Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy

Christopher, Hansen-Barkun; Myriam, Martel; James, Douketis; Abraham, Neena S.; Zachary, Liederman; Kaplovitch, Eric; Schulman, Sam; Spyropoulos, Alex C.; Almadi, Majid A; Barkun, Alan N.

doi:10.14309/ajg.0000000000002076

Cited by 4 publications

(5 citation statements)

References 42 publications

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“…The thromboembolic event rate of 0.6% observed in the current study was similar to the arterial thromboembolic event rate of 0.7% among patients in the PAUSE trial undergoing endoscopic gastrointestinal procedures. 11 For this patient in our study, the indication for anticoagulation was atrial fibrillation with a CHADS65 score of 1. In addition, the patient had a history of type 1 aortic dissection 8 months prior to the colonoscopy, which was managed with ascending aorta and aortic arch replacement and bioprosthetic aortic valve replacement.…”

Section: Discussionmentioning

confidence: 89%

“…The major bleeding rate in the present study was similar to the 0.9% major bleeding rate reported from the PAUSE trial data. 11 Other cohorts where postprocedure bleeding ranged from 2.5 to 3.6%. 4 Over 90% of the patients in our cohort had small polyps (less than 10 mm in diameter), and over 80% underwent cold snare polypectomy.…”

Section: Discussionmentioning

confidence: 99%

“…This is consistent with findings from other studies. 11 19 The patients with a low thromboembolic risk, including patients with atrial fibrillation with a CHADS65 score < 4 and patients with venous thromboembolism treated for more than 3-6 months, will particularly benefit from delayed resumption of oral anticoagulant after resection of large lesions.…”

Section: Discussionmentioning

confidence: 99%

“…4 Similarly, data from the Periprocedural Anticoagulation Use for Surgery Evaluation (PAUSE) trial, a prospective cohort study with a standardized protocol for DOAC interruption, reported a bleeding rate of 2.5% among the subgroup of patients undergoing endoscopic gastrointestinal procedures. 10,11 The recently published American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline recommended continuation of VKA and temporary interruption of DOACs for patients undergoing colonoscopy and cold snare polypectomy of small polyps. 4 Due to insufficient evidence, the committee was unable to reach a recommendation on the timing of DOAC resumption; however, the accompanying dissemination tool indicated that the DOAC could be restarted the day after the colonoscopy in most patients.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Periprocedural Anticoagulation Management of Patients Undergoing Colonoscopy with Polypectomy

Chan,

Yoon,

Drury

et al. 2024

TH Open

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Introduction/Objective Colonoscopy with polypectomy is an integral component of colorectal cancer screening. There are limited data and consensus on periprocedural anticoagulation management, especially regarding bleeding risk with uninterrupted anticoagulation and thromboembolic risk with interruption. Our aim was to determine the incidence of bleeding and thromboembolic complications among colon screening participants undergoing colonoscopy following implementation of a novel patient care pathway for standardized periprocedural anticoagulation management. Methods We conducted a retrospective study including all participants (age 50–74) on an oral anticoagulant (e.g., vitamin K antagonists, direct oral anticoagulants) referred to the British Columbia Colon Screening Program for colonoscopy following abnormal fecal immunochemical test in a 6-month period (March–August 2022). Data relating to their specific periprocedural anticoagulant management and colonoscopy results including method of polypectomy were obtained. Primary outcomes were major bleeding and arterial or venous thromboembolic events from time of oral anticoagulant interruption until 14 days of postcolonoscopy. Secondary outcomes included nonmajor and minor bleeding, acute coronary syndrome, emergency room visit, hospital admission, and death due to any cause. Results Over the 6-month period, 162 participants completed standardized periprocedural anticoagulation management, colonoscopy ± polypectomy, and 14-day follow-up. One (0.6%) had a major bleeding event and one (0.6%) had an arterial thromboembolic event. Conclusions A novel patient care pathway for standardized periprocedural anticoagulation management with a multidisciplinary team is associated with low rates of major bleeding and thrombotic complications after colonoscopy with polypectomy.

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Section: Discussionmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Periprocedural Anticoagulation Management of Patients Undergoing Colonoscopy with Polypectomy

Chan,

Yoon,

Drury

et al. 2024

TH Open

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Perioperative Management of Patients Taking Direct Oral Anticoagulants

Douketis,

Spyropoulos

2024

JAMA

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ImportanceDirect oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism.ObservationsFor elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (&lt;6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.Conclusions and RelevanceWhen patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.

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Optimal direct oral anticoagulant for upper gastrointestinal endoscopic submucosal dissection

Ono,

Hatta,

Tarasawa

et al. 2024

J Gastroenterol

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Background The patients taking direct oral anticoagulants (DOACs) are at high risk for developing ischemic stroke and delayed bleeding in upper gastrointestinal endoscopic submucosal dissection (ESD). We aimed to identify the optimal DOAC based on both adverse events in upper gastrointestinal ESD. Methods A retrospective population-based cohort study was conducted using the Diagnosis Procedure Combination database in Japan. We included patients on a DOAC undergoing upper gastrointestinal ESD between 2012 and 2021. The primary outcomes were ischemic stroke occurring after upper gastrointestinal ESD and delayed bleeding in gastroduodenal and esophageal ESD. Inverse probability weightings were applied to balance the four DOAC groups (dabigatran, rivaroxaban, apixaban, and edoxaban), and logistic regression analyses were performed to compare the outcomes. Results We analyzed 9729 patients on a DOAC undergoing upper gastrointestinal ESD. Ischemic stroke developed after upper gastrointestinal ESD in 1.4%, 0.7%, 0.6%, and 0.8% of patients taking dabigatran, rivaroxaban, apixaban, and edoxaban, respectively, after weighting. Rivaroxaban and apixaban showed significantly lower risk of ischemic stroke compared with dabigatran (odds ratio, 0.15 and 0.12, respectively) in standard doses. The delayed bleeding developed after gastroduodenal ESD in 7.6%, 14.6%, 19.2%, and 17.3% of patients taking each DOAC, respectively, with the lowest risk in dabigatran, followed by rivaroxaban. A similar pattern was observed in delayed bleeding in esophageal ESD (3.2%, 5.4%, 7.5%, and 5.5% in each DOAC), but with no significant results. Conclusions Rivaroxaban might be an optimal DOAC for upper gastrointestinal ESD showing a lower risk for both ischemic stroke and delayed bleeding.

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Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy

Cited by 4 publications

References 42 publications

Periprocedural Anticoagulation Management of Patients Undergoing Colonoscopy with Polypectomy

Periprocedural Anticoagulation Management of Patients Undergoing Colonoscopy with Polypectomy

Perioperative Management of Patients Taking Direct Oral Anticoagulants

Optimal direct oral anticoagulant for upper gastrointestinal endoscopic submucosal dissection

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