Gastroenterological Endoscopy. Группа авторов

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СКАЧАТЬ aspiration; PEG/PEJ: percutaneous endoscopic gastrostomy/jejunostomy^aEnteral stent deployment risk is controversial for American Society for Gastrointestinal Endoscopy (ASGE), low risk for Japanese guidelines, and high risk for European Society for Gastrointestinal Endoscopy (ESGE).^bPEG on aspirin or clopidogrel therapy is low risk for ASGE, but high risk for ESGE and Japanese guidelines; does not apply to dual antiplatelet therapy.^cEUS-FNA of solid masses on acetylsalicylic acid/nonsteroidal anti-inflammatory drugs is low risk.

Table 11.2 Risk stratification for discontinuation of clopidogrel, prasugrel, or ticagrelor, and warfarin therapy based on risk of thrombosis and consideration of need for bridge therapy

Low risk	High risk
Clopidogrel, prasugrel, or ticagrelor
Ischemic heart disease without coronary stents	Drug-eluting coronary artery stents within 12 months of placement
Cerebrovascular disease	Bare metal coronary artery stents within 1 month of placement
Peripheral vascular disease
Warfarin
Prosthetic metal heart valve in aortic position	Prosthetic metal heart valve in mitral position
Xenograft heart valve	Prosthetic heart valve and atrial fibrillation
Atrial fibrillation without valvular disease	Atrial fibrillation and mitral stenosisa
> 3 months after venous thromboembolism	< 3 months after venous thromboembolism
Thrombophilia syndromes
a Uncertainty exists regarding the thrombotic risk of temporarily discontinuing warfarin in patients with atrial fibrillation and mitral stenosis, but there is insufficient evidence at present to alter the risk category

      Anticoagulants Agents Management

      Warfarin should be continued for low-risk endoscopic procedures (

Table 11.3); however the international normalized ratio (INR) should not exceed the therapeutic range measured in the week before the procedure.^11,14 For low-risk endoscopic procedures, the morning dose of DOACs should be omitted on the day of the procedure.^11,14 For high-risk endoscopic procedures in patients at low thrombotic risk, warfarin should be discontinued 5 days before the procedure.^11,14 For high-risk endoscopic procedures in patients at high thrombotic risk, warfarin should be discontinued 5 days prior to the procedure, with bridging therapy with LMWH.^11,14 For high-risk endoscopic procedures in patients on DOACs, the last dose of DOACs should be taken at least 48 hours before the procedure (72 hours prior for patients on dabigatran with a creatinine clearance of 30–50 mL/min).^11,14

      Although all guidelines recommend bridging therapy for patients with high thromboembolic risk requiring temporary withdrawal of anticoagulants, a recent meta-analysis of 35 studies found an increased risk of overall and major bleeding but a similar thromboembolic risk in patients receiving periprocedural heparin-bridging therapy.^16,17 Thus, caution should be taken to balance the benefits of bridging therapy and the risks of bleeding in patients needing temporary discontinuation of anticoagulant. All patients on warfarin should be advised that there is an increased risk of postprocedure bleeding compared to nonanticoagulated patients, even when temporarily discontinued.^11,14 In a multivariate analysis, however, most bleeding was immediate and successfully treated endoscopically without significant consequence.¹⁸ Hemorrhage secondary to high-risk endoscopic procedures can often be controlled by further endoscopic therapeutic measures, and is rarely fatal. Thrombotic adverse events such as stroke from interruption of anticoagulation can be catastrophic.¹⁹

      Postendoscopic Procedure

      If APAs or anticoagulants are discontinued, there is consensus that antithrombotic therapy should be resumed upon completion of the procedure. Warfarin should be restarted within 24 hours of the procedure in patients with valvular heart disease and a low risk for thromboembolism; in patients at high risk for thromboembolism, UFH or LMWH should be restarted as soon as “bleeding stability allows” and continued until the INR reaches an appropriate therapeutic level.²⁰ UFH may be restarted 2 to 6 hours after a therapeutic procedure. The optimal time to restart LMWH after endoscopy has not been determined. Delaying reinitiation of LMWH 48 to 72 hours after surgery should be considered in patients believed to be at high risk for bleeding adverse events.² There are no data regarding optimal timing of resumption of DOACs after endoscopic procedures. If they cannot be restarted within 24 hours after a high-risk procedure, then bridge therapy should be considered for patients at high risk for thromboembolism.^21,22 Reinitiation of DOACs should be delayed for at least 48 hours after high-risk procedures because full anticoagulation occurs shortly after administration; for patients in whom biliary sphincterotomy is performed, resumption of these agents should be delayed for at least 72 hours; for patients who are at high risk of delayed bleeding and who are at low risk for antithrombotic events, it would be reasonable to hold anticoagulation for 7 days.²³ APAs should be resumed once hemostasis has been achieved. Clopidogrel administered at maintenance doses has delayed onset and can be reinitiated within 24 hours; clopidogrel loading results in rapid onset of action and should be considered among patients at risk for thrombosis with a lower risk of bleeding than anticipated; other APAs, including aspirin, can be reinitiated within 24 hours.

      Endoscopy Procedures in the Actively Bleeding Patient on Antithrombotic Therapy

      Endoscopic evaluation and therapy in patients using antithrombotics with active GIB is both warranted and safe.⁵ The decision to stop, reduce, and/or reverse antithrombotic therapy (and thereby risking thromboembolic consequences) must be weighed against the risk of continued bleeding. Reversal of anticoagulation with four-factor prothrombin complex concentrate (PCC) rather than fresh-frozen plasma should be used for patients with VKA-associated major bleeding, in addition to intravenous vitamin K.²⁴ Vitamin K should not be given routinely in patients with mechanical valves because this may create a hypercoagulable condition.²⁵ However, endoscopic hemostatic therapy is very effective even in patients with moderately elevated INR, and it should not be postponed to correct coagulopathy in patients with an INR < 2.5, as normalizing the INR does not reduce re-bleeding. Patients who require anticoagulation after endoscopic therapy receive UFH because of its relatively shorter half-life after successful endoscopic hemostasis for high-risk stigmata.

      Regarding the new DOACs in patients with severe GIB, hemodialysis can be used in patients receiving dabigatran but not for rivaroxaban, edoxaban, and apixaban because of their decreased renal excretion and because they are highly protein bound. Charcoal hemoperfusion also may be effective.²⁵ Although factor VIIa and four-factor PCC have been used in these situations, their value in reversing the clinical anticoagulant effects and controlling clinical hemorrhage is uncertain.²⁶

      For patients on APAs with life-threatening or serious bleeding, options include stopping these agents and/or administration of platelets. Consultation with the prescribing specialist should occur in situations of significant GIB in patients with high risk for thrombosis. The risk of an adverse cardiac event associated with cessation of the APA therapy likely exceeds the benefit of decreasing postendoscopic bleeding.

      References

      [1] Baron TH, Kamath PS, McBane RD. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med. 2013; 368(22):2113–2124

      [2] СКАЧАТЬ