Clin Endosc.  2014 Jul;47(4):320-323. 10.5946/ce.2014.47.4.320.

Management of Antithrombotic Therapy for Gastroenterological Endoscopy from a Cardio-Cerebrovascular Physician's Point of View

• Oh HG

• KMID: 1907931
• DOI: http://doi.org/10.5946/ce.2014.47.4.320

Abstract

Periprocedural management of antithrombotics for gastroenterological endoscopy is a common clinical issue. To decide how to manage the use of antithrombotics in patients undergoing endoscopy, the risk for hemorrhage and thromboembolism during the procedure must be considered. For low-risk procedures, no adjustments in antithrombotics are needed. For high-risk procedures with a low thromboembolic risk, discontinuation of warfarin at 5 days, and clopidogrel at 5 to 7 days before the procedure has been recommended. However, it is better to continue aspirin use even during high-risk procedures. A heparin bridging therapy may be considered before endoscopy in patients with a high thromboembolic risk. The management of patients taking antithrombotics remains complex, especially in high-risk settings.

Keyword

Endoscopy; Antithrombotics; Hemorrhage; Thromboembolism

MeSH Terms

Aspirin
Endoscopy*
Hemorrhage
Heparin
Humans
Thromboembolism
Warfarin
Aspirin
Heparin
Warfarin

Reference

1. Eisen GM, Baron TH, Dominitz JA, et al. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc. 2002; 55:775–779. PMID: 12024126.

2. ASGE Standards of Practice Committee. Anderson MA, Ben-Menachem T, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009; 70:1060–1070. PMID: 19889407.

3. Veitch AM, Baglin TP, Gershlick AH, et al. Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut. 2008; 57:1322–1329. PMID: 18469092.

4. Boustière C, Veitch A, Vanbiervliet G, et al. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2011; 43:445–461. PMID: 21547880.

5. Heldwein W, Dollhopf M, Rösch T, et al. The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy. 2005; 37:1116–1122. PMID: 16281142.

6. Oda I, Gotoda T, Hamanaka H, et al. Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time and complications from a large consecutive series. Dig Endosc. 2005; 17:54–58.

7. Takizawa K, Oda I, Gotoda T, et al. Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection: an analysis of risk factors. Endoscopy. 2008; 40:179–183. PMID: 18322872.

8. Armstrong MJ, Gronseth G, Anderson DC, et al. Summary of evidence-based guideline: periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013; 80:2065–2069. PMID: 23713086.

9. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001; 285:2864–2870. PMID: 11401607.

10. Cannegieter SC, Rosendaal FR, Briët E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation. 1994; 89:635–641. PMID: 8313552.

11. Hering D, Piper C, Bergemann R, et al. Thromboembolic and bleeding complications following St. Jude Medical valve replacement: results of the German Experience With Low-Intensity Anticoagulation Study. Chest. 2005; 127:53–59. PMID: 15653962.

12. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e326S–e350S. PMID: 22315266.

13. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011; 124:e574–e651. PMID: 22064601.

14. Grines CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007; 115:813–818. PMID: 17224480.

15. Holmes DR Jr, Dehmer GJ, Kaul S, Leifer D, O'Gara PT, Stein CM. ACCF/AHA clopidogrel clinical alert: approaches to the FDA "boxed warning": a report of the American College of Cardiology Foundation Task Force on clinical expert consensus documents and the American Heart Association endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2010; 56:321–341. PMID: 20633831.

16. Kleiman NS. Grabbing the horns of a dilemma: the duration of dual antiplatelet therapy after stent implantation. Circulation. 2012; 125:1967–1970. PMID: 22438531.

17. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010; 35:64–101. PMID: 20052816.

18. Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med. 1997; 336:1506–1511. PMID: 9154771.

19. Schulman S, Elbazi R, Zondag M, O'Donnell M. Clinical factors influencing normalization of prothrombin time after stopping warfarin: a retrospective cohort study. Thromb J. 2008; 6:15. PMID: 18925967.

20. Eikelboom JW, Hirsh J, Spencer FA, Baglin TP, Weitz JI. Antiplatelet drugs: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl):e89S–e119S. PMID: 22315278.

21. Baron TH, Kamath PS, McBane RD. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med. 2013; 368:2113–2124. PMID: 23718166.