subjects were stratified by primary ECH diagnosis, severity/type of ECH, age, CHA2DS2-VASc score, or the presence/absence of a gastrointestinal or genitourinary cancer. RESULTS We identified 764 257 patients with AF (mean age 75 years, 49% women) without a documented history of stroke. Of these, 98 647 (13%) had an ECH-associated hospitalization, and 22 748 patients (3%) developed an ischemic stroke during the study period. Compared to patients without ECH, subjects with ECH had ≈15% higher rate of ischemic stroke (overall adjusted hazard ratio, 1.15 [95% CI, 1.11-1.19]). The risk appeared to remain elevated for at least 18 months after the index ECH. In subgroup analyses, the risk was highest in subjects with a primary admission diagnosis of ECH, severe ECH, gastrointestinal-type ECH, with gastrointestinal or genitourinary cancer, and age ≥60 years. CONCLUSIONS Patients with AF hospitalized with ECH may have a slightly elevated risk for future ischemic stroke. Particular consideration should be given to the optimal balance between the benefits and risks of anticoagulation therapy and the use of nonanticoagulant alternatives, such as left atrial appendage closure in this vulnerable population.
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Affiliation(s)
- Eric Zhou
- NYU Grossman School of Medicine, New York, NY (E.Z.)
| | - Aaron Lord
- Department of Neurology, NYU Langone Health, New York, NY (A.L., K.I., J.T., S.Y.)
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons (A.B., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.B., M.S.V.E.), Columbia University, New York, NY
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical Center, Worcester (N.H.)
- Department of Psychiatry, University of Massachusetts, Worcester (N.H.)
| | - Adam de Havenon
- Departments of Neurology, University of Utah Medical Center, Salt Lake City (A.d.H.)
| | - Farhaan Vahidy
- Center for Outcomes Research, The Houston Methodist Neurological Institute, TX (F.V.)
| | - Koto Ishida
- Department of Neurology, NYU Langone Health, New York, NY (A.L., K.I., J.T., S.Y.)
| | - Jose Torres
- Department of Neurology, NYU Langone Health, New York, NY (A.L., K.I., J.T., S.Y.)
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN (E.A.M.)
| | - Brian Mac Grory
- Department of Neurology, Brown University, Providence, RI (B.M.G., K.F.)
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, CT (K.N.S.)
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.E.G.)
| | - Karen Furie
- Department of Neurology, Brown University, Providence, RI (B.M.G., K.F.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons (A.B., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.B., M.S.V.E.), Columbia University, New York, NY
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY (A.L., K.I., J.T., S.Y.)
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29
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Tomaselli GF, Mahaffey KW, Cuker A, Dobesh PP, Doherty JU, Eikelboom JW, Florido R, Gluckman TJ, Hucker WJ, Mehran R, Messé SR, Perino AC, Rodriguez F, Sarode R, Siegal DM, Wiggins BS. 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. J Am Coll Cardiol 2020; 76:594-622. [DOI: 10.1016/j.jacc.2020.04.053] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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31
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Kaide CG, Gulseth MP. Current Strategies for the Management of Bleeding Associated with Direct Oral Anticoagulants and a Review of Investigational Reversal Agents. J Emerg Med 2020; 58:217-233. [DOI: 10.1016/j.jemermed.2019.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/30/2019] [Accepted: 10/13/2019] [Indexed: 01/19/2023]
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32
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Sostres C, Marcén B, Laredo V, Alfaro E, Ruiz L, Camo P, Carrera-Lasfuentes P, Lanas Á. Risk of rebleeding, vascular events and death after gastrointestinal bleeding in anticoagulant and/or antiplatelet users. Aliment Pharmacol Ther 2019; 50:919-929. [PMID: 31486121 DOI: 10.1111/apt.15441] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 02/19/2019] [Accepted: 07/06/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with gastrointestinal bleeding during anticoagulant and/or antiplatelet therapy represent a clinical challenge. AIM To determine the risk/rates of rebleeding, vascular events and death in patients treated with antiplatelet or anticoagulant agents who developed major gastrointestinal bleeding METHODS: This was an observational cohort study of patients who developed gastrointestinal bleeding while on antiplatelet and/or anticoagulant therapy. Drug use information was collected prospectively during bleeding events. Cox proportional hazards models were used to evaluate rebleeding, vascular events and death. RESULTS Among 871 patients (mean age 78.9 ± 8.6 years), 38.9% used an anticoagulant, 52.5% used an antiplatelet and 8.6% used both; 93.1% interrupted treatment after gastrointestinal bleeding and 80.5% restarted therapy within 7.6 ± 36.4 days; 38.7% had upper gastrointestinal bleeds, 46.7% lower gastrointestinal bleeds and 14.6% gastrointestinal bleeds of unknown origin. Median follow-up was 24.9 months (IQR: 7.0-38.0). Resumption of both therapies was associated with a higher risk of rebleeding, lower risk of ischaemic events or death and a similar risk for upper and lower gastrointestinal events. Resumption of therapy ≤ 7 days after bleeding showed a similar pattern with no differences in death. Rebleeding rates were higher in anticoagulant vs antiplatelet patients (138.0 vs 99.0 events per 1000 patient-years), and the bleeding location was identical in 61.8% of cases. CONCLUSIONS Resumption of anticoagulant or antiplatelet therapy after a gastrointestinal bleeding event was associated with a lower risk of vascular events and death and a higher rebleeding risk. The benefits of early reinstitution of anticoagulant/antiplatelet therapy outweigh the gastrointestinal-related risks.
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Affiliation(s)
- Carlos Sostres
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.,IIS Aragón, Zaragoza, Spain.,CIBERehd, Zaragoza, Spain
| | - Beatriz Marcén
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Viviana Laredo
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Enrique Alfaro
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Lara Ruiz
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Patricia Camo
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Ángel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.,IIS Aragón, Zaragoza, Spain.,CIBERehd, Zaragoza, Spain.,University of Zaragoza, Zaragoza, Spain
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33
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Seelig J, Pisters R, Hemels ME, Huisman MV, Ten Cate H, Alings M. When to withhold oral anticoagulation in atrial fibrillation - an overview of frequent clinical discussion topics. Vasc Health Risk Manag 2019; 15:399-408. [PMID: 31571891 PMCID: PMC6755244 DOI: 10.2147/vhrm.s187656] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/28/2019] [Indexed: 12/14/2022] Open
Abstract
Stroke prevention with oral anticoagulants in patients with atrial fibrillation predisposes for bleeding. As a result, in select patient groups anticoagulation is withheld because of a perceived unfavorable risk-benefit ratio. Reasons for withholding anticoagulation can vary greatly between clinicians, often leading to discussion in daily clinical practice on the best approach. To guide clinical decision-making, we have reviewed available evidence on the most frequently reported reasons for withholding anticoagulation: previous bleeding, frailty and age, and an overall high bleeding risk.
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Affiliation(s)
- Jaap Seelig
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Martin E Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.,Anticoagulation Clinic Maastricht, Maastricht, The Netherlands
| | - Marco Alings
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
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Kozieł M, Ding WY, Kalarus Z, Lip GYH. Considerations when restarting anticoagulants in patients with atrial fibrillation after bleeding. Expert Rev Hematol 2019; 12:845-855. [PMID: 31334670 DOI: 10.1080/17474086.2019.1647779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Introduction: Oral anticoagulants (OACs) are established treatments to reduce thromboembolic risk in patients with atrial fibrillation (AF). Due to their mechanisms of action, they are associated with increased bleeding risk. Evaluation with bleeding risk scores may be useful to identify patients at high risk. However, the approach in patients who have suffered a recent bleeding event while on OACs is a contentious issue. If a decision is made to re-initiate OACs, the optimal timing for this remains controversial. Areas covered: Bleeding risk scores were designed to evaluate risk in patients with AF and indications for OACs. Some practical schemes were created to manage bleeding in this population. The types of bleeding were classified as minor, major non-life-threatening and major life-threatening bleeding. In AF patients suffering from severe acute bleeding, it is recommended to withhold OACs until the underlying cause is identified and treated. Each case will require an individualized decision to restarting OAC therapy after consideration of the risks, benefits, alternatives and patient's choice in the matter. Expert opinion: Management of major bleeding and restarting OACs in patients with a recent major bleeding poses a special challenge due to high bleeding and thrombotic risk. This will be discussed in this review.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University , Aalborg , Denmark
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Oakland K, Desborough MJ, Murphy MF, Schachter M, Jairath V. Rebleeding and Mortality After Lower Gastrointestinal Bleeding in Patients Taking Antiplatelets or Anticoagulants. Clin Gastroenterol Hepatol 2019; 17:1276-1284.e3. [PMID: 29277620 DOI: 10.1016/j.cgh.2017.12.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/27/2017] [Accepted: 12/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients who develop lower gastrointestinal bleeding (LGIB) while receiving anticoagulants or anti-platelets have increased severity of bleeding and risk of rebleeding. We compared outcomes of patients receiving antiplatelets, anticoagulants, or direct oral anticoagulants (DOACs) who develop LGIB, as well as the effects of withholding these drugs on their course of bleeding. METHODS We performed a retrospective study of 2528 consecutive adult patients with LGIB at 143 hospitals in the United Kingdom, from September through December 2015; 917 were taking anticoagulant or antiplatelet drugs and 1218 were taking neither (unexposed). We collected data on demographic features of patients, interventions or medications, outcomes, laboratory test results, and patient readmission until patient death, discharge, or 28 days after admission (whichever came first). Rebleeding was defined as additional transfusion requirements and/or a decrease in hematocrit ≥20% after 24 hrs of clinical stability. Multivariate regression was used to examine the relationship between drug class on presentation with LGIB and rebleeding, mortality, and cardiovascular events. Rates of rebleeding and cardiovascular complications in patients who had these drugs withheld were also analyzed. RESULTS Patients receiving antiplatelets, but not those receiving warfarin (n = 232) or DOACs (n = 102), had a higher risk of in-hospital rebleeding (monotherapy hazard ratio [HR], 3.57; 95% CI, 1.13-11.28; n = 504 and dual antiplatelet therapy hazard ratio, 5.3; 95% CI, 1.56-18.54; n = 79) compared with the unexposed group. This risk was not lower in patients who received antiplatelets and had the drug withheld for fewer than 5 days, compared to those who continued the drug throughout admission (HR, 0.98; 95% CI, 0.45-2.17) No differences were observed in risk-adjusted mortality or readmission with further bleeding for patients receiving antiplatelets, DOACs, or warfarin. Cardiovascular events were too few to allow meaningful comparison. CONCLUSIONS In patients with LGIB, antiplatelet drugs, but not warfarin or DOACs, are associated with an increased risk of rebleeding. Withholding antiplatelets during admission does not lead to reduction in rebleeding.
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Affiliation(s)
- Kathryn Oakland
- NHS Blood and Transplant, Oxford, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
| | - Michael J Desborough
- NHS Blood and Transplant, Oxford, United Kingdom; Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Mike Schachter
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Vipul Jairath
- Division of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Department of Medicine, Division of Gastroenterology, University Hospital, Ontario, Canada
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Oakland K, Chadwick G, East JE, Guy R, Humphries A, Jairath V, McPherson S, Metzner M, Morris AJ, Murphy MF, Tham T, Uberoi R, Veitch AM, Wheeler J, Regan C, Hoare J. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019; 68:776-789. [PMID: 30792244 DOI: 10.1136/gutjnl-2018-317807] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/07/2019] [Accepted: 01/16/2019] [Indexed: 01/28/2023]
Abstract
This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.
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Affiliation(s)
| | | | - James E East
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, UK
| | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Vipul Jairath
- Robarts Clinical Trials, Inc., London, Ontario, Canada.,Medicine and Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | | | - Magdalena Metzner
- Department of Gastroenterology, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - A John Morris
- Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Tony Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, UK
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - James Wheeler
- Department of Colorectal Surgery, Addenbrooke's Hospital, Cambridge, UK
| | | | - Jonathan Hoare
- Department of Surgery and Cancer, Imperial College, London, UK
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Abstract
INTRODUCTION The 2010 Affordable Care Act introduced the Hospital Readmissions Reduction Program to reduce health care utilization. Diverticular disease and its complications remain a leading cause of hospitalization among gastrointestinal disease. We sought to determine risk factors for 30-day hospital readmissions after hospitalization for diverticular bleeding. MATERIALS AND METHODS We utilized the 2013 National Readmission Database sponsored by the Agency for Healthcare Research and Quality focusing on hospitalizations with the primary or secondary discharge diagnosis of diverticular hemorrhage or diverticulitis with hemorrhage. We excluded repeat readmissions, index hospitalizations during December and those resulting in death. Our primary outcome was readmission within 30 days of index hospital discharge. Secondary outcomes of interest included medical and procedural comorbid risk factors. The data were analyzed using logistic regression analysis. RESULTS In total, 29,090 index hospitalizations for diverticular hemorrhage were included. There were 3484 (12%) 30-day readmissions with recurrent diverticular hemorrhage diagnosed in 896 (3%).Index admissions with renal failure [odds ratio (OR), 1.31; 95% confidence interval (CI), 1.19-1.43], congestive heart failure (OR, 1.30; 95% CI, 1.17-1.43), chronic pulmonary disease (OR, 1.19; 95% CI, 1.09-1.29), coronary artery disease (OR, 1.12; 95% CI, 1.03-1.21), atrial fibrillation (OR, 1.12; 95% CI, 1.02-1.22) cirrhosis (OR, 1.95; 95% CI, 1.29-2.93, performance of blood transfusion (OR, 1.23; 95% CI, 1.15-1.33), and abdominal surgery (OR, 1.24; 95% CI, 1.03-1.49) had increased risk of 30-day readmission. CONCLUSIONS The 30-day readmission rate for diverticular hemorrhage was 12% with multiple identified comorbidities increasing readmission risk.
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Resumption of anticoagulant therapy after anticoagulant-related gastrointestinal bleeding: A systematic review and meta-analysis. Thromb Res 2019; 175:102-109. [DOI: 10.1016/j.thromres.2019.01.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/03/2019] [Accepted: 01/28/2019] [Indexed: 11/23/2022]
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Dunne PDJ, Laursen SB, Laine L, Dalton HR, Ngu JH, Schultz M, Rahman A, Anderloni A, Murray IA, Stanley AJ. Previous Use of Antithrombotic Agents Reduces Mortality and Length of Hospital Stay in Patients With High-risk Upper Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2019; 17:440-447.e2. [PMID: 29705263 DOI: 10.1016/j.cgh.2018.04.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 04/16/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Anti-thrombotic agents are risk factors for upper gastrointestinal bleeding (UGIB). However, few studies have evaluated their effects on patient outcomes. We assessed the effects of anti-thrombotic agents on outcomes of patients with high-risk UGIB. METHODS We performed a prospective study of 619 patients with acute UGIB (defined by hematemesis, coffee-ground vomit or melena) who required intervention and underwent endoscopy at 8 centers in North America, Asia, and Europe, from March 2014 through March 2015. We collected data recorded on use of anti-thrombotic agents, clinical features, and laboratory test results to calculate AIMS65, Glasgow-Blatchford Score, and full Rockall scores. We also collected and analyzed data on co-morbidities, endoscopic findings, blood transfusion, interventional radiology results, surgeries, length of hospital stay, rebleeding, and mortality. RESULTS Of the 619 patients who required endoscopic therapy, data on use of anti-thrombotic agents was available for 568; 253 of these patients (44%) used anti-thrombotic agents. Compared to patients not taking anti-thrombotic agents, patients treated with anti-thrombotics were older (P < .001), had a higher mean American Society of Anesthesiologists classification score (P < .0001), had a higher mean Rockall score (P < .0001), a higher mean AIMS65 score (P < .0001), and more frequently bled from ulcers (P < .001). There were no differences between groups in sex, systolic blood pressure, level of hemoglobin at hospital admission, frequency of malignancies, Glasgow-Blatchford Score, need for surgery or interventional radiology, number of rebleeding events, or requirement for transfusion. All-cause mortality was lower in patients who took anti-thrombotic drugs (11 deaths, 4%) than in patients who did not (37 deaths, 12%) (P = .002); this was due to lower bleeding-related mortality in patients taking anti-thrombotic drugs (3 deaths, 1%) than in patients who were not (19 deaths, 6%) (P = .003). Patients taking anti-thrombotic drugs had mean hospital stays of 6.9 days (95% CI, 2-23 days) compared to 7.9 days for non-users of anti-thrombotic agents (95% CI, 2-26 days) (P = .04). CONCLUSIONS Despite being older, with higher American Society of Anesthesiologists classification, AIMS65, and Rockall scores, patients who have UGIB that requires endoscopic therapy and take anti-thrombotic drugs have lower mortality due to GI bleeding and shorter hospital stays, with similar rates of rebleeding, surgery, and transfusions, compared with those not taking anti-thrombotic drugs.
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Affiliation(s)
- Philip D J Dunne
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK.
| | - Stig B Laursen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Harry R Dalton
- Gastrointestinal Unit, Royal Cornwall Hospital, Truro, UK
| | - Jing H Ngu
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Michael Schultz
- Gastroenterology Unit, Southern District Health Board, Dunedin Hospital, Dunedin, New Zealand
| | - Adam Rahman
- Department of Gastroenterology, Saint Joseph's Health Care, London, Ontario, Canada
| | - Andrea Anderloni
- Department of Gastroenterology, Humanitas Hospital, Milan, Italy
| | - Iain A Murray
- Gastrointestinal Unit, Royal Cornwall Hospital, Truro, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
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Aoki T, Hirata Y, Yamada A, Koike K. Initial management for acute lower gastrointestinal bleeding. World J Gastroenterol 2019; 25:69-84. [PMID: 30643359 PMCID: PMC6328962 DOI: 10.3748/wjg.v25.i1.69] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/17/2018] [Accepted: 12/01/2018] [Indexed: 02/06/2023] Open
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospital admission. Patients with LGIB often experience persistent or recurrent bleeding and require blood transfusions and interventions, such as colonoscopic, radiological, and surgical treatments. Appropriate decision-making is needed to initially manage acute LGIB, including emergency hospitalization, timing of colonoscopy, and medication use. In this literature review, we summarize the evidence for initial management of acute LGIB. Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding. Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy. Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia. How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events. In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB. Managing acute LGIB based on this information would improve clinical outcomes. Further investigations are needed to distinguish patients with LGIB who require early colonoscopy and hemostatic intervention.
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Affiliation(s)
- Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
| | - Yoshihiro Hirata
- Division of Advanced Genome Medicine, the Institute of Medical Science, the University of Tokyo, Tokyo 108-8639, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, the University of Tokyo, Tokyo 113-8655, Japan
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To Scope or Not to Scope? The Safety of Upper Endoscopy in the Setting of Pulmonary Embolism. Am J Gastroenterol 2019; 114:165-168. [PMID: 30315307 DOI: 10.1038/s41395-018-0285-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to describe the frequency of upper endoscopy and associated outcomes in subjects hospitalized with upper GI bleeding (UGIB) and pulmonary embolism (PE). METHODS We performed a cross-sectional study using the Nationwide Inpatient Sample from 2007 to 2014. The association between upper endoscopy and in-hospital mortality was evaluated using propensity score matching. RESULTS A total of 44,412 subjects had a coexistent PE and UGIB. 63.5% had an inpatient upper endoscopy with a lower likelihood of in-hospital death and a shorter length of stay. CONCLUSIONS A substantial proportion of inpatients with PE and UGIB undergo endoscopy with a relatively lowmortality rate.
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Sengupta N, Marshall AL, Jones BA, Ham S, Tapper EB. Rebleeding vs Thromboembolism After Hospitalization for Gastrointestinal Bleeding in Patients on Direct Oral Anticoagulants. Clin Gastroenterol Hepatol 2018; 16:1893-1900.e2. [PMID: 29775794 DOI: 10.1016/j.cgh.2018.05.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/20/2018] [Accepted: 05/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Little is known about outcomes of patients hospitalized for gastrointestinal bleeding (GIB) while they are taking direct oral anticoagulants (DOAC). We aimed to determine the frequency at which patients resume DOAC therapy following hospitalization for GIB in a real-world setting, and the risks and benefits. METHODS We conducted a retrospective analysis of medical claims data from the Truven Health Marketscan Commercial Claims and Encounters Database, from January 1, 2010, through December 31, 2014. We collected data on 1338 adults treated with DOACs and hospitalized for GIB (dabigatran, n = 679; rivaroxaban, n = 608, apixaban, n = 51). Patients who developed GIB within 1 year of DOAC initiation, and had a DOAC claim filled within 1 month of GIB, were included in the analysis. Postdischarge readmissions due to thromboembolism and recurrent GIB within 90 days were reviewed. We used proportional hazards to identify factors associated with thromboembolism and recurrent GIB. RESULTS The median age of patients who did not resume DOAC therapy was older (79 vs 78 y for patients who did resume DOAC therapy; P = .0005). Higher proportions of patients who did not resume DOAC had heart failure (25% vs 20% who did resume DOAC therapy; P = .01), received blood (36% vs 24%; P < .0001), and required intensive care (18% vs 12%; P = .003). Restarting DOAC therapy within 30 days was not associated with thromboembolism within 90 days (hazard ratio [HR], 0.98; 95% CI, 0.37-2.21) or recurrent GIB (HR, 1.44; 95% CI 0.72-2.68). On multivariate regression, prior venous thromboembolism was associated with postdischarge thromboembolism (HR, 3.30; 95% CI, 1.29-7.38), and thienopyridine use was associated with recurrent GIB (HR, 3.12; 95% CI, 1.55-5.81). A higher proportion of patients who resumed treatment with rivaroxaban, compared with other DOACs, had recurrence of GIB (log rank, P = .04). CONCLUSIONS In a retrospective analysis of medical claims data from adults treated with DOACs and hospitalized for GIB, we found that older patients who require blood and intensive care were less likely to restart treatment with DOACs after GIB. Resuming DOAC therapy was not associated with thromboembolism within 90 days or recurrence of GIB; a history of venous thromboembolism and thienopyridine use were associated with a risk of subsequent thromboembolism and GIB respectively.
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Affiliation(s)
- Neil Sengupta
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, Chicago, Illinois; Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
| | | | - Blake A Jones
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Sandra Ham
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, Shehab N, Mock J, Myers T, Dentali F, Crowther MA, Agarwal A, Bhatt M, Khatib R, Riva JJ, Zhang Y, Guyatt G. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257-3291. [PMID: 30482765 PMCID: PMC6258922 DOI: 10.1182/bloodadvances.2018024893] [Citation(s) in RCA: 299] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. CONCLUSIONS Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding.
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Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation and Anemia Service, Kaiser Permanente Colorado, Aurora, CO
| | - Jack Ansell
- School of Medicine, Hofstra Northwell, Hempstead, NY
| | - Anne Holbrook
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jane Skov
- Unit for Health Promotion Research, Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Meha Bhatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL; and
| | - John J Riva
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Vajravelu RK, Mamtani R, Scott FI, Waxman A, Lewis JD. Incidence, Risk Factors, and Clinical Effects of Recurrent Diverticular Hemorrhage: A Large Cohort Study. Gastroenterology 2018; 155:1416-1427. [PMID: 30056095 PMCID: PMC6219900 DOI: 10.1053/j.gastro.2018.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/12/2018] [Accepted: 07/22/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Although recurrent diverticular hemorrhage is common, its incidence and risk factors have not been measured outside of small institutional cohorts. We analyzed the incidence of and risk factors for recurrent diverticular hemorrhage and whether discontinuing anticoagulation after diverticular hemorrhage is associated with ischemic stroke. METHODS We performed a retrospective cohort study of patients enrolled in the OptumInsight Clinformatics database from 2000 through 2016. Incidence rates for initial and recurrent diverticular hemorrhage were calculated by identifying patients who had hospitalizations with a primary discharge diagnosis consistent with diverticular hemorrhage. The hazard ratios of second diverticular hemorrhage associated with anticoagulants or platelet aggregation inhibitors were calculated using Cox proportional hazards regression adjusted for demographics, comorbidities, and medication use. The hazard ratio for ischemic stroke among patients who discontinued anticoagulation after diverticular hemorrhage was calculated similarly. RESULTS In the cohort analyzed, 14,925 patients had an initial diverticular hemorrhage; 1368 of these patients had a second episode. The unstandardized incidence rates of initial and second diverticular hemorrhage were 10.9 per 100,000 person-years (95% confidence interval [CI] 10.7-11.0) and 3625.6 per 100,000 person-years (95% CI 3436.0-3823.0). Platelet aggregation inhibitors were associated with second episodes of diverticular hemorrhage (hazard ratio 1.47; 95% CI 1.15-1.88), whereas all classes of anticoagulation agents were not associated. Among patients with a potential indication for stroke prophylaxis, those who discontinued anticoagulation after the diverticular hemorrhage had an increased hazard of ischemic stroke (hazard ratio 1.93; 95% CI 1.17-3.19). CONCLUSIONS In this retrospective cohort study, platelet aggregation inhibitors, but not anticoagulants, were associated with recurrent diverticular hemorrhage. Discontinuing anticoagulation was associated with increased hazard for ischemic stroke.
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Affiliation(s)
- Ravy K Vajravelu
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Ronac Mamtani
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank I Scott
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Adam Waxman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Nagata N, Yasunaga H, Matsui H, Fushimi K, Watanabe K, Akiyama J, Uemura N, Niikura R. Therapeutic endoscopy-related GI bleeding and thromboembolic events in patients using warfarin or direct oral anticoagulants: results from a large nationwide database analysis. Gut 2018; 67:1805-1812. [PMID: 28874418 PMCID: PMC6145295 DOI: 10.1136/gutjnl-2017-313999] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/19/2017] [Accepted: 07/30/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the risks of postendoscopy outcomes associated with warfarin with direct oral anticoagulants (DOACs), taking into account heparin bridging and various types of endoscopic procedures. DESIGN Using the Japanese Diagnosis Procedure Combination database, we identified 16 977 patients who underwent 13 types of high-risk endoscopic procedures and took preoperative warfarin or DOACs from 2014 to 2015. One-to-one propensity score matching was performed to compare postendoscopy GI bleeding and thromboembolism between the warfarin and DOAC groups. RESULTS In the propensity score-matched analysis involving 5046 pairs, the warfarin group had a significantly higher proportion of GI bleeding than the DOAC group (12.0% vs 9.9%; p=0.002). No significant difference was observed in thromboembolism (5.4% vs 4.7%) or in-hospital mortality (5.4% vs 4.7%). The risks of GI bleeding and thromboembolism were greater in patients treated with warfarin plus heparin bridging or DOACs plus bridging than in patients treated with DOACs alone. Compared with percutaneous endoscopic gastrostomy, patients who underwent endoscopic submucosal dissection, endoscopic mucosal resection and haemostatic procedures including endoscopic variceal ligation or endoscopic injection sclerotherapy were at the highest risk of GI bleeding among the 13 types of endoscopic procedures, whereas those who underwent lower polypectomy endoscopic sphincterotomy or endoscopic ultrasound-guided fine needle aspiration were at moderate risk. CONCLUSION The risk of postendoscopy GI bleeding was higher in warfarin than DOAC users. Heparin bridging was associated with an increased risk of bleeding and did not prevent thromboembolism. The bleeding risk varied by the type of endoscopic procedure.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Care Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
| | - Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Chi TY, Liu Y, Zhu HM, Zhang M. Thromboelastography-derived parameters for the prediction of acute thromboembolism following non-steroidal anti-inflammatory drug-induced gastrointestinal bleeding: A retrospective study. Exp Ther Med 2018; 16:2257-2266. [PMID: 30186466 PMCID: PMC6122363 DOI: 10.3892/etm.2018.6468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 05/25/2018] [Indexed: 12/28/2022] Open
Abstract
Efficacy of thromboelastography (TEG)-derived parameters for the prediction of acute thromboembolism (AT) in patients with non-steroidal anti-inflammatory drug (NSAID)-induced gastrointestinal bleeding (GIB) remains to be determined. A retrospective propensity score matching (PSM) study was performed to evaluate this efficacy. Patients with NSAID-induced GIB (98 with AT; 830 without AT) were matched for age, sex and history of cardiovascular and cerebrovascular diseases using PSM. Multivariate logistic regression was used to determine the efficacy of TEG-derived predictors of AT. Mean Decrease Gini (MDG) coefficients were used to rank the importance of the variables from random forest algorithm results. Univariate analysis indicated that the following indexes were significantly different between the two groups: Reaction time (R value), coagulation forming time, solidification angle, maximum amplitude (MA), coagulation index (CI), hemoglobin levels, D-dimer levels, platelet aggregation test (pAgt) results, fibrinogen levels and Acute Physiology and Chronic Health Evaluation II score (all P<0.001). Multifactor logistic regression analysis indicated that the R value (P=0.010), solidification angle (P=0.004), MA (P=0.038), D-dimer levels (P=0.012) and pAgt results (P=0.015) were independent predictors of AT in patients with NSAID-induced GIB, achieving an area under the curve of 0.999 in receiver operating characteristic curve analyses. The five most important parameters according to the MDG scores (MDGS) were: Solidification angle (MDGS=58.14), R value (MDGS=20.42), pAgt results (MDGS=15.61), D-dimer levels (MDGS=12.78) and CI (MDGS=12.61). The results of the present study indicated that TEG-derived parameters including the R value, solidification angle, MA and CI, as well as D-dimer levels and pAgt score were significant predictors of AT in patients with NSAID-induced GIB.
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Affiliation(s)
- Tian-Yu Chi
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Ying Liu
- Department of Gastroenterology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Hong-Ming Zhu
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Mei Zhang
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing 100053, P.R. China
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Abstract
Peptic ulcer bleeding remains an important medical emergency. Important recent advances are reviewed. These include further support for a more restrictive transfusion strategy aiming for a target haemoglobin of 70-90 g/L. The Glasgow-Blatchford score remains the most useful assessment score for identifying the lowest risk patients suitable for outpatient management and predicting the need for intervention. Newer scores such as the AIMS65 and Progetto Nazionale Emorragia Digestive score (PNED) may be more accurate in predicting mortality. Pre-endoscopy erythromycin improves outcomes and is underused. A new disposable Doppler probe appears to provide more accurate determination of both rebleeding risk and the success of endoscopic therapy than purely visual guidance. Over-the-scope clips and haemostatic powders appear to have some role as endoscopic salvage therapies. Non- H. pylori, non-aspirin/non-steroidal anti-inflammatory drug (NSAID) ulcers contribute to an increasing percentage of bleeding peptic ulcers and are associated with a high rebleeding rate. The optimal management of these ulcers remains to be determined.
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Affiliation(s)
- Ian LP Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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Schulman S, Aisenberg J. Are NSAIDs Double Trouble? J Am Coll Cardiol 2018; 72:268-270. [DOI: 10.1016/j.jacc.2018.04.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
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Resumption of Warfarin After Hospitalization for Lower Gastrointestinal Bleeding and Mortality Benefits. J Clin Gastroenterol 2018; 52:545-550. [PMID: 28266939 DOI: 10.1097/mcg.0000000000000821] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS To evaluate whether resumption of warfarin after hospitalization for lower gastrointestinal bleeding (LGIB) is associated with improved 90-day and 6-month survival. BACKGROUND LGIB is a common complication for patients on warfarin. There is limited data to guide clinicians on the optimal management of warfarin following hospitalization for LGIB. STUDY We identified patients hospitalized with LGIB while on warfarin using a validated, machine-learning algorithm. Patients were classified as those who had warfarin resumed at discharge and those who did not. Univariate and multivariate Cox proportional hazards were used to determine whether resuming warfarin was associated with improved 90-day and 6-month mortality. RESULTS In total, 607 patients were admitted with warfarin-associated LGIB. A total of 403 (66.4%) patients had warfarin held at discharge. Discontinuation of warfarin was associated with an increased 90-day and 6-month mortality on univariate analysis [hazard ratio (HR), 2.07, 95% confidence interval (CI), 1.04-4.58, P=0.04; HR, 1.78, 95% CI, 1.02-3.27, P=0.04]. On multivariate regression adjusting for age, comorbidities, and transfusion requirement, only a higher Charlson Index was associated with increased 90-day mortality (HR, 1.18, 95% CI, 1.07-1.29, P=<0.001). At 6 months, only older age was associated with an increased mortality on multivariate regression (HR, 1.02, 95% CI, 1.00-1.05, P=0.02), with no significantly increased mortality risk with holding warfarin (HR, 1.48, 95% CI, 0.84-2.78, P=0.18) CONCLUSIONS:: There was no association between resumption of warfarin at discharge following hospitalization for LGIB and either 90-day or 6-month mortality on multivariate analysis. Mortality in LGIB was largely driven by age and comorbidities.
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