Gastrointestinal bleeding associated with myocardial infarction

The Incidence and Risk Factors of Acute Myocardial Infarction Among Patients with Gastrointestinal bleeding: A Retrospective Study

Purpose

Patients with gastrointestinal bleeding (GIB) and acute myocardial infarction (AMI) have higher mortality than that with either GIB or AMI alone. The aims of this study were to determine the incidence and risk factors of AMI in patients with GIB.

Patients and Methods

From January 2015 to January 2018, we retrospectively studied 1287 patients with GIB in Renmin Hospital of Wuhan University. Various demographic, laboratory and outcome data were reviewed by charts.

Results

Thirty-seven patients had AMI and were placed in AMI group and the rest 1250 patients were in non-AMI group. Patients with AMI were more likely to be older than 70 years, have hypertension, coronary heart disease, chronic kidney disease, and have the recent history of taking aspirin before admission. The ROC curve of hemoglobin (HB) on admission showed area under curve was 0.762, the optimal cut-off value is 76.5g/L. Logistic regression analysis showed that age ≥ 70 years old, coronary heart disease and HB < 76.5g/L on admission were independent risk factors of AMI in patients with GIB. The mortality of patients during hospitalization in AMI group and in non-AMI group were 45.95% and 5.48%, respectively. Patients who displayed a history of liver disease and HB < 76.5g/L on admission had a higher death rate.

Conclusion

GIB increased the risk of subsequent AMI, especially in patients over 70 years old, with history of coronary heart disease and HB < 76.5g/L on admission. Patients with GIB and AMI who had history of liver disease and HB < 76.5g/L on admission had a higher mortality rate. Clinicians should identify the high-risk patients of AMI among the GIB population early and prevent AMI.

Risk factors, prediction model, and prognosis analysis of myocardial injury after acute upper gastrointestinal bleeding

Background

Cardiovascular complications in patients with acute upper gastrointestinal bleeding (AUGIB) have been associated with a high-risk of subsequent adverse consequences. This study aimed to analyze the risk factors for myocardial injury in AUGIB patients, predict the risk of myocardial injury, and explore the clinical prognosis and influencing factors in AUGIB patients with myocardial injury.

Materials and methods

A retrospective case-control study based on AUGIB patients in the First Affiliated Hospital of Xi'an Jiaotong University from 2016 to 2020 was performed. We divided the enrolled patients into a myocardial injury group and a control group according to whether they developed myocardial injury. The variables significant in the univariate analysis were subjected to binary logistic regression for risk factor analysis and were used to establish a nomogram for predicting myocardial injury. In addition, logistic regression analysis was performed to better understand the risk factors for in-hospital mortality after myocardial injury.

Result

Of the 989 AUGIB patients enrolled, 10.2% (101/989) developed myocardial injury. Logistic regression analysis showed that the strong predictors of myocardial injury were a history of hypertension (OR: 4.252, 95% CI: 1.149-15.730, P = 0.030), blood urea nitrogen (BUN) (OR: 1.159, 95% CI: 1.026-1.309, P = 0.018) and left ventricular ejection fraction (LVEF) <68% (OR: 3.667, 95% CI: 1.085-12.398, P = 0.037). The patients with a tumor history (digestive system tumors and non-digestive system tumors) had no significant difference between the myocardial injury group and the control group (P = 0.246). A prognostic nomogram model was established based on these factors with an area under the receiver operator characteristic curve of 0.823 (95% CI: 0.730-0.916). The patients with myocardial injury had a much higher in-hospital mortality rate (10.9% vs. 2.0%, P < 0.001), and an elevated D-dimer level was related to in-hospital mortality among the AUGIB patients with myocardial injury (OR: 1.273, 95% CI: 1.085-1.494, P = 0.003).

Conclusion

A history of hypertension, renal dysfunction, and cardiac function with LVEF <68% were strong predictors of myocardial injury. Coagulopathy was found to be associated with poor prognosis in AUGIB patients with myocardial injury.

Proton Pump Inhibitors and Risk of Cardiovascular Disease: A Self-Controlled Case Series Study

INTRODUCTION

We investigated cardiovascular risk due to proton pump inhibitor (PPI) treatment using a self-controlled case series (SCCS) study design, a type of case-only design and an approach to overcome between-person confounding in which individuals act as their own control.

METHODS

We conducted an SCCS study using the National Health Insurance Service-Health Screening cohort in Korea (2002-2015). The cohort included 303,404 adult participants without prior cardiovascular events, who were followed up until December 2015. The primary outcome was a composite of stroke or myocardial infarction. The SCCS method estimated the age-adjusted incidence rate ratio between periods with and without exposure to PPI among patients with primary outcomes. As sensitivity analysis, conventional multivariable Cox proportional regression analyses were performed, which treated the exposure to PPI and H2 blocker during follow-up as time-dependent variables.

RESULTS

In the SCCS design, 10,952 (3.6%) patients with primary outcomes were included. There was no association between PPI exposure and primary outcome (incidence rate ratio 0.98, 95% confidence interval [CI] 0.89-1.09). In the time-dependent Cox regression analyses, both PPI (adjusted hazard ratio 1.36, 95% CI 1.24-1.49) and H2 blocker (adjusted hazard ratio 1.46, 95% CI 1.38-1.55) were associated with an increased risk of the primary outcome.

DISCUSSION

Negative findings in the SCCS design suggest that association between increased cardiovascular risk and PPI, frequently reported in prior observational studies, is likely due to residual confounding related to conditions with PPI treatment, rather than a true relationship.

Diabetes is an independent risk factor for infection after non-arthroplasty shoulder surgery: a national database study

OBJECTIVES

Diabetes has been associated with poor healing and prior literature has shown worse functional outcomes in diabetic patients undergoing both open and arthroscopic shoulder surgery. However, the effects of diabetes on perioperative complications for patients undergoing non-arthroplasty type shoulder procedures are not well defined. The purpose of this study was to analyze the effects of diabetes on 30-day complications following non-arthroplasty shoulder surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open and arthroscopic shoulder procedures (excluding arthroplasty) from 2011 to 2018. Diabetic patients were identified and compared to a non-diabetic cohort. Demographic data and postoperative complications within 30 days were analyzed. Multivariable regression was used to determine the effect of diabetes on shoulder surgery.

RESULTS

We identified 99,970 patients who underwent shoulder surgery in our cohort and 13.9% (13,857 patients) of these patients were diabetics. Within the diabetic cohort, 4,394 (31.7%) were insulin dependent. Diabetics were more likely to be older, female, and have a higher body mass index (P < 0.01). Diabetics had a higher rate of associated medial comorbidities (P < 0.05). Diabetics were less likely to be smokers and on average had shorter surgeries (P < 0.05). Univariate analysis showed that diabetes was associated with increased risk for infectious and other major and minor complications; however, multivariate regression revealed that diabetes was only independently associated with infection (OR 1.33, P = 0.38).

CONCLUSION

While diabetes is associated with increased likelihood of infection following shoulder surgery, absent commonly associated comorbidities, they are not at increased risk for other 30-day postoperative complications.

Development of myocardial infarction and ischemic stroke after acute upper gastrointestinal bleeding

Cardiovascular disease, mainly including coronary artery disease and stroke, is the leading cause of mortality and morbidity worldwide. The traditional risk factors of cardiovascular disease include smoking, alcohol abuse, hypertension, diabetes mellitus, hyperlipidemia, and psychosocial stress. Herein, we reported one patient who developed myocardial infarction and ischemic stroke after acute upper gastrointestinal bleeding and discussed the potential association between cardiovascular disease and acuter upper gastrointestinal bleeding.

Outcome of acute upper gastrointestinal bleeding in patients with coronary artery disease: A matched case-control study

BACKGROUND/AIM

The risk of upper gastrointestinal bleeding (UGIB) increases in patients with coronary artery disease (CAD) due to the frequent use of antiplatelets. There is some data reporting on treatment outcomes in CAD patients presenting with UGIB. We aim to determine the clinical characteristics and outcomes of UGIB in patients with CAD, compared with non-CAD patients.

PATIENTS AND METHODS

We conducted a prospective multi-center cohort study (THAI UGIB-2010) that enrolled 981 consecutive hospitalized patients with acute UGIB. A matched case-control analysis using this database, which was collected from 11 tertiary referral hospitals in Thailand between January 2010 and September 2011, was performed.

RESULT

Of 981 hospitalized patients with UGIB, there were 61 CAD patients and 244 gender-matched non-CAD patients (ratio 1:4). UGIB patients with CAD were significantly older, and had more frequently used antiplatelets and warfarin than in non-CAD patients. Compared with non-CAD, the CAD patients had significantly higher Glasgow-Blatchford score, full and pre-endoscopic Rockall score and full. Peptic ulcer in CAD patients was identified more often than in non-CAD patients. UGIB patients with CAD and non-CAD had similar outcomes with regard to mortality rate, re-bleeding, surgery, embolization, and packed erythrocyte transfusion. However, CAD patients had longer duration of hospital stays than non-CAD patients. Two CAD patients died from cardiac arrest after endoscopy, whereas three non-CAD patients died from pneumonia and acute renal failure during their hospitalization.

CONCLUSION

In Thailand, patients presenting with UGIB, concomitant CAD did not affect clinical outcome of treatment, compared with non-CAD patients, except for longer hospital stay.

Acute Myocardial Infarction Risk in Patients with Coronary Artery Disease Doubled after Upper Gastrointestinal Tract Bleeding: A Nationwide Nested Case-Control Study

Prior studies of upper gastrointestinal bleeding (UGIB) and acute myocardial infarction (AMI) are small, and long-term effects of UGIB on AMI have not been delineated. We investigated whether UGIB in patients diagnosed with coronary artery disease (CAD) increased their risk of subsequent AMI. This was a population-based, nested case-control study using Taiwan’s National Health Insurance Research Database. After propensity-score matching for age, gender, comorbidities, CAD date, and follow-up duration, we identified 1,677 new-onset CAD patients with AMI (AMI^[+]) between 2001 and 2006 as the case group and 10,062 new-onset CAD patients without (AMI^[−]) as the control group. Conditional logistic regression was used to examine the association between UGIB and AMI. Compared with UGIB^[−] patients, UGIB^[+] patients had twice the risk for subsequent AMI (adjusted odds ratio [AOR] = 2.08; 95% confidence interval [CI], 1.72–2.50). In the subgroup analysis for gender and age, UGIB^[+] women (AOR = 2.70; 95% CI, 2.03–3.57) and patients < 65 years old (AOR = 2.23; 95% CI, 1.56–3.18) had higher odds of an AMI. UGIB^[+] AMI^[+] patients used nonsignificantly less aspirin than did UGIB^[−] AMI^[+] patients (27.69% vs. 35.61%, respectively). UGIB increased the risk of subsequent AMI in CAD patients, especially in women and patients < 65. This suggests that physicians need to use earlier and more aggressive intervention to detect UGIB and prevent AMI in CAD patients.

Safety of esophagogastroduodenoscopy within 30 days of myocardial infarction: a retrospective cohort study from a Canadian tertiary centre

BACKGROUND

Patients who experience myocardial infarction (MI) are at risk of gastrointestinal (GI) bleeding complications. Endoscopic evaluation may lead to cardiopulmonary complications. Guidelines and studies regarding the safety of endoscopy in this population are limited.

OBJECTIVE

To evaluate the safety of endoscopy in a retrospective cohort of post-MI patients at a Canadian tertiary centre.

METHODS

Using hospital diagnostic⁄procedure codes, the charts of patients meeting the inclusion criteria of having ST elevation MI or non-ST elevation MI, and GI bleeding detected at endoscopy were reviewed. The information retrieved included demographics, medical history, medications, endoscopy details and cardiopulmonary⁄GI events.

RESULTS

A total of 121 patients experienced an MI and underwent endoscopy within 30 days. However, only 44 met the inclusion criteria and were reviewed. The mean age of the patients was 75 years, and 55% were female. The mean hemoglobin level was 86 g⁄L, and 38 of 44 patients required a transfusion. Comorbidities included hypertension (82%), diabetes (46%), heart failure (55%), stroke (21%), lung disease (27%), previous MI (46%), cardiac bypass surgery (30%), history of GI bleed (25%), history of ulcer (18%) and ejection fraction <50% (48%). The median number of days to endoscopy after MI was three. Complications included seven patients with acute coronary syndrome, one with arrhythmia, one with respiratory failure, one with aspiration pneumonia and two with perforation. Age, hemoglobin level or timing of endoscopy did not significantly predict a complication.

CONCLUSIONS

Patients with GI bleeding after MI often have comorbidities and are on antiplatelet agents. Endoscopy is a valuable tool in the diagnosis and management of bleeding complications, but must be weighed against the potential risk of other complications, which in the present study occurred in more than 25% of procedures.

Safety and efficacy of ERCP after recent myocardial infarction or unstable angina

BACKGROUND

ERCP after myocardial infarction (MI) or unstable angina (UnA) can potentially entail significant cardiovascular risks.

OBJECTIVE

To analyze the safety of ERCP after MI or UnA.

DESIGN

Retrospective study.

PATIENTS

Adult patients less than 30 days after MI or UnA.

SETTING

Three hospitals from 1985 to 2010, encompassing 7600 ERCPs.

INTERVENTIONS

ERCP.

MAIN OUTCOME MEASUREMENTS

ERCP diagnosis, therapy, efficacy, and complications.

RESULTS

Thirteen patients (mean age 77.9 ± 11.4 years) underwent ERCP on average 6.9 ± 7.7 days after MI. ERCP indications were suspected choledocholithiasis/gallstone pancreatitis (n = 10); cholangitis (n = 7); obstructive jaundice with suspected pancreatic mass (n = 1); and biliary stent removal/replacement (n = 2). ERCP revealed choledocholithiasis (n = 8); previous stent (n = 2); and nonpathologic findings (n = 3). Therapies included balloon sweep (n = 11), sphincterotomy (n = 8), visible stones extracted by balloon sweep (n = 8), and biliary stent placement/replacement/removal (n = 3). Two mild complications occurred: hypotension during ERCP successfully treated with ephedrine and obstructing periampullary clot successfully removed at repeat ERCP. Eleven patients subsequently did well (mean hospital discharge 6.5 days after ERCP); 1 patient with metastatic ovarian cancer remained ventilator dependent, and another patient with multiple comorbidities had a fatal pulmonary embolus 10 days after ERCP. Six patients underwent ERCP 7.5 ± 5.2 days after UnA for suspected choledocholithiasis (n = 5) and bile duct injury (n = 1). ERCP findings included choledocholithiasis (n = 3), cystic duct leak (n = 1), ampullary stenosis (n = 1), and nonpathologic findings (n = 1). Sphincterotomy was performed in 5 patients, visible stones were extracted by balloon sweep in 3, and a biliary stent was inserted in 1. One mild complication occurred: hypotension during ERCP which was successfully treated with ephedrine. All 6 patients were discharged (mean 8.0 days after ERCP).

LIMITATIONS

Small study size; retrospective study.

CONCLUSIONS

This study suggests that therapeutic ERCP involves acceptable risks when performed soon after MI or UnA for suspected choledocholithiasis or other therapeutic indications and may be performed in such situations when strongly indicated.

Therapeutic endoscopy for acute upper gastrointestinal bleeding

Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding (UGIB). The performance of endoscopic therapy depends on findings of stigmata of recent hemorrhage (SRH). For peptic ulcer disease-the most common etiology of UGIB-endoscopic therapy is indicated for findings of major SRH, such as active bleeding, oozing, or the presence of a nonbleeding visible vessel, but not indicated for minor SRH, such as a pigmented flat spot or a simple ulcer with a homogeneous clean base. Endoscopic therapies include injection, ablation, and mechanical therapy. Monotherapy reduces the risk of rebleeding in patients with peptic ulcer disease with major SRH to about 20%. Combination therapy, especially injection followed by either ablation or mechanical therapy, is generally recommended to further reduce the risk of rebleeding to about 10%. Endoscopic dual hemostasis by an experienced endoscopist reduces the risk of rebleeding, the need for surgery, the number of blood transfusions required, and the length of hospital stay. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis.

Emergency endoscopy for upper gastrointestinal bleeding in patients with coronary artery disease

BACKGROUND

Endoscopy is useful for diagnosis and treatment of upper gastrointestinal bleeding (UGIB). However, both endoscopy and UGIB may compromise the cardiovascular function. The present study is to investigate the cardiovascular responses of emergency endoscopy for patients with UGIB and stable coronary artery disease (CAD).

METHODS

Consecutive 50 patients with known CAD and 50 patients without CAD history (non-CAD group) in whom emergency endoscopy was requested for UGIB were prospectively enrolled. All patients received ambulatory electrocardiographic monitoring before, during, and after endoscopies. Cardiac indices including supraventricular and ventricular arrhythmia, ST ischemic change, and autonomic nervous function evaluated by heart rate variability were compared.

RESULTS

All patients in both groups had successful primary hemostasis, and peptic ulcer bleeding was the main etiology (82%). Compared with the non-CAD group, patients with CAD had a significantly higher incidence (42% vs 16%, P = .004) and frequency (1.19 vs 0.12 events per minute, P = .003) of ventricular arrhythmias during endoscopy. Nine patients with CAD and 1 patient without CAD had ischemic ST changes (P = .016). Comorbidity with congestive heart failure was not only associated with a higher frequency (P = .02) but also a more severe fluctuation (P = .002) of ventricular arrhythmia. None in both groups had angina or MI before, during, or after endoscopy. Heart rate variability did not show a difference.

CONCLUSIONS

Ventricular arrhythmias and myocardial ischemia, although mostly subclinical, were common in patients with stable CAD undergoing emergent endoscopy for UGIB, especially in those with concomitant congestive heart failure.

Gastrointestinal bleeding in high risk survivors of myocardial infarction: the VALIANT Trial

AIMS

The risk of gastrointestinal (GI) bleeding limits the use of antiplatelet and anticoagulant drugs. Risk factors for GI bleeding in post- myocardial infarction (MI) patients have not been well defined. We sought to identify risk factors for GI bleeding in patients following MI.

METHODS AND RESULTS

The VALsartan In Acute myocardial iNfarcTion trial (VALIANT) enrolled 14 703 post-MI patients with left ventricular dysfunction and/or heart failure and followed them for a median of 24.7 months. In the present secondary analysis, times from baseline to first GI bleeding were identified from the VALIANT serious adverse event database. Potential risk factors were explored from medical history, demographics, clinical profile, and medications, both at baseline and during follow-up. We also explored the relationship between the occurrence of GI bleeding and subsequent mortality. During follow-up, 98 (0.7%) patients had a serious GI bleeding event. These patients were older, had more comorbidities, were more likely to be taking additional antiplatelet drugs, and had worse left ventricular systolic and renal function. The Kaplan-Meier estimated rate of GI bleeding at 6 months was 0.37% (95% CI 0.27-0.47). In a multivariable Cox model, dual antiplatelet therapy was the most powerful predictor of GI bleeding, with an adjusted hazard ratio of 3.18 (95% CI 1.91-5.29). Other predictors were non-white race, history of alcohol abuse, increasing age, worse New York Heart Association class, anticoagulant therapy, diabetes, lower estimated glomerular filtration rate, and male sex. Gastrointestinal bleeding was associated with increased risk of death [adjusted hazard ratio 2.54 (95% CI 1.66-3.89)].

CONCLUSION

Following MI, clinical characteristics can identify patients with increased risk of GI bleeding. The use of dual antiplatelet agents appears to be the most profound risk factor. Whether these patients would benefit from GI prophylaxis therapy remains unknown.

Prospective study of cardiac troponin I release in patients with upper gastrointestinal bleeding

BACKGROUND AND AIM

The rate of cardiac injury in upper gastrointestinal hemorrhage is unclear. The aims of this study were to determine prospectively the risk of cardiac troponin I release and associated adverse cardiac events in patients with acute upper gastrointestinal hemorrhage.

METHODS

From January to September 2003, we prospectively studied patients with documented hematemesis and melena referred to the gastroenterology unit in a tertiary teaching hospital in Melbourne, Australia. Serial assays for cardiac troponin I were performed at 0, 12 and 24 h. Serial creatine kinase levels and electrocardiographs were also performed. Clinical and biochemical data were collected. The primary endpoint was a troponin level >0.5 microg/L within 24 h of recruitment. Various clinical variables were then compared between the groups of patients with or without troponin rise.

RESULTS

A total of 156 patients were included in the study. The mean age was 67 years (range 19-96). There were 104 (67%) male patients. A troponin level of greater than 0.5 microg/L was found in 30/156 (19%); 126 (81%) patients had normal troponin levels. Age greater than 65 years, signs of hemodynamic instability at presentation, a recent history of cardiac disease, cardiovascular compromise following endoscopy, and re-bleeding were associated with troponin release.

CONCLUSION

Upper gastrointestinal bleeding is associated with a risk of cardiac injury of up to 19%. Troponin assay could be used to screen for cardiac damage, especially in elderly patients who present with hemodynamic instability.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

Upper gastrointestinal bleeding in patients with acute coronary syndromes: clinical predictors and prophylactic role of proton pump inhibitors

OBJECTIVES

To determine the risk and the clinical predictors of in-hospital upper gastrointestinal (UGI) bleeding in patients with acute coronary syndromes (ACS), and to study the prophylactic role of proton pump inhibitors (PPI) in this setting.

BACKGROUND

Patients with ACS are usually treated by a combination of antiplatelet, antithrombotic and thrombolytic medications, thereby increasing the risk of bleeding.

STUDY

A retrospective study of 1023 patients hospitalized with ACS at the American University of Beirut Medical Center from September 2001 to November 2005. The main outcome measurements were the incidence of in-hospital UGI bleeding and its predictors; the utilization rate of PPI and its determinants.

RESULTS

Seven patients developed in-hospital UGI bleeding (0.7%) and 2 had major bleeding (0.2%). All required blood transfusion and none died in the hospital. Significant predictors of UGI bleeding were prior history of UGI bleeding or peptic ulcer disease (P<0.01), creatinine > 2 mg/dL (P=0.01), and home intake of aspirin, clopidogrel (P<0.05), or nonsteroidal anti-inflammatory drugs (P<0.05). Sixty-nine percent of patients received PPI during their hospital stay. There was no significant difference in the incidence of UGI bleeding between patients receiving and those not receiving PPI (0.7% vs. 0.6%, P= 0.88).

CONCLUSIONS

The risk of UGI bleeding is relatively low in patients hospitalized with ACS and does not appear to be significantly reduced by the use of PPI. The utilization rate of PPI was relatively high. Better patient selection and risk stratification for the prophylactic use of PPI are warranted.

Safety and utility of oesophago-gastro-duodenoscopy in acute myocardial infarction

AIM

To study the safety and utility of performing an oesophago-gastro-duodenoscopy (EGD) in the setting of an acute myocardial infarction (AMI).

METHODS

Case records of all patients who underwent an EGD for various indications within 4 weeks of an AMI between January 2001 and April 2006 were analyzed. Demographic data, indications for endoscopy, outcomes and complications were noted. Main outcome measures included safety and utility of endoscopy in AMI.

RESULTS

A total of 87 EGDs were performed on 85 patients with AMI. Seventy (83%) patients had a non-ST elevation MI, whereas 15 (17%) had ST elevation MI. Mean time between EGD and AMI was 6+/-1.8 days. Indications for EGD were hematemesis and/or melena on presentation in 38 (44.7%), hematemesis and/or melena post anticoagulation in 27 (31.8%). EGD findings were gastric ulcer/erosions in 30 (34%), oesophago-gastric varices in 20 (22%), erosive oesophagitis in 17 (20%) and duodenal ulcer in 11 (13%). Diagnostic yield of EGD was 88%. Endoscopic interventions were performed in 26 (30%) patients with high risk of bleeding lesion. There were no EGD-related mortality, whereas 14 patients re-bled. A total of 21 patients died, including 7/14 (50%) who re-bled, compared with 14/71 (19%) without rebleed (P=0.008). There were no EGD-related deaths. Fourteen patients were on mechanical ventilation and 6/14 (43%) of these died as compared with 15/88 (17%) who were not ventilated (P=0.027).

CONCLUSION

EGD is safe and useful in diagnosis and management of gastrointestinal hemorrhage in patients with AMI, and allows decisions about anticoagulation. Re-bleed and need for mechanical ventilation predicts poor outcome in these patients.

Safety of endoscopy after myocardial infarction based on cardiovascular risk categories: a retrospective analysis of 135 patients at a tertiary referral medical center

GOALS

To establish the safety of endoscopic procedures performed in patients with recent myocardial infarction (MI) based upon specific cardiac risk categories.

BACKGROUND

There are no specific guidelines that dictate when to perform endoscopy in patients after recent MI, as this population may be at increased risk for cardiopulmonary complications at the time of endoscopy.

STUDY

Retrospective analysis of data collected over 48 months on 135 patients who experienced a MI and within the next 30 days had an endoscopic procedure performed. Data on chronology of complications and certain cardiac risk categories were collected and analyzed.

RESULTS

There was early termination of endoscopic procedures for a major cardiopulmonary complication in 2 of 135 patients (1.5%). The complications occurred on hospital day 0 postMI. Performance of endoscopic procedures on the day of the MI was found to be a risk factor for a procedure-related complication (P=0.02). ST segment elevation myocardial infarction was seen in 19 patients (16.0%), severely depressed ejection fraction in 30 patients (22.2%), and troponin-I peak greater than 1.6 ng/mL in 96 patients (71.0%). No statistically significant increased risk of endoscopy was found in these subsets of patients (P=0.99).

CONCLUSIONS

Endoscopic procedures can be safely performed early post-MI without imparting a significant cardiopulmonary risk. Timing of endoscopy increases risk of complications, but evidence of significant recent cardiac damage as demonstrated by ST segment elevation, depressed left ventricular ejection fraction, or troponin-I peak greater than 1.6 ng/mL does not increase risk of cardiopulmonary complication.

Predictors and outcomes associated with gastrointestinal bleeding in patients with acute coronary syndromes

BACKGROUND

Potent antiplatelet and anticoagulant agents along with early revascularization are increasingly used in patients hospitalized with acute coronary syndromes (ACS). An important complication associated with these therapies is gastrointestinal bleeding (GIB); yet, the predictors, optimal management, and outcomes associated with GIB in ACS patients are poorly studied.

METHODS

We investigated the incidence, predictors, pathological findings, and clinical outcomes associated with GIB in patients with ACS hospitalized at a United States tertiary center between 1996 and 2001.

RESULTS

Three percent (80/3,045) of ACS patients developed clinically significant GIB. Predictors of GIB were older age, female gender, non-smoking status, peak troponin I, and prior heart failure, diabetes, or hypertension. Patients with GIB were more critically ill with lower blood pressure and higher heart rates. GIB was associated with an increased need for transfusion, mechanical ventilation, and inotropes/pressors. In-hospital mortality was significantly higher in ACS patients with versus without GIB (36% vs. 5%, P < 0.001). Thirty patients (38%) with GIB underwent endoscopy with no procedural complications of death, arrhythmia, urgent ischemia, or hemodynamic deterioration.

CONCLUSION

In patients with ACS, GIB is associated with older age, female sex, peak troponin I, non-smoking status, diabetes, hypertension, and heart failure. Hospital mortality is increased eightfold when ACS patients experience GIB. More studies are needed to establish the safety of and optimal timing of endoscopy in these patients.

Factors associated with myocardial infarction after emergency endoscopy for upper gastrointestinal bleeding in high-risk patients: a prospective observational study

BACKGROUND

Because myocardial infarction (MI) after emergency endoscopy for upper gastrointestinal bleeding carries high mortality, we investigated factors associated with procedure-related MI in high-risk patients.

METHODS

Consecutive patients with coronary artery disease or age-based risk for coronary artery disease (men, age >45 years; women, >55 years) who underwent emergency endoscopy were enrolled at a single ED. Demographic, laboratory, and outcome data were recorded. Patients fit 1 of 3 groups: MI before endoscopy (pre-panendoscopy [PES] MI), MI after endoscopy (post-PES MI), or non-MI.

RESULTS

We enrolled 108 high-risk patients, including 5 (4.6%) with MI diagnosed preendoscopy. Five patients (4.6%) had MIs postendoscopy. Compared with non-MI patients, significantly more post-PES MI patients had heart disease (60.0% vs 12.2%; P = .021), lower systolic pressure on arrival (86.2 +/- 16.6 vs 128.0 +/- 27.2 mm Hg; P = .002), lower diastolic pressure on arrival (50.0 +/- 6.3 vs 69.5 +/- 15.8 mm Hg; P = .003), lower hemoglobin on arrival (6.7 +/- 1.1 vs 9.1 +/- 2.4 g/dL; P = .021), and more persistent shock status preendoscopy (80.0% vs 13.3%; P = .002). There was no significant difference in factors including duration of procedure and rates of recurrent bleeding, postprocedure complication, and mortality.

CONCLUSIONS

Heart disease, lower blood pressure or hemoglobin level on arrival, and persistent shock before endoscopy are associated with increased risk for procedure-related MI.

Predictive Risk Factors for Upper Gastrointestinal Bleeding with Simultaneous Myocardial Injury

The aims of this study were to: (1) evaluate the epidemiology of simultaneous upper gastrointestinal bleeding (UGIB) and myocardial injury using parameters including troponin I (TnI); and (2) investigate the predictive risk factors of this syndrome. One hundred and fifty-five patients (101 men, 54 women; mean age, 64.7+/-10.4 years; range, 38-94 years) at the emergency department (ED) with the major diagnosis of UGIB were included. They underwent serial electrocardiography (ECG) and cardiac enzyme follow-up. Emergent gastroendoscopy was performed within 24 hours in most patients except for those who refused or were contraindicated. Mild myocardial injury was defined as the presence of any of the following: typical ST-T change on ECG, elevated creatine kinase-MB (CK-MB)>12 U/L, or TnI>0.2 ng/dL. Moderate myocardial injury was defined as the presence of any two of the previously mentioned conditions. In total, 51 (32.9%) and 12 (7.74%) patients developed mild and moderate myocardial injuries, respectively. Myocardial injury was more common among patients with variceal bleeding (20/25=80.0%) than those with ulcer bleeding (23/112=20.5%). It could partially be attributed to a higher baseline TnI level in cirrhotic patients. After adjusting for significant risk factors revealed by the univariate analysis, UGIB patients with a history of liver cirrhosis and more than three cardiac risk factors comprised a high-risk group for simultaneously developing myocardial injury. Other factors including age, gender, the color of nasogastric tube irrigation fluid, history of nonsteroidal anti-inflammatory drug use, vasopressin or terlipressin administration, vital signs, and creatinine recorded at the ED were not significant predictors. Those who developed myocardial injury had a longer hospital stay (mean duration, 8.73+/-6.94 vs. 6.34+/-2.66 days; p=0.03) and required transfusion of more units of packed erythrocytes.

The utility of upper endoscopy in patients with concomitant upper gastrointestinal bleeding and acute myocardial infarction

Patients who present with upper gastrointestinal bleeding (UGIB) in the setting of acute myocardial infarction (AMI) may have suffered an UGIB that subsequently led to an AMI or endured an AMI and subsequently suffered a UGIB as a consequence of anticoagulation. We hypothesized that patients in the former group bled from more severe upper tract lesions. The aim of this study was to evaluate predictors for endoscopic therapy in patients who suffer a concomitant UGIB and AMI. Retrospective, single center medical record abstraction of hospital admissions from January 1, 1996-December 31, 2002. During the study period, 183 patients underwent an esophagogastroduodenoscopy (EGD) within 7 days of suffering an AMI and UGIB (AMI group N=105, UGIB group N=78). A higher proportion of patients in the UGIB group (41%) was found to have high-risk UGI lesions requiring endoscopic treatment compared to patients in the AMI group (17%; P < 0.004). UGIB as the inciting event and patients suffering from hematemesis and hemodynamic instability were significantly associated with requiring endoscopic therapy. Although predominantly diagnostic, endoscopic findings in the AMI group did alter the decision to perform cardiac catheterization in 43% of patients. Severe complications occurred in 1% (95% confidence interval, 0%-4%) of patients. We conclude that in patients suffering from concomitant UGIB and AMI, urgent endoscopy was most beneficial in patients with UGIB as the initial event and those presenting with hematemesis and hemodynamic instability. In patients without these clinical features, urgent endoscopy may be delayed, unless cardiac management decisions are dependent on endoscopic findings.

Characterization of ischemic colitis associated with myocardial infarction: an analysis of 23 patients

PURPOSE

The study characterizes the clinical presentation of ischemic colitis (IC) associated with myocardial infarction (MI) and helps determine whether the primary mechanism for this association is thrombus, embolus, or localized nonocclusive mesenteric ischemia (NOMI) associated with systemic hypotension.

METHODS

We compared 23 study patients presenting with IC occurring simultaneously with or within 3 days after MI who were admitted to 5 medical centers versus (1) 32 patients with IC without MI (IC-controls) or (2) 32 patients with MI without IC (MI-controls).

RESULTS

Of 17,500 patients admitted to the study sites with MI, 23 (0.13%) had IC. Study patients had a high in-hospital mortality of 39%. An Acute Physiology and Chronic Health Evaluation (APACHE) II score greater than 15 was a significant predictor of mortality in these patients (P<.04). Compared with the IC-controls, study patients had a significantly lower mean arterial pressure (MAP) (76.0 +/- 17.1 mm Hg vs 98.3 +/- 18.6 mm Hg, P<.0001) and a significantly higher rate of hypotension (57% vs 9%, odds ratio [OR] = 12.6, confidence interval [CI]: 3.10-49.7, P<.001). The 2 groups, however, had a similar mean number of risk factors for thromboembolism per patient. Study patients had more severe illness than IC-controls, as demonstrated by mean APACHE II scores (19.0 +/- 5.5 vs 10.4 +/- 4.8, P<.0001). Study patients had a significantly higher incidence of complications, including respiratory failure (57% vs 13%, P=.001), altered mental status (48% vs 13%, P<.01), and renal insufficiency or failure (61% vs 28%, P<.04). Study patients had a significantly lower minimum hematocrit. Study patients had a significantly higher rate of prolonged hospitalization (>30 days) or in-hospital death (74% vs 19%, OR = 12.3, CI: 3.47-43.5, P<.0001). Compared with MI-control patients, study patients had a significantly lower MAP, significantly higher rate of hypotension, much higher mean APACHE II score, much higher incidence of complications, and significantly worse hospital outcome.

CONCLUSIONS

Patients with both IC and MI present as a clinically distinct group from patients with either IC alone or MI alone. They have significantly more complications and worse in-hospital prognoses. They present with a dramatically lower MAP and a higher frequency of hypotension. This last finding suggests that the most common and most important mechanism for IC with MI may be hypotension from cardiogenic shock. Hypotension is the cardinal risk factor for generalized NOMI with acute mesenteric ischemia and may be an important risk factor for localized NOMI with IC. An APACHE II score greater than 15 may be a predictor of mortality from IC after MI.

Safety and efficacy of nasogastric intubation for gastrointestinal bleeding after myocardial infarction: an analysis of 125 patients at two tertiary cardiac referral hospitals

Our purpose was to analyze risks versus benefits of nasogastric (NG) intubation for gastrointestinal (GI) bleeding performed soon after myocardial infarction (MI). While NG intubation and aspiration is relatively safe, clinically beneficial, and routinely performed in the general population for recent GI bleeding, its safety after MI is unstudied and unknown. In addition to the usual complications of NG tubes, patients status post-MI may be particularly susceptible to myocardial ischemia or cardiac arrhythmias from anxiety or discomfort during intubation. We studied NG intubation within 30 days of MI in 125 patients at two hospitals from 1986 through 2001. Indications for NG intubation included melena in 55 patients; fecal occult blood with an acute hematocrit decline, severe anemia, or sudden hypotension in 37; hematemesis in 18; bright red blood per rectum in 8; and dark red blood per rectum in 7. The intubation was performed on average 5.3 +/- 7.2 (SD) days after MI. NG aspiration revealed bright red blood in 38 patients, "coffee grounds"-appearing blood in 45, and clear (or bilious) fluid in 42. Among 114 of the patients undergoing esophagogastroduodenoscopy (EGD), EGD revealed the cause of bleeding in 79 (95%) of 83 patients with a grossly bloody NG aspirate versus 12 (39%) of 31 patients with a clear aspirate (P < 0.0001, OR = 31.3, OR CI = 9.4-103.1). Among 85 patients undergoing EGD within 16 hr of NG intubation, stigmata of recent hemorrhage were present in 28 (42%) of 66 with a bloody NG aspirate versus 3 (16%) of 19 with a clear aspirate (P = 0.06, OR = 3.93). Among 35 patients undergoing lower GI endoscopy, lower endoscopy revealed the cause of bleeding in 14 (56%) of 25 patients with a clear NG aspirate versus 1 (10%) of 10 patients with a grossly bloody aspirate (P < 0.04, OR = 11.46, OR CI = 1.55-78.3). The two NG tube complications (epistaxis during intubation and gastric erosions from NG suctioning) were neither cardiac nor major (requiring blood transfusions). This study suggests that short-term NG intubation is relatively safe and may be beneficial and indicated for acute GI bleeding after recent MI. Aside from improving visualization at EGD, the potential benefits include providing a rational basis for the timing of endoscopy (urgent versus semielective), for prioritizing the order of endoscopy (EGD versus colonoscopy), and for avoiding or deferring endoscopy in low-yield situations (e.g., colonoscopy when the NG aspirate is bloody). These benefits may be particularly relevant in patients after recent MI due to their increased endoscopic risks.

Incidence and prognostic impact of gastrointestinal bleeding after percutaneous coronary intervention for acute myocardial infarction

We examined the incidence, presentation, and outcome of patients who developed gastrointestinal bleeding after percutaneous coronary intervention for acute myocardial infarction in the Primary Angioplasty in Myocardial Infarction trials. Of the 3,130 patients, 71 (2.3%) developed gastrointestinal bleeding, which was more likely to occur in elderly patients. Gastrointestinal bleeding was independently associated with a prolonged hospital stay and greater in-hospital and 6-month mortality.

Myocardial infarction and cardiac complications in emergency department patients admitted to the intensive care unit with gastrointestinal hemorrhage

Patients admitted with significant gastrointestinal hemorrhage (GIH) often experience in-hospital cardiac complications. This retrospective study examined 68 patients admitted from the Emergency Department to the Intensive Care Unit (ICU) over a 1-year period. The patients were 75% Caucasian, 60% male, with a mean age of 57 +/- 19 years. Medical co-morbidity was noted in 70%, and 54% of patients had a history of significant alcohol use. A systolic blood pressure < 100 mm Hg was present in 26%, hemoglobin < 7 mg/dL in 32%, and three patients (4%) expired. Death, acute myocardial infarction or other cardiac complications were noted in 32% of patients. Patients older than 60 years were three times more likely to have a complicated course than were younger patients, and those with a co-morbidity were 14.8 times more likely. Patients with a history of significant alcohol use were 31% less likely to have an inpatient complication than those without such a history. Regression analysis supported the protective effect of a history of significant alcohol use and also demonstrated that a history of peptic ulcer disease was predictive of inpatient complications. Older GIH patients and those with co-morbidities may benefit from ICU disposition given their greater risk. Younger patients presenting with hematemesis and a history of significant alcohol use tended to have fewer complications such that it may be possible to manage these patients outside of the ICU if hemodynamically stable.

Safety and efficacy of colonoscopy after myocardial infarction: an analysis of 100 study patients and 100 control patients at two tertiary cardiac referral hospitals

BACKGROUND

The purpose of this study is to analyze the risks vs. the benefits of colonoscopy soon after myocardial infarction.

METHODS

A total of 100 consecutive patients undergoing colonoscopy within 30 days after myocardial infarction at two large tertiary cardiac referral hospitals were studied. The study group was compared with 100 control patients with neither myocardial infarction nor unstable angina during the preceding 6 months (matched for age, colonoscopy indication, and colonoscopist) who underwent colonoscopy.

RESULTS

Indications for colonoscopy were bleeding per rectum (37 patients), fecal occult blood (36 patients, hematocrit < 30% in 25), iron deficiency anemia (11 patients, hematocrit < 25% in 9), and other (16 patients). Colonoscopy was performed at a mean of 15.5 (8.3) days after myocardial infarction. Two patients underwent colonoscopic colonic decompression. Colonoscopy was diagnostic in 46 (47%) of the study patients vs. 41% of the control patients ( p = 0.47, chi-square test). The relative rate of ischemic colitis was significantly higher in study vs. control patients (14 vs. 2, p < 0.005). Other diagnoses in study patients were the following: colon cancer (8), bleeding internal hemorrhoids (5), pseudomembranous colitis (5), high-risk adenomatous polyp (large or villous histopathology) (4), and other (10). Urgent colonoscopy was diagnostic in 63% of cases. Twenty-three patients had a major therapeutic benefit consequent to colonoscopy, including colon cancer surgery in 5. Study patients were significantly sicker than control patients (APACHE II score 9.9 [4.3] vs. 7.4 [2.8], p < 0.0001) and suffered significantly more colonoscopic complications compared with control patients (9 vs. 1; OR 5.2: 95% CI [1.2, 9.8], p < 0.03). Minor complications without clinical sequelae occurred in 8 study patients (asymptomatic hypotension or bradycardia). One major complication occurred in this group that was probably not procedure related.

CONCLUSIONS

Colonoscopy in patients with a recent myocardial infarction is associated with a higher rate of minor, transient, and primarily cardiovascular complications compared with control patients but is relatively infrequently associated with major complications. Colonoscopy is beneficial and indicated after myocardial infarction, despite a higher risk, in certain circumstances. The relative frequency of ischemic colitis was relatively high in study patients.

Lower gastrointestinal bleeding in elderly patients

Lower gastrointestinal bleeding (LGIB) is one of the common medical emergencies that can become life-threatening in elderly patients. Increased prevalence of cerebrovascular and cardiovascular diseases, malignancy, polypharmacy, and the use of nonsteroidal anti-inflammatory drugs in elderly patients adversely affects the outcome of LGIB. Diverticular bleeding, vascular ectasia, polyps and hemorrhoids are among the common causes of LGIB in the elderly. In a majority of cases, LGIB stops spontaneously with resuscitation and supportive therapy. In those elderly patients in whom LGIB continues, benefits of endoscopic, angiographic, or surgical intervention should not be withheld because of age alone. However, the timing of tests and the type of intervention should be custom tailored for frail elderly patients. Such a decision should depend upon functional status, its impact on outcome, and the consent process.

The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: technique, indications, and contraindications

Flexible sigmoidoscopy and colonoscopy have revolutionized the clinical management of colonic diseases. Colonoscopy has a broad range of indications, including evaluating lower GI symptoms such as lower GI bleeding, evaluating abnormal radiographic findings, and screening and surveillance for colon cancer. Colonoscopy is increasingly being used therapeutically. Patient evaluation, patient instructions, and colonic preparation before colonoscopy are essential for safe and efficient colonoscopy. Intravenous sedation reduces patient pain and anxiety during colonoscopy, but requires monitoring by pulse oximetry and automated measurements of vital signs. An experienced colonoscopist can complete colonoscopy in 90% or more of cases, using maneuvers to maintain the colonic lumen in view, straighten the colonoscope, and avoid looping during colonic intubation.

The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders

Esophagogastroduodenoscopy has revolutionized the clinical management of upper gastrointestinal diseases. Millions of EGDs are performed annually in the United States for many indications, such as gastrointestinal bleeding, abdominal pain, dysphagia, or surveillance of premalignant lesions. Esophagogastroduodenoscopy is very safe, with a low risk of serious complications such as perforation, cardiopulmonary arrest, or aspiration pneumonia. It is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Esophagogastroduodenoscopy is increasingly being used therapeutically to avoid surgery. New endoscopic technology such as endosonography, endoscopic sewing, and the endoscopic videocapsule will undoubtedly extend the frontiers and increase the indications for endoscopy.

Interventional endoscopy

Interventional endoscopy is a general label given to endoscopic procedures used to deal with a variety of gastrointestinal disorders. The interventional endoscopic procedures of interest in this review are those used specifically with gastric disorders. They include hemostasis, endoscopic ultrasound, endoscopic mucosal resection, stenting, percutaneous endoscopic gastrostomy tube placement and photodynamic laser therapy. Here, we review the latest data related to (a) a number of general issues having an impact on this diverse group of procedures (eg, such as proper patient selection criteria, consent in the era of open access endoscopy, protocol for anticoagulation, and sedation); (b) the methodology and outcomes of each of these unique procedures as they apply to the stomach; and (c) some of the latest technologic advances and developments that will potentially have an impact the future use of these procedures.