Risk of rebleeding, vascular events and death after gastrointestinal bleeding in anticoagulant and/or antiplatelet users

Abstract

Summary Background Patients with gastrointestinal bleeding during anticoagulant and/or antiplatelet therapy represent a clinical challenge. Aim To determine the risk/rates of rebleeding, vascular events and death in patients treated with antiplatelet or anticoagulant agents who developed major gastrointestinal bleeding Methods This was an observational cohort study of patients who developed gastrointestinal bleeding while on antiplatelet and/or anticoagulant therapy. Drug use information was collected prospectively during bleeding events. Cox proportional hazards models were used to evaluate rebleeding, vascular events and death. Results Among 871 patients (mean age 78.9 ± 8.6 years), 38.9% used an anticoagulant, 52.5% used an antiplatelet and 8.6% used both; 93.1% interrupted treatment after gastrointestinal bleeding and 80.5% restarted therapy within 7.6 ± 36.4 days; 38.7% had upper gastrointestinal bleeds, 46.7% lower gastrointestinal bleeds and 14.6% gastrointestinal bleeds of unknown origin. Median follow‐up was 24.9 months (IQR: 7.0‐38.0). Resumption of both therapies was associated with a higher risk of rebleeding, lower risk of ischaemic events or death and a similar risk for upper and lower gastrointestinal events. Resumption of therapy ≤ 7 days after bleeding showed a similar pattern with no differences in death. Rebleeding rates were higher in anticoagulant vs antiplatelet patients (138.0 vs 99.0 events per 1000 patient‐years), and the bleeding location was identical in 61.8% of cases. Conclusions Resumption of anticoagulant or antiplatelet therapy after a gastrointestinal bleeding event was associated with a lower risk of vascular events and death and a higher rebleeding risk. The benefits of early reinstitution of anticoagulant/antiplatelet therapy outweigh the gastrointestinal‐related risks.

No Differences in Gastrointestinal Bleeding Risk among Clopidogrel-, Ticagrelor-, or Prasugrel-Based Dual Antiplatelet Therapy

“…Our study provides information about the location and the etiology of gastrointestinal bleeding. More patients had lower than upper gastrointestinal bleeding, in agreement with findings from our previous studies analyzing gastrointestinal bleeding events in patients taking DAPT [8] and antiplatelets in general [29]. In fact, currently, there are more hospital admissions of patients presenting with lower than with upper gastrointestinal bleeding [33], which can be explained in part by the large number of patients receiving concomitant treatment with PPI [8].…”

“…The paradoxical outcome is that these new antiplatelets are not used in patients with higher cardiovascular risk and who might benefit the most. Additionally, the management of DAPT in patients with gastrointestinal bleeding is a challenge in clinical practice because recent evidence suggests a benefit from the early resumption of antiplatelet therapy [29]. Given this lack of conclusive findings, we conducted a study to determine the risk for specific types of major and minor gastrointestinal events in patients taking DAPT, depending on the type of treatment used.…”

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

“…bleeding, it was recommended that in patients with peptic ulcer hemorrhage, antithrombotic agents could be restarted the same day or not be interrupted at all if endoscopy demonstrates a Forrest III (clean base) ulcer [33]. A recent retrospective cohort study, including 871 GI bleeding patients, of whom 25 % had peptic ulcer hemorrhage and all of whom were taking antithrombotic medications (52.5 % antiplatelet agents), showed that at long-term follow-up (mean 24.9 months), resumption of either antiplatelet or anticoagulant therapy was associated with a higher risk of rebleeding, but a lower risk of an ischemic event or death [34]. Moreover, the investigators reported that when compared to late resumption of antithrombotic therapy, early resumption (≤ 7 days) following the bleeding episode showed no difference in mortality, a lower rate of ischemic events (13.6 % vs. 20.4 %), yet a significantly higher rate of GI rebleeding (30.6 % vs. 23.1 %; P = 0.04).…”

Improving Efficiency of Antioxidant and Cytoprotective Therapy in Patients With Nsaid-Gastropathy and Concomitant Ischemic Heart Disease

“…Згідно зі світовою статистикою [5], майже 5-7% населення планети, серед яких частка людей похилого вік сягає 40-60%, постійно приймають НПЗП, застосування яких пов'язане з цілим рядом побічних явищ і ризиків, серед яких лідером є ураження слизової оболонки шлунково-кишкового тракту (ШКТ) від стравоходу до прямої кишки. Однак частота ушкодження гастродуоденальної зони (ГДЗ) розвивається приблизно в 6 разів частіше, що обґрунтовує актуальність проблеми гастробезпеки при застосуванні неселективних НПЗП, прийом яких асоціюється із розвитком НПЗП-гастропатії та підвищеним ризиком кровотеч і перфорацій ШКТ [1][2][3][4].…”