Managing Antithrombotic Risk in ACS Patients with History of GI Bleeding

The title of the talk was Cardiogastroenterologist: Managing Antiplatelet and Antithrombotic Agents.¹ and it was presented by Dr Neena Abraham, professor of medicine, department of gastroenterology and hepatology, Mayo Clinic, Scottsdale, Arizona. It covered the use of these agents in patients with cardiac disease and a history of gastrointestinal bleeding and for this gastroenterology fellow, it was one of the most important presentations during the 2015 American College of Gastroenterology Scientific Session.  

Why?

By 2030, >40% of US adults will have >1 varieties of cardiovascular disease and as such there is expected to be an increase in prescriptions for antiplatelet agents for both primary and secondary prevention. Concomitantly, hemorrhagic complications may impede outcomes in 10% of acute coronary syndromes (ACS) and percutaneous coronary interventions (PCI).  A meta-analysis of cardiovascular events occurring in patients on dual antiplatelet therapy who received oral anticoagulants after ACS found that the number needed to treat to prevent recurrent ACS post PCI is 77.² However, the number needed to harm (major bleeding) was 111.²  While oral anticoagulants diminish ischemic risk with time, longer treatment durations increase bleeding risks. In fact, GI bleeding in post-ACS patients is associated with increased in-hospital mortality and 30-day mortality.

The patients and newer oral anticoagulants and antithrombotics on the market are complex and demand a multidisciplinary approach. Cardiologists, gastroenterologists, and the primary care providers who know their at-risk patients well -must weigh the risks of coronary ischemic events vs the risk of re-bleeding whenever we consider initiating, pausing, or discontinuing these agents.  

Dr Abraham highlighted some common questions about stopping and starting antithrombotic and antiplatelet agents:  Can a patient’s aspirin can be stopped (and in what settings); can other antiplatelet agents be held; can endoscopy be performed safely post-ACS; and when can antiplatelet/antithrombotic agents be restarted? Some of the questions have been studied in depth.

First, it is reasonable to perform endoscopic procedures in patients taking aspirin.³  In fact, discontinuation of aspirin therapy in cardiovascular patients is associated with increased mortality within 30 days; thus, when aspirin absolutely must be held,  restarting aspirin ideally within 1 to 3 days postprocedurally-within 7 days at the longest-is generally recommended.  When a patient needs an elective procedure and is taking antiplatelet agents other than aspirin, it is recommended that the procedure be deferred until the need for the antiplatelet agent ends. Otherwise, in the absence of bleeding, elective procedures should be deferred 5 to 7 days after clopidogrel cessation, 7 to 9 days after prasugrel, and 3 to 5 days after ticagrelor.

Regarding post-ACS endoscopy, in patients whose GI bleeding led to ACS, (that is Type II demand ischemia), endoscopy within 48 to 72 hours post-ACS is recommended.

Dual antiplatelet therapy is recommended after cardiac stenting for at least 1 month after a bare metal stent and for at least 6 months following drug eluting stent. Short-term discontinuation of thienopyridine is relatively safe in patients with a drug eluting stent if aspirin therapy is maintained. 

Primary care providers who tend to have the most frequent contact with these patients have an especially important role in this arena. Minimizing your patients’ risk factors through counseling on avoidance of NSAIDS, using the low dose aspirin, eradicating H. pylori, and dose-adjusting anticoagulants/antithrombotics when indicated for renal insufficiency are all important.

By following these recommendations and using a multidisciplinary approach, PCPs,  gastroenterologists and cardiologists can mitigate risks of GI bleeding and recurrent ACS in a high-risk population.

References:

1. Abraham N. Cardiogastroenterologist: Managing Antiplatelet and Antithrombotic Agents. Presentation at: 2015 American College of Gastroenterology Scientific Session; October 17, 2015; Honolulu, Hawaii.

2. Komosci A et al. Use of new-generation oral anticoagulant agents in patients receiving antiplatelet therapy after an acute coronary syndrome: systematic review and meta-analysis of randomized control trials. Arch Intern Med. 2012;172:1537-1545.

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