Management of Anticoagulants &
Antiplatelet Agents Pre and Post
Endoscopy
Thomas Savides, M.D.
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
• Learn the cardiovascular risk of modifying
antiplatelet therapy in the peri-endoscopic
setting
• Understand 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
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•
•
•
Risk of bleeding vs risk of thrombosis
Bleeding risk from endoscopic procedure
Thromboembolism risk if stop antithrombotics
Emergency vs elective procedure
Anti-Thrombotic Agents
• Anticoagulants
– Warfarin
– Heparin
– Low molecular weight heparin
• Anti-platelet agents
– Aspirin
– Non-steroidal antiinflammatory 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 Risk
High Risk
•
•
•
•
•
•
•
•
•
•
•
•
EGD
Colonoscopy
EUS
EUS FNA solid lesion
Colon polypectomy <1 cm
Stricture dilation
Stent placement
ERCP with stent or balloon
dilation
• Argon plasma coagulation
•
•
•
•
EMR/ESD
Ampullectomy
ERCP with sphincterotomy
ERCP with large balloon
dilation of papilla
Colon polypectomy > 1 cm
EUS FNA of cystic lesions
Percutaneous endoscopic
gastrostomy (PEG)
Esophageal variceal band
ligation
Boustiere, 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 disease
• Prosthetic Valve
• Coronary artery disease and stents
• Deep Venous Thrombosis/Pulmonary Embolus
• Stroke/Transient Ischemic Attack
• Hypercoagulable states
Management of antithrombotic agents for endoscopic procedures.
ASGE Standards of Practice Committee. 2009
Atrial Fibrillation
High risk conditions for thomboembolic events
• Previous stroke (CVA) or transient ischemic
attack (TIA)
• CHADS2 score ≥ 3
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•
•
•
•
CHF=1
HTN=1
Age ≥ 75=1
Diabetes=1
Previous CVA/TIA=2
• Associated valvular heart disease
Kwok and Faigel, AJG 2009
Prosthetic Valve
High risk conditions for thomboembolic events
• Bioprosthetic valve <3 months old
• Mechanical valve in mitral position
• Mechanical valve with previous
thromboembolic event
Coronary Artery Disease and Stents
High risk conditions for thomboembolic events
• Recent acute coronary event <4-6 weeks
• Discontinuing dual antiplatelet therapy in:
– Drug-eluting stent < 1 year
– Bare metal stent < 1 month
Deep Venous Thrombosis/Pulmonary Emboli
High risk conditions for thomboembolic events
• Discontinuing anticoagulation <3 months from
event
• Recurrent DVT/PE
• Severe hypercoagulable states
– Cancer
– Paroxysmal nocturnal hemoglobinuria
– Myeloproliferative syndrome
Stroke/Transient Ischemic Attack
High risk conditions for thomboembolic events
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•
•
•
Cardioembolic events
Carotid artery disease
Recent carotid endarterectomy
Hypercoagulable state
General Approach to Patients on
Antithrombotic agents who need endoscopy
• Delay elective endoscopy until patient at lower risk for
thromboembolism
• Discuss with patient’s cardiovascular or neurovascular
physician whether (or when) drugs can be stopped
• Realize that only limited data exist
• Guidelines 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 Bleeding
Stop Aspirin?
Stop Clopidogrel or
Prasugrel?
EGD ± biopsy
Low
No
No
EGD with stricture
dilation
Low
No
No
EGD with APC
Low
No
Yes
EGD with stent
placement
Low
No
Yes
EGD with variceal
band ligation
High
No
Yes
EGD with PEG
placement
High
No
?
EGD with EMR/ESD
High
Yes
Yes
Boustiere, ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011
Colonoscopy Procedures
Procedure
Risk of Bleeding
Stop aspirin
Stop clopidogrel or
prasugrel?
Colonoscopy ±
biopsy
Low
No
No
Colonoscopy with
polypectomy <1 cm
Low
No
No
Colonoscopy with
polypectomy >1 cm
High
No
Yes
Colonoscopy with
EMR/ESD
High
Yes
Yes
Boustiere, ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011
ERCP Procedures
Procedure
Risk Bleeding
Stop Aspirin?
Stop Clopidogrel or
Prasugrel?
ERCP Diagnostic
Low
No
No
ERCP with Stent
Placement
Low
No
No
ERCP with
sphincterotomy
High
No
Yes
ERCP with
High
sphincterotomy and
large balloon
papillary dilation
Yes
Yes
Boustiere, ESGE Guidelines: Endoscopy and antiplatelet agents. Endoscopy 2011
EUS Procedures
Procedure
Risk Bleeding
Stop Aspirin?
Stop Clopidogrel or
Prasugrel?
EUS Diagnostic
Low
No
No
EUS with FNA Solid
Mass
Low
No
Yes
EUS FNA Cysts
High
Yes
Yes
ERCP FNA
Therapeutic
High
Yes
Yes
Boustiere, 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 reanticoagulation after procedure
• Warfarin 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
• Warfarin
– Consider holding warfarin
– Consider vitamin K, FFP, Factor VIIa
• AHA/ACC recommendations
– Fresh frozen plasma (FFP) preferable to high dose Vitamin K
– Avoid high-dose Vitamin K (10 mg) in patients with mechanical
valves as may cause hypercoagulable state
» Low dose Vitamin K (1-2 mg) may be fine
• Antiplatelet agents
– Consider stopping drug
– Consider 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) preferred
– Especially 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 established
– Because risk of rebleeding is greatest in 1st 72 hours,
consider restart aspirin 3-5 days after hemostasis
– Uncertain about clopidogrel, but perhaps restart in 35 days
– If 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 GIB
• GIB in setting of ACS has 4-7 fold increased
risk of in-hospital morality
• Risk of EGD and Colonoscopy 1-2% in setting
of ACS
• Note that with advent of intravenous PPI, less
need for emergent need for EGD in mildmoderate 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 data
• Recent NEJM article (Bhatt 2010) suggests no
Conclusions
• Most endoscopic procedures safe to perform
even if patient taking aspirin and/or NSAIDs
• Continuing 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