Endoscopy-Related Bleeding and Thromboembolic Events in Patients on Direct Oral Anticoagulants or Vitamin K Antagonists

Santiago, Enrique Rodríguez de; Aldehuelo, Rubén Sánchez; Pons, Fausto Riu; Escaja, Carlos Rodríguez; Fernández‐Esparrach, Glòria; Cañete-Ruiz, Angel; Ferre‐Aracil, Carlos; Pérez-Corte, Daniel; León, Raquel Ríos; Marcos-Prieto, Héctor Miguel; Delgado-Guillena, Pedro; García-Rodríguez, Ana; Guarner-Argente, Carlos; Muriel, Alfonso; Fuente-Briongos, Elsa de la; Paredes, Ana García García de; Parejo-Carbonell, Sofía; Téllez, Luís; Senosiaín-Lalastra, Carla; Burgos‐Santamaría, Diego; Aicart-Ramos, M.; Muñoz, Beatriz; Peñas-García, Beatriz; Pagano, Giulia; Urquiza, Gemma Casals; Ferreruela, Miguel Urpi; Jorge-Turrión, Miguel Ángel de; Barreiro-Alonso, Eva; Fraile-López, Miguel; Gómez-Outomuro, Ana; Altamirano, María Isabel; Esteban, M Núñez; Ruiz-Andreu, Mireia; Arribas-Anta, Julia; Rosa, Diego de Frutos; Herreros–de–Tejada, Alberto; Arias-Rivera, María Luisa; Roldán-Fernández, Marta; Martín, Antonio Fuertes; Zamora, Javier; Vázquez-Sequeiros, Enrique; Albillos, Agustı́n; Foruny, José Ramón; Longoria, Aida Argüelles; González, Carmen María González; González-Martín, Juan Ángel; Tavío-Hernádez, Eduardo; Martínez-Sánchez, Alba; López-Durán, Sergio; Mesonero-Gismero, Francisco; Riveras, Pablo Pérez; Cid, Ana García; Rodríguez-Carrasco, Marta; Torrego, Teresa Álvarez-Nava; Esteban, David; López-Cerón, María

doi:10.1016/j.cgh.2020.11.037

Cited by 10 publications

(7 citation statements)

References 17 publications

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“…Of importance, only 1 of the 4 events was adjudicated as related to the periprocedural DOAC interruption (0.18%), with the other 3 events occurring 11–24 days after DOAC resumption. Reported thromboembolic risks in anticoagulated patients undergoing elective endoscopy reached 5.4% in a nationwide Japanese cohort (25), although lower 30-day thromboembolic rates more in keeping with our findings were reported in an Italian cohort of 529 patients (0.4%) (26) and a Spanish cohort of 598 patients (0.7%) (27).…”

Section: Discussionsupporting

confidence: 90%

“…Indeed, the endoscopies performed in the PAUSE cohort included a large proportion of gastroscopies and colonoscopies with what were likely diagnostic procedures with or without biopsies and the removal of small colonic polyps. These are procedures that are associated with a low risk of bleeding, even in anticoagulated patient population (26,27,34–36), in contrast to higher-risk endoscopies such as endoscopic retrograde cholangiopancreatography and endoscopic submucosal dissection (22,25,26,32,33,37,38). Again, the lack of detailed intraprocedural information and scarcity of patients undergoing more sophisticated advanced endoscopic procedures does not allow our PAUSE subanalysis data to further inform guidelines on this aspect of management.…”

Section: Discussionmentioning

confidence: 99%

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Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy

et al. 2022

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INTRODUCTION:The periprocedural management of patients with atrial fibrillation (AF) using a direct oral anticoagulant (DOAC) undergoing elective gastrointestinal (GI) endoscopic procedure remains uncertain. We investigated the safety of a standardized periprocedural DOAC management strategy.METHODS:The Periprocedural Anticoagulation Use for Surgery Evaluation cohort study enrolled adult patients receiving a DOAC (apixaban, rivaroxaban, or dabigatran) for AF scheduled for an elective procedure or surgery. This analysis addresses patients undergoing digestive endoscopy. Standardized periprocedural management consisted of DOAC interruption 1 day preendoscopy with resumption 1 day after procedure at low-moderate risk of bleeding or 2 days in case of a high bleeding risk. Thirty-day outcomes included GI bleeding, thromboembolic events, and mortality.RESULTS:Of 556 patients on a DOAC (mean [SD] age of 72.5 [8.6] years; 37.4% female; mean CHADS2 score 1.7 [1.0]), 8.6% were also on American Society of Anesthesiology (ASA) and 0.7% on clopidogrel. Most of the patients underwent colonoscopies (63.3%) or gastroscopies (14.0%), with 18.9% having both on the same procedural day. The mean total duration of DOAC interruption was 3.9 ± 1.6 days. Four patients experienced an arterial thromboembolic event (0.7%, 0.3%–1.8%) within 24.2 ± 5.9 days of DOAC interruption. GI bleeding events occurred in 2.5% (1.4%–4.2%) within 11.1 ± 8.1 days (range: 0.6; 25.5 days) of endoscopy, with major GI bleeding in 0.9% (0.4%–2.1%). Three patients died (0.5%; 0.2%–1.6%) 15.6–22.3 days after the endoscopy.DISCUSSION:After a contemporary standardized periprocedural management strategy, patients with AF undergoing DOAC therapy interruption for elective digestive endoscopy experienced low rates of arterial thromboembolism and major bleeding.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy

et al. 2022

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“…Some administrative database studies indicated that direct oral anticoagulants might entail a lower risk of CSPEB than vitamin K antagonists and suggest preoperative switching of anticoagulants (32,33). However, we lack RCTs, and these results have not been replicated in other cohorts that found no difference (28,34). Another matter of debate is the timing of anticoagulant withdrawal and resumption, and no consensus exists, as shown in Table 1.…”

Section: Medicationmentioning

confidence: 97%

Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions

et al. 2022

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The most common major adverse event of endoscopic mucosal resection (EMR) is clinically significant post-EMR bleeding (CSPEB), with an incidence of 6%-7% in large lesions. Repeat colonoscopy, blood transfusions, or other interventions are often needed. The associated direct costs are much higher than those of an uncomplicated EMR. In this review, we discuss the aspects related to CSPEB of large nonpedunculated polyps, such as risk factors, predictive models, and prophylactic measures, and we highlight evidence for preventive treatment options and explore new methods for bleeding prophylaxis. We also provide recommendations for steps that can be taken before, during, and after EMR to minimize bleeding risk. Finally, this review proposes future directions to reduce CSPEB incidence.

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“…7 Due to their safety profile and ease of use, direct oral anticoagulant (DOAC) use is increasing among all patients, including those with cirrhosis. [8][9][10] However, because patients with cirrhosis are excluded from all trials examining the safety and efficacy of DOACs, there are limited data to guide their use in this population.…”

Section: Rates Of Bleeding and Discontinuation Of Directmentioning

confidence: 99%

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2021

Clinical Gastroenterology and Hepatology

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Endoscopy-Related Bleeding and Thromboembolic Events in Patients on Direct Oral Anticoagulants or Vitamin K Antagonists

Cited by 10 publications

References 17 publications

Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy

Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy

Preventing Postendoscopic Mucosal Resection Bleeding of Large Nonpedunculated Colorectal Lesions

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