Etiology of gastrointestinal bleeding in patients on dual antiplatelet therapy

In-hospital and delayed mortality in patients with upper gastrointestinal bleeding on antithrombotic treatment: effects of withdrawal and resuming

BACKGROUND

Antithrombotic drugs pose a dual challenge to acute upper gastrointestinal bleeding, with associated risks of bleeding complications and thromboembolic events upon withdrawal. We aimed to determine the impact of antithrombotic medications on in-hospital and delayed outcomes and whether suspension and resumption influenced delayed mortality.

METHODS

This study was a prospective registry analysis of patients between 2013-2021. Anticoagulants and antiplatelets were classified as antithrombotic. The examined outcomes included in-hospital mortality and delayed 6-month cardiovascular, bleeding, and mortality events.

RESULTS

A total of 1345 patients were included. 21.7% were taking anticoagulants and 19.1% were taking antiplatelets. Patients on antithrombotic therapy have a longer delay in endoscopic performance (11 ± 11 h vs. 9.6 ± 8 h; p = 0.027) and less need for therapy (38.5% vs. 48.1%;p = 0.002), with gastric erosion being more usual (14.2% vs. 9.1%; p = 0.006).In-hospital mortality was higher in patients not taking antithrombotic (12% vs. 8%;p = 0.022) and suspension < 72 h was associated with increased mortality (14.9% vs. 2.3%;p = 0.001).Delayed mortality was higher in patients taking antithrombotic (9.4% vs. 6%; p=0.034) and in those who suspended them for more than 7days (17% vs. 8.7%; p=0.033), with no differences when it lasted<72h.Patients on antithrombotic therapy exhibited more delayed cardiovascular (13.7% vs. 3.4%; p<0.0001) and hemorrhagic events (22.9% vs. 12.9%; p<0.0001), with no differences observed in patients who withheld antithrombotic medication.Multivariate analysis identified ASA, disseminated malignancy, and NSAIDs as independent risk factors for in-hospital mortality, whereas antithrombotic therapy and hemoglobin levels were protective factors.

CONCLUSION

Patients with upper gastrointestinal bleeding treated with antithrombotic drugs had lower in-hospital mortality despite increased comorbidities and older age. Conversely, delayed 6-month mortality was higher. Shorter antithrombotic suspension durations increased in-hospital mortality, whereas suspension for > 7 days increased delayed mortality.

Single-center study of interventional embolization for treatment of massive hemorrhage from peptic ulcer caused by antiplatelet drugs in elderly patients: Therapeutic effects and prognostic factors

BACKGROUND

Interventional embolization is an important method for the treatment of peptic ulcer bleeding , which can effectively stop bleeding and improve the success rate of treatment. At present, the effect of interventional embolization in the treatment of massive bleeding from gastrointestinal ulcer caused by antiplatelet drugs in elderly patients has been confirmed in many studies, but the incidence of postoperative rebleeding is high, and there are many influencing factors for rebleeding. There are still 10%-30% of patients with rebleeding, which is a serious threat to their life safety, and the results are different across studies and reports. Therefore, this study aimed to analyze the influencing factors for rebleeding in patients with gastrointestinal ulcer bleeding caused by antiplatelet drugs after interventional embolization through single and multi-factor methods, so as to provide a reference for future clinical treatment.

AIM

To investigate the effect of interventional embolization in the treatment of massive hemorrhage from peptic ulcer caused by antiplatelet drugs in elderly patients, and to analyze the prognostic factors.

METHODS

From May 2016 to May 2020, 255 patients with massive gastrointestinal ulcer hemorrhage caused by antiplatelet drugs at our hospital were prospectively selected. All patients received interventional embolization. The hemostatic effect, complications, and prognosis were recorded. Logistic regression equation was used to analyze the prognostic factors.

RESULTS

The effective rate of hemostasis was 94.90% in 255 elderly patients with gastrointestinal ulcer bleeding caused by antiplatelet drugs, and the complication rate was 2.75% (7/255). After 30 d of follow-up, it was found that antiplatelet drugs caused serious bleeding in elderly patients with gastrointestinal ulcer. The bleeding rate was 12.81%. According to the 30-day prognosis, the patients were divided into either a rebleeding group (n = 31) or a non-rebleeding group (n = 211); the two groups differed significantly in age, duration of antiplatelet drug use, ulcer history, gastrointestinal malignant tumor hist

ory, Helicobacter pylori positive status, hematemesis, shock, blood transfusion, Hb, ALB, ANC, BUN, PLT, ulcer location, and ulcer size (P < 0.05). Logistic regression analysis showed that age, duration of antiplatelet drug use, ulcer history, Helicobacter pylori positive status, shock, blood transfusion, ANC, BUN, and Forrest grade Ia were the prognostic risk factors for elderly patients with peptic ulcer bleeding caused by antiplatelet drugs, while Hb, ALB, and PLT were identified to be prognostic protective factors (P < 0.05).

CONCLUSION

Interventional embolization can improve the hemostatic effect of antiplatelet drugs in elderly patients with gastrointestinal ulcer hemorrhage, but rebleeding tends to occur. Since rebleeding is closely related to blood transfusion, BUN, Hb, and other factors, it is recommended that clinical monitoring and intervention of the above indicators be carried out to reduce the incidence of rebleeding and improve the prognosis.

Readmissions Rates After Myocardial Infarction for Gastrointestinal Bleeding: A National Perspective

BACKGROUND AND AIMS

Gastrointestinal (GI) bleeding is one most common complications of acute myocardial infarction (AMI). We aimed to determine the incidence, in-hospital outcomes, associated healthcare burden and predictors of GI bleeding within 30 days after AMI.

METHODS

Data were extracted from Nationwide Readmission Database 2010-2014. Patients were included if they had a primary diagnosis of ST or non-ST elevation myocardial infarction. Exclusion criteria were admissioned in December, aged less than 18 years and a diagnosis of type-2 MI. The primary outcome was 30-day readmission with upper or lower GI bleeding. Secondary outcomes were in-hospital mortality, etiology of bleeding, in-hospital complications, procedures, length of stay, and total hospitalization charges. Independent predictors of readmission were identified using multivariate logistic regression analysis.

RESULTS

Out of the 3,520,241 patients discharged with ACS, 10,018 (0.3%) were readmitted with GI bleeding within 30 days of discharge. 60% had lower GI bleeding. Most common sources suspected were GI cancers in 17% and hemorrhoidal bleeding in 10%. In hospital mortality rate for readmission was 3.6%. Independent predictors of readmission were age, Charlson comorbidity score, history of chronic kidney disease, GI tumor, inflammatory bowel disease and artificial heart valve. Type of treatment for AMI had no impact on readmission. Patients readmitted had higher rates of shock (adjusted odds ratio, 1.48, 95% CI 1.01-3.72).

CONCLUSIONS

In the first nationwide study, 30-day incidence of GI bleeding after AMI is 0.3%. GI bleeding complicating AMI carries a substantial in-hospital mortality and cost of care.

Digestive system injury induced by drugs for secondary prevention of ischemic stroke

The recurrence of ischemic stroke can be reduced by active secondary prevention, including antithrombotic, lipid-lowering, antihypertensive, and hypoglycemic treatment. However, long-term use of drugs for secondary prevention can cause damage to the digestive system, reduce patient compliance, increase the recurrence of stroke, and even lead to ulcer bleeding and life-threatening events. It is necessary to early identify populations at a high risk for digestive system injury, understand the adverse reactions of various drugs, and standardize the treatment, which can improve the effect of secondary prevention of ischemic stroke.

Panax Notoginseng Saponin Attenuates Gastric Mucosal Epithelial Cell Injury Induced by Dual Antiplatelet Drugs through COX and PI3K/Akt/ VEGF-GSK-3β-RhoA Network Pathway

OBJECTIVE

To elucidate the underlying mechanism of Panax notoginseng saponin (PNS) on gastric epithelial cell injury and barrier dysfunction induced by dual antiplatelet (DA).

METHODS

Human gastric mucosal epithelial cell (GES-1) was cultured and divided into 4 groups: a control, a DA, a PNS+DA and a LY294002+PNS+DA group. GES-1 apoptosis was detected by flow cytometry, cell permeability were detected using Transwell, level of prostaglandins E2 (PGE2), 6-keto-prostaglandin F1α (6-keto-PGF1α) and vascular endothelial growth factor (VEGF) in supernatant were measured by enzyme linked immunosorbent assay (ELISA), expression of phosphatidylinositide 3-kinase (PI3K), phosphorylated-PI3K (p-PI3K), Akt, phosphorylated-Akt (p-Akt), cyclooxygenase-1 (COX-1), cyclooxygenase-2 (COX-2), glycogen synthase kinase-3β (GSK-3β) and Ras homolog gene family member A (RhoA) were measured by Western-blot.

RESULTS

DA induced apoptosis and hyper-permeability in GES-1, reduced supernatant level of PGE2, 6-keto-PGF1α and VEGF (P<0.05). Addition of PNS reduced the apoptosis of GES-1 caused by DA, restored the concentration of PGE2, 6-keto-PGF1α and VEGF (P<0.05). In addition, PNS attenuated the alteration of COX-1 and COX-2 expression induced by DA, up-regulated p-PI3K/p-Akt, down-regulated RhoA and GSK-3β. LY294002 mitigated the effects of PNS on cell apoptosis, cell permeability, VEGF concentration, and expression of RhoA and GSK-3β significantly.

CONCLUSIONS

PNS attenuates the suppression on COX/PG pathway from DA, alleviates DA-induced GES-1 apoptosis and barrier dysfunction through PI3K/Akt/VEGF-GSK-3β-RhoA network pathway.

Gastroenterological Perspectives on Acute Cardiac Care — the Management of Patients with Implanted Coronary Stents Following an Acute Coronary Syndrome

Cardiovascular and digestive diseases frequently share the same risk factors such as obesity, unhealthy diet, or several social behaviors, and the increasing prevalence of patients with overlapped cardiovascular and digestive symptoms is a challenging problem in the daily practice. Patients with gastro-esophageal reflux disease can exhibit various forms of chest pain that can be very similar to angina. Furthermore, antithrombotic therapies used for preventive or curative purposes in patients with cardiovascular diseases are frequently associated with gastrointestinal side effects including bleeding. At the same time, in patients with coronary stents presenting to the emergency department with chest pain, angina triggered by stent thrombosis or restenosis should be differentiated from angina-like symptoms caused by a gastrointestinal disease. The aim of this review was to present the complex inter-relation between gastroesophageal diseases and angina in patients on dual antiplatelet therapy following an acute coronary syndrome, with a particular emphasis on the role of anemia resulting from occult or manifest gastrointestinal bleeding, as a precipitating factor for triggering or aggravating angina.