Thomas Savides MD Professor of Clinical Medicine University of California San Diego Disclosures None Learning Objectives Accurately assess the risk of bleeding in patients on anticoagulants and antiplatelet agents before endoscopic procedures ID: 667616
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Management of Anticoagulants & Antiplatelet Agents Pre and Post Endoscopy
Thomas Savides, M.D.Professor of Clinical MedicineUniversity of California, San DiegoSlide2
Disclosures
NoneSlide3
Learning Objectives
Accurately assess the risk of bleeding in patients on anticoagulants and antiplatelet agents before endoscopic proceduresLearn the cardiovascular risk of modifying antiplatelet therapy in the peri-endoscopic settingUnderstand current best-practice recommendations for management of anticoagulants after endoscopic proceduresSlide4
Balancing Risks of Bleeding vs Risk of Thromboembolism
Bleed after endoscopy
Thromboembolic EventSlide5
Issues to Consider
Risk of bleeding vs risk of thrombosisBleeding risk from endoscopic procedureThromboembolism risk if stop antithromboticsEmergency vs elective procedureSlide6
Anti-Thrombotic Agents
AnticoagulantsWarfarinHeparinLow molecular weight heparin
Anti-platelet agentsAspirinNon-steroidal anti-inflammatory agents (NSAID)Thienopyridine (clopidogrel, ticlopidine)Glycoprotein IIb/IIIa receptor inhibitorsSlide7
ASGE and ESGE Guidelines on Endoscopy and Antithrombotic AgentsSlide8
Management of antithrombotic agents for endoscopic procedures.
ASGE Standards of Practice Committee. 2009Slide9
Bleeding Risks For Endoscopic ProceduresSlide10
Management of antithrombotic agents for endoscopic procedures.
ASGE Standards of Practice Committee. 2009Slide11
Bleeding Risk During Endoscopic Procedures - ESGE
Low RiskEGDColonoscopyEUS
EUS FNA solid lesionColon polypectomy <1 cmStricture dilationStent placementERCP with stent or balloon dilationArgon plasma coagulation
High RiskEMR/ESDAmpullectomyERCP with sphincterotomyERCP with large balloon dilation of papillaColon polypectomy > 1 cmEUS FNA of cystic lesions
Percutaneous endoscopic gastrostomy (PEG)Esophageal variceal band ligationBoustiere, ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011Slide12
What are the risks of thromboembolic events around endoscopy?
Depends on the condition for which antithrombotic therapy is being used
Low Risk
High RiskSlide13
High Risk Conditions for Thromboembolic Events
Atrial Fibrillation with h/o embolic events or valve diseaseProsthetic ValveCoronary artery disease and stentsDeep Venous Thrombosis/Pulmonary EmbolusStroke/Transient Ischemic Attack
Hypercoagulable statesSlide14
Management of antithrombotic agents for endoscopic procedures.
ASGE Standards of Practice Committee. 2009Slide15
Atrial FibrillationHigh risk conditions for
thomboembolic events
Previous stroke (CVA) or transient ischemic attack (TIA)CHADS2 score ≥ 3CHF=1HTN=1
Age ≥ 75=1Diabetes=1Previous CVA/TIA=2Associated valvular heart disease
Kwok and Faigel, AJG 2009Slide16
Prosthetic ValveHigh risk conditions for
thomboembolic eventsBioprosthetic valve <3 months oldMechanical valve in mitral position
Mechanical valve with previous thromboembolic eventSlide17
Coronary Artery Disease and Stents
High risk conditions for thomboembolic eventsRecent acute coronary event <4-6 weeks
Discontinuing dual antiplatelet therapy in:Drug-eluting stent < 1 yearBare metal stent < 1 monthSlide18
Deep Venous Thrombosis/Pulmonary Emboli
High risk conditions for thomboembolic events
Discontinuing anticoagulation <3 months from eventRecurrent DVT/PESevere hypercoagulable statesCancerParoxysmal nocturnal hemoglobinuriaMyeloproliferative syndromeSlide19
Stroke/Transient Ischemic AttackHigh risk conditions for
thomboembolic eventsCardioembolic eventsCarotid artery disease
Recent carotid endarterectomyHypercoagulable stateSlide20
General Approach to Patients on Antithrombotic agents who need endoscopy
Delay elective endoscopy until patient at lower risk for thromboembolismDiscuss with patient’s cardiovascular or neurovascular physician whether (or when) drugs can be stopped
Realize that only limited data existGuidelines from ASGE, ESGE are only suggestions - Need to weigh the risks and benefits for each individual patientSlide21
Elective Procedures in Patients on antithrombotic drugsSlide22
EGD Procedures
Procedure
Risk BleedingStop Aspirin?Stop Clopidogrel or Prasugrel?
EGD ± biopsyLowNoNo
EGD with stricture dilationLowNoNoEGD with APCLowNoYesEGD with stent placementLowNo YesEGD with variceal band ligationHighNoYesEGD with PEG placementHighNo?EGD with EMR/ESDHighYesYesBoustiere, ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011Slide23
Colonoscopy Procedures
Procedure
Risk of BleedingStop aspirinStop clopidogrel or prasugrel?
Colonoscopy ± biopsyLowNo
NoColonoscopy with polypectomy <1 cmLowNoNoColonoscopy with polypectomy >1 cmHighNoYesColonoscopy with EMR/ESDHighYesYesBoustiere, ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011Slide24
ERCP Procedures
Procedure
Risk BleedingStop Aspirin?Stop Clopidogrel or Prasugrel?ERCP Diagnostic
LowNoNoERCP with Stent PlacementLow
NoNoERCP with sphincterotomyHighNoYesERCP with sphincterotomy and large balloon papillary dilationHighYesYesBoustiere, ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011Slide25
EUS Procedures
Procedure
Risk BleedingStop Aspirin?Stop Clopidogrel or Prasugrel?
EUS DiagnosticLowNoNoEUS with FNA Solid Mass
LowNoYesEUS FNA CystsHighYesYesERCP FNA TherapeuticHighYesYesBoustiere, ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011Slide26
Warfarin Management prior to Endoscopy
Avoid using Vitamin K to reverse anticoagulation before elective procedures because delays therapeutic re-anticoagulation after procedureWarfarin can usually be stopped for 4-7 days and then be restarted the following day
1% risk of thromboembolic events after temporary warfarin cessation (Garcia, Arch Intern Med 2008)High risk patients for thromboembolic events should consider bridging therapy with low molecular weight heparin.Slide27
Management of antithrombotic agents for endoscopic procedures.
ASGE Standards of Practice Committee. 2009Slide28
Management of antithrombotic agents in the
ELECTIVE endoscopic setting
Management of antithrombotic agents for endoscopic procedures. ASGE Standards of Practice Committee. 2009Slide29
Endoscopic Techniques Can Decrease Bleeding After Elective Polypectomy
Boustiere
, ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011Slide30
Endoscopy in the Acutely Bleeding Patient Receiving Antithrombotic TherapySlide31
Stopping or Reversing Antithrombotic Agents in the acutely bleeding patient
WarfarinConsider holding warfarinConsider vitamin K, FFP, Factor VIIaAHA/ACC recommendations
Fresh frozen plasma (FFP) preferable to high dose Vitamin KAvoid high-dose Vitamin K (10 mg) in patients with mechanical valves as may cause hypercoagulable stateLow dose Vitamin K (1-2 mg) may be fineAntiplatelet agentsConsider stopping drugConsider platelet transfusionSlide32
Efficacy of endoscopic therapy in patients actively taking antithrombotic drugs
Retrospective studies suggest endoscopic therapy seems safe and effective (even with INR >4)Mechanical hemostasis (i.e. clips) preferredEspecially if will resume antithrombotic medsSlide33
Restarting antithrombotic agents after endoscopic hemostasis
Resumption of aspirin + PPI has lower rate of recurrent peptic ulcer bleeding than switching to clopidogrel (Chan, NEJM 2005)Continuation of low dose aspirin after endoscopic hemostasis results in lower all cause mortality (12.9% vs 1.3%) and higher rebleed rate (10.3% vs 5.4%) (Sung JJ, Ann
Int Med 2010)Slide34
Asia-Pacific Working Group Consensus on Non-Variceal
Bleeding (Sung JJ,Gut 2011)Among aspirin users with high
cardiothrombotic risk who develop ulcer bleeding, aspirin should be resumed as soon as possible once hemostasis is establishedBecause risk of rebleeding is greatest in 1st 72 hours, consider restart aspirin 3-5 days after hemostasisUncertain about clopidogrel, but perhaps restart in 3-5 daysIf dual therapy; no data; depends on type of stent and when placedSlide35
Endoscopy in the Setting of Acute Coronary Syndrome
1-3% of patients with ACS will have GIBGIB in setting of ACS has 4-7 fold increased risk of in-hospital moralityRisk of EGD and Colonoscopy 1-2% in setting of ACSNote that with advent of intravenous PPI, less need for emergent need for EGD in mild-moderate UGI bleeds
Management of antithrombotic agents for endoscopic procedures. ASGE Standards of Practice Committee. 2009Slide36
Management of antithrombotic agents in the URGENT endoscopic setting
Management of antithrombotic agents for endoscopic procedures. ASGE Standards of Practice Committee. 2009Slide37
Do proton pump inhibitors impair efficacy of clopidogrel
?Mixed initial dataRecent NEJM article (Bhatt 2010) suggests noSlide38
Conclusions
Most endoscopic procedures safe to perform even if patient taking aspirin and/or NSAIDsContinuing antithrombotic therapy may improve overall outcomes (i.e. survival after ACS) even if higher rate of rebleeding
Need to individualize for each patient given limited data available for guidelinesSlide39
Thank You
Del Mar, California