Clinical review: gastrointestinal bleeding after percutaneous coronary intervention: a deadly combination

Chronic anemia and non-ST elevation acute coronary syndrome - double jeopardy

This review outlines the priorities from cardiology and gastroenterology perspectives, resolves some of the misconceptions, and uses the evidence available to suggest strategies for optimizing management of these patients. The dual presentation of acute active gastrointestinal (GI) blood loss together with an acute coronary syndrome (NSTEACS or STEMI) is outside the remit of this review but has been previously reviewed by our group. The review covers NSTEACS together with chronic or sub-acute anemia, anemia that cannot be accounted for by chronic kidney disease, heart failure, or inflammatory disorders. Identification of a potential GI etiology of anemia is important as it allows adjustment to both GI and CV investigations and treatments that can reduce the likelihood and impact of bleeding complications.

Epidemiology and Risk Factors for Upper Gastrointestinal Bleeding

Although the incidence of nonvariceal upper gastrointestinal bleeding (UGIB) has been decreasing worldwide, nonvariceal UGIB continues to be a significant problem. Even with the advent of advanced endoscopic procedures and potent medications to suppress acid production, UGIB carries significant morbidity and mortality. Some of the most common risk factors for nonvariceal UGIB include Helicobacter pylori infection, nonsteroidal antiinflammatory drugs (NSAIDs), aspirin, selective serotonin reuptake inhibitors, and other antiplatelet and anticoagulant medications. In patients with cardiovascular disease and kidney disease, UGIB tends to be more severe and has greater morbidity. Many of the newer NSAIDs have been removed from the market.

Upper gastrointestinal haemorrhage in the acute cardiac care setting: antiplatelets and endoscopy

Upper gastrointestinal haemorrhage (UGIH) in cardiac patients receiving antiplatelets presents a difficult management problem. The aim of this study was to describe a series of cardiac inpatients receiving antiplatelets who underwent endoscopy for an acute UGIH. Cardiac inpatients receiving antiplatelets and requiring endoscopy for UGIH over an 18-month period were followed up. Forty-one patients were studied. Most patients (25 [61%]) presented with melaena. Antiplatelets were withheld in 34 (83%) patients; predominantly in those with higher pre-endoscopy Rockall scores (median, 4; interquartile range [IQR], 3-5 versus median, 3; IQR, 2-4; P < 0.05). Positive findings were identified at endoscopy in 80%. Duodenal ulcers were the most common lesion and adrenaline the most common method of haemostasis. Median time to first endoscopy was 0 (IQR, 0-1) days. Seven (17%) patients re-bled, median Rockall score was six (IQR, 4-8). Three (7%) patients experienced procedural complications, two patients became hypoxic and one patient died. Following endoscopy, antiplatelets were restarted after a median of three (IQR, 3-5) days. On discharge, 27/28 (96%) patients continued with antiplatelet and proton-pump inhibitor therapy. Thirty-day inpatient mortality was 7% (3 patients). One patient re-bled within six months of discharge. Endoscopy helped assess the risk of re-bleeding and timing of antiplatelet re-introduction in cardiac inpatients experiencing UGIH.

Temporal trends in gastrointestinal bleeding associated with percutaneous coronary intervention: analysis of the 1998-2006 Nationwide Inpatient Sample (NIS) database

BACKGROUND

Gastrointestinal bleeding (GIB) after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) and coronary artery disease (CAD) is associated with high morbidity and mortality.

METHODS

The NIS database from 1998 to 2006 was used to identify 1,216,759 PCIs performed for ACS and CAD. We sought to analyze temporal trends in the incidence and in-hospital outcomes of GIB associated with PCI along with its predictors.

RESULTS

The overall incidence of GIB was 1.04% (95% confidence interval (CI), 1.02%-1.06%). The incidence of GIB decreased over the study period (P for trend <.0001). The overall mortality in the GIB group was 6.0% (95% CI, 5.6%-6.4%). The adjusted OR for in-hospital mortality and GIB was 4.70 (95% CI, 4.23-5.23; P < .0001); this remained high and essentially unchanged over the study period. Independent predictors of GIB included rectum/anal cancer (OR, 4.64; 95% CI, 3.20-6.73; P < .0001), stomach cancer (OR, 2.74; 95% CI, 1.62-4.66; P = .0002), esophageal cancer (OR, 1.99; 95% CI, 1.08-3.69; P = .0288), colon cancer (OR, 1.69; 95% CI, 1.43-2.02; P < .0001), congestive heart failure (OR, 1.43; 95% CI, 1.35-1.52; P < .0001), and acute myocardial infarction (OR, 1.23; 95% CI, 1.13-1.35; P < .0001).

CONCLUSIONS

Although the incidence of GIB associated with PCI decreased from 1998 to 2006 in the face of aggressive therapies for ACS and CAD, the risk of GIB-associated death remained high. Underlying GI malignancy is a significant independent predictor of GIB associated with PCI; identifying these patients may reduce the rate of GIB.

Managing adverse effects and drug-drug interactions of antiplatelet agents

Antiplatelet therapies have reduced the frequency of adverse events associated with plaque rupture in several clinical situations. These therapies include established antiplatelet agents (such as aspirin, clopidogrel, or glycoprotein IIb/IIIa inhibitors) as well as new agents (such as prasugrel and ticagrelor). In this Review, we address the most important adverse events of antiplatelet therapy, including hemorrhage, hematologic reactions, and dyspnea. We discuss strategies to reduce the incidence of complications and outline potential methods to manage adverse reactions. Interactions between antiplatelet agents and other drugs--such as proton-pump inhibitors, calcium-channel blockers, statins, warfarin, or NSAIDs--are also addressed, as well as specific issues relating to the use of antiplatelet therapies in elderly patients.

Gastrointestinal bleeding in percutaneous coronary intervention and acute coronary syndromes

The increasingly prevalent use of antithrombotic drug combinations and an aging population are resulting in growing rates of gastrointestinal bleeding (GIB). GIB is a serious condition in the setting of stable and acute coronary syndromes, associated with high rates of ischemic events. Physicians should be aware of GIB in high-risk populations, especially the elderly and patients with anemia. We discuss the risk of GIB in patients treated with different antiplatelet and antithrombotic medications and their combinations, factors associated with GIB, and its optimal management and prevention.