Mortality Rate in Upper Gastrointestinal Bleeding Associated with Anti-Thrombotic Therapy Before and During Covid-19 Pandemic

Abstract

Introduction During the last few years, a progressive higher proportion of patients have had upper gastrointestinal bleeding (UGIB) related to antithrombotic therapy. The introduction of direct oral anticoagulant (DOAC) and COVID-19 pandemic may change the incidence, mortality, and follow-up, especially in patients at high risk of bleeding. Patients and Methods We studied the use of anti-thrombotic therapy (AT) in patients with upper gastrointestinal bleeding for 5 years (January 2017–December 2021) including Covid-19 pandemic period (March 2020–December 2021). We analyzed mortality rate, rebleeding rate and need for transfusion in patients with AT therapy compared with those without AT therapy and risk factors for mortality, and also the incidence of gastrointestinal bleeding in patients admitted for COVID-19 infection. Results A total of 824 patients were admitted during Covid-19 pandemic period and 1631 before pandemic period; a total of 426 cases of bleeding were recorded in patients taking antithrombotic therapy and the frequency of antithrombotic therapy in patients with UGIB was higher in pandemic period (24.39% versus 13.8%). Unadjusted mortality was 12.21%, similar with patients with no antithrombotic treatment but age-adjusted mortality was 9.62% (28% lower). The rate of endoscopy was similar but fewer therapeutic procedures were required. Mean Hb level was 10% lower, and more than 60% of patients required blood transfusion. Conclusion Mortality was similar compared with patients with no antithrombotic therapy, fewer therapeutic endoscopies were performed and similar rebleeding rate and emergency surgery were noted. Hb level was 10% lower and a higher proportion of patients required blood transfusions. Mortality was higher in DOAC treatment group compared with VKA patients but with no statistical significance. The rate of upper gastrointestinal bleeding in Covid-19 positive hospitalized cases was 0.58%. The mortality risk in multivariate analysis was associated with GB score, with no endoscopy performed, with obscure and variceal bleeding and with LMWH versus VKA therapy.

The Prevalence of Gastrointestinal Bleeding in COVID-19 Patients: A Systematic Review and Meta-Analysis

“…Chen et al suggest that GIB is an independent prognostic indicator of the composite endpoint and death [ 25 ]. These findings are also supported by Popa et al [ 30 ]. Popa et al also suggest that the administration of anticoagulants does not affect mortality.…”

“…In 17 of the 33 studies [ 26 , 27 , 28 , 29 , 30 , 31 , 34 , 35 , 37 , 38 , 43 , 44 , 48 , 53 , 54 , 55 , 56 ] in the meta-analysis, upper or lower gastrointestinal bleeding could be distinguished. Thus, it was possible to distinguish the prevalence of GI bleeding into the upper and lower gastrointestinal tract into two subgroups.…”

“…Popa et al also suggest that the administration of anticoagulants does not affect mortality. [ 30 ] Additionally, Patell et al report an increase in mortality in patients with active cancer who suffer from COVID-19 and experience bleeding episodes [ 48 ].…”

O uso dos Anticoagulantes Orais de Ação Direta (DOACs) como terapia anticoagulante na COVID-19

“…A anticoagulação profilática envolve diversas classes farmacológicas, incluindo-se agentes antiplaquetários (aspirina, inibidores do receptor P2Y12: tienopiridínicosticlopidina, clopidogrel, prasugrel e ciclopentriltriazolpirimidinasticagrelor), e os anticoagulantes como Heparina Não Fracionada (HNF), Heparina de Baixo Peso Molecular (HBPM), antagonistas da vitamina K e os Anticoagulantes Orais de Ação Direta (DOACs) (POPA P, et al, 2022).…”

The Reduction of After-Hours and Weekend Effects in Upper Gastro-intestinal Bleeding Mortality During the COVID-19 Pandemic Compared to the Pre-Pandemic Period

“… 4 The antithrombotic treatment represents an important etiological factor in UGIB, because of its increasing use in cardiovascular and cerebrovascular disease. 15 Obscure bleeding (when no cause of bleeding was found) can be recorded in 5 to 21% of cases. 7 , 16 …”