Gastrointestinal Bleeding after Percutaneous Coronary Intervention

Abstract

Percutaneous coronary intervention (PCI) is now performed in a wide range of patients with coronary artery disease. Complications of PCI include in-stent re-stenosis and in-stent thrombosis. According to the recent 2005 guidelines of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions, dual antiplatelet therapy with low-dose aspirin and thienopyridine derivatives such as ticlopidine and clopidogrel should be used in patients who have undergone PCI. A serious complication of dual antiplatelet therapy is bleeding, most of which arise from the gastrointestinal (GI) tract. In this article we review published studies about GI bleeding in patients who have undergone PCI. The prevalence of GI bleeding in patients who are administered dual antiplatelet therapy following PCI is approximately 2%, and GI bleeding after PCI is associated with increased morbidity, mortality, duration of hospitalization and cost. Advanced age, a history of peptic ulcer disease, co-administration of non-steroidal anti-inflammatory drugs, co-administration of anticoagulants, and physiological stress are considered to be the major risk factors for GI bleeding in patients undergoing antiplatelet therapy following PCI. Recent clinical and experimental studies indicate that administration of low-dose aspirin may also increase the risk of adverse events in the small intestine. Although some prophylactic strategies such as proton-pump inhibitor, H₂ receptor antagonist and eradication of Helicobacter pylori are proposed, there are few randomized controlled trials assessing the best strategy for the prevention of GI bleeding after PCI. Further extensive studies are required to ascertain the beneficial effect of prophylactic agents for dual antiplatelet therapy following PCI.

Low-dose Aspirin and Comorbidities are Significantly Related to Bleeding Peptic Ulcers in Elderly Patients Compared with Nonelderly Patients in Japan

“…A large number of elderly people with cardiovascular disease, cerebrovascular disease and chronic joint pain have been prescribed low-dose aspirin, antithrombotic drugs, NSAIDs and corticosteroids for primary or secondary prevention of cardiovascular disease, cerebrovascular disorders and arthralgia (18)(19)(20)(21)(22). In the present study, a univariate analysis focused on prescribed medications indicated that low-dose aspirin, antithrombotic drugs and corticosteroids are exacerbating factors for bleeding gastric and/or duodenal ulcers in elderly patients compared with nonelderly patients.…”

“…The relationship between H. pylori infection and aspirin-related peptic ulcers is controversial. Some studies have indicated that H. pylori infection exacerbates aspirin-induced peptic ulcers that are reduced by eradication (20,33,34), while other studies have reported that H. pylori infection is not a risk factor for the development of aspirin-induced peptic ulcers (34)(35)(36). The results of the present study showing a decrease in the rate of H. pylori infection and an increase in the rate of aspirin use in elderly bleeding ulcer patients suggest that the risk of aspirin-induced bleeding is reduced in H. pylori-infected patients.…”

Evaluation of GI bleeding after implantation of left ventricular assist device

“…The high rates of PUD bleeding in these patients has been attributed to nonsteroidal anti-inflammatory drug (NSAID) induced damage to the upper GI tract mucosa coupled with NSAID ± thiopyridine induced platelet inhibition and anticoagulation. (19, 20) We therefore conclude that an upper endoscopic examination is the best initial test in LVAD patients presenting with acute GIB, and provides the highest likelihood of finding a source for the bleed.…”

Meta‐analysis of risk and protective factors for gastrointestinal bleeding after percutaneous coronary intervention

“…Gastrointestinal bleeding (GIB) is an important complication after PCI. Several studies have shown that incidence of GIB in patients undergoing PCI ranges from 0.4% to 4.3% (Nadatani et al, ; Tanigawa et al, ; Toyokawa et al, ; Nikolsky, Mehran, & Stone, ; Nikolsky, Stone, et al, ; Ng et al, ). Major bleeding can reduce blood volume, increase heart rate, and decrease myocardial perfusion, so antiplatelet therapies have to be changed after bleeding.…”