Management of Anticoagulants amp Antiplatelet Agents Pre and Post Endoscopy Thomas Savides MD Professor of Clinical Medicine University of California San Diego Disclosures None Learning Objectives ID: 773146
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Management of Anticoagulants & Antiplatelet Agents Pre and Post Endoscopy Thomas Savides, M.D.Professor of Clinical MedicineUniversity of California, San Diego
Disclosures None
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 procedures
Balancing Risks of Bleeding vs Risk of Thromboembolism Bleed after endoscopy Thromboembolic Event
Issues to Consider Risk of bleeding vs risk of thrombosisBleeding risk from endoscopic procedureThromboembolism risk if stop antithromboticsEmergency vs elective procedure
Anti-Thrombotic Agents AnticoagulantsWarfarinHeparinLow molecular weight heparinAnti-platelet agents AspirinNon-steroidal anti-inflammatory agents (NSAID)Thienopyridine (clopidogrel, ticlopidine)Glycoprotein IIb/IIIa receptor inhibitors
ASGE and ESGE Guidelines on Endoscopy and Antithrombotic Agents
Management of antithrombotic agents for endoscopic procedures. ASGE Standards of Practice Committee. 2009
Bleeding Risks For Endoscopic Procedures
Management of antithrombotic agents for endoscopic procedures. ASGE Standards of Practice Committee. 2009
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 2011
What are the risks of thromboembolic events around endoscopy? Depends on the condition for which antithrombotic therapy is being used Low Risk High Risk
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 states
Management of antithrombotic agents for endoscopic procedures. ASGE Standards of Practice Committee. 2009
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 2009
Prosthetic ValveHigh risk conditions for thomboembolic eventsBioprosthetic valve <3 months oldMechanical valve in mitral position Mechanical valve with previous thromboembolic event
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 month
Deep Venous Thrombosis/Pulmonary Emboli High risk conditions for thomboembolic events Discontinuing anticoagulation <3 months from eventRecurrent DVT/PESevere hypercoagulable statesCancerParoxysmal nocturnal hemoglobinuriaMyeloproliferative syndrome
Stroke/Transient Ischemic AttackHigh risk conditions for thomboembolic eventsCardioembolic eventsCarotid artery disease Recent carotid endarterectomyHypercoagulable state
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 patient
Elective Procedures in Patients on antithrombotic drugs
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 2011
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 2011
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 2011
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 2011
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.
Management of antithrombotic agents for endoscopic procedures. ASGE Standards of Practice Committee. 2009
Management of antithrombotic agents in the ELECTIVE endoscopic setting Management of antithrombotic agents for endoscopic procedures. ASGE Standards of Practice Committee. 2009
Endoscopic Techniques Can Decrease Bleeding After Elective Polypectomy Boustiere , ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011
Endoscopy in the Acutely Bleeding Patient Receiving Antithrombotic Therapy
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 transfusion
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 meds
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)
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 placed
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. 2009
Management of antithrombotic agents in the URGENT endoscopic setting Management of antithrombotic agents for endoscopic procedures. ASGE Standards of Practice Committee. 2009
Do proton pump inhibitors impair efficacy of clopidogrel ?Mixed initial dataRecent NEJM article (Bhatt 2010) suggests no
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 guidelines
Thank You Del Mar, California