So, we're going to review the bleeding risk of endoscopic procedures, describe some patient risk factors for bleeding, review antithrombotic agents, and understand current national guidelines and how we can apply those to our clinical practice. So, to start, about 40% of adults in the United States take at least one antithrombotic for a cardiovascular condition. The rate of GI bleed in cardiac patient increases with age. One in five risk of developing GI bleed in patients who are over 75 years old on both an anticoagulant and an antiplatelet agent. The ED visits for GI bleeding have increased 17% in the last 10 years, and that's for all ages. So, GI providers really must weigh the risk and the benefit of discontinuing antithrombotics prior to endoscopy. And this takes multidisciplinary management, guideline-based care, and informed consent. All things that we're going to talk about in the next 20 minutes. And I just wanted to highlight some of the guidelines, and I'll be referencing these throughout the talk. The most recent one is the American College of Gastroenterology and the Canadian Association of Gastroenterology Clinical Practice Guidelines. The European Society of Gastrointestinal Endoscopy and British Society of Gastroenterology also have a recently updated guideline. This is from 2021. And then ASG guideline as well. And so, if we really take a step back and think about how do we decide what to do with these antithrombotics, we have to start with what's the bleeding risk of a procedure. And so, to quantify a bleeding risk, we have to look at what's the risk from the procedure, the risk from the patient's thromboembolic standpoint, and then antithrombotic medications. Important things for us to consider, starting with the nature of the procedure. Is this an elective procedure, or is it urgent or emergent? What is the procedure bleeding risk? Is it high or low? What's the nature of the cardio-neurovascular risk? Is it a drug-eluting stent, carotid stenosis, atrial fibrillation? What's the nature of the antithrombotic? Is it a measurable effect? What's the duration of action? Is it reversible? What's the risk of stopping it versus if bleeding controls can it be controlled? And then communication with prescribing provider. And so, what is your request for duration of hold? What are your plans for resumption? And do you need bridging agents? And if we look at endoscopy procedure risk, on the left is the high bleeding risk procedures. On the right is the low bleeding risk procedures. I won't go through all of them, but I do want to point out that colonoscopy with or without biopsies is considered low risk. Colonoscopy with a polypectomy of one centimeter or larger is considered high risk. And one of the things that has come up in the most recent guidelines is that you probably can perform polypectomy of small polyps, less than one centimeter, while people are still on their antithrombotics. So let's look at the patient status. Stroke risk assessment tools for patients with atrial fibrillation can be really helpful. This is a very common indicator or common reason for why people are on antithrombotics to begin with. And so the CHADS-2 score looks at CHF, hypertension, age, diabetes, and history of stroke or TIA. A score that's two or higher is high risk for a cardiovascular event, and oral anticoagulation is recommended in those patients. And then the CHADS-2 vascular is another assessment that can be used. And so when we look at the cardio-neurovascular risk, we can stratify patients into low, moderate, and high. So starting from the bottom, patients who have bilefic aortic valves without AFib or any other risk factors are low risk. Patients who have had a venous thromboembolism, but it's 12 months or more ago, they don't have any other risk factors, they're low risk. And contrast that to the high risk, those on red, patients who have a mitral valve prosthesis, who have had a CVA or a TIA within three months, those who have had a clot within three months or severe thrombofilia, those who have rheumatic valvular heart disease, those are the patients where they're high risk. And when you look at that high risk category, if a patient's coming in for an elective procedure, so for example, routine colorectal cancer screening, or a Barrett's esophagus screening or surveillance, even a esophageal variceal screening, really want to consider deferring that procedure until the patient is no longer high risk. Particularly something like a CVA and TIA, you know, if they could do the procedure more safely after that three month period, then for a screening or surveillance procedure, we would want to push it out till they are able to reduce their risk category. There's additional risk factors from a patient standpoint for bleeding. And so we know patients in older age, those who use tobacco, obstructive sleep apnea, male gender, renal insufficiency, a history of prior GI bleed, and those who use NSAIDs are at higher risk for GI bleeding. We really have to approach this in a multidisciplinary aspect. And so it's not just the GI APPs and the endoscopists in this, but it also includes hematology and neurology, cardiology, vascular surgery, and oncology. And to bring it back to us, APPs really are essential to that patient procedure preparation. And so it's the guideline based protocols. And it's that communication with the prescribing provider, the ancillary services, which ultimately is leading towards that patient safety. And so to go through some of the antithrombotic agents, we can split them into anticoagulants. So your warfarin, your heparin, factor Xa inhibitors, direct thrombin inhibitors, and your antiplatelets. And I just want to point out that the factor Xa inhibitors and your direct thrombin inhibitors are the DOACs, the direct oral anticoagulants. So we'll go through those. For warfarin, warfarin inhibits your vitamin K dependent clotting factors. That's your factors 2, 7, 9, and 10. There's about a 1% risk of thromboembolic event after temporary discontinuation. And obviously we're generalizing right now. It really does have to be an individualized risk stratification. Avoiding vitamin K before elective procedures is recommended. And the reason for that is because it increases their immediate risk of thromboembolic events, and it delays the ability to re-anticoagulate them after the procedures. And so the recommendation is to, when needed, hold the warfarin for the appropriate duration of time and let the body naturally come back to its normal state. The most recent guideline, the ACG and CAG guideline, recommends that you continue warfarin for your low-risk elective procedures, and you hold it for five days for advanced endoscopic procedures with a high risk of bleeding. Should we bridge patients who are on warfarin? This is another change that had come out of that most recent guideline. Bridging is actually not recommended in the majority of patients. There were two randomized controlled trials, which this is based off of. They're called the BRIDGE trial and the PERIOP2 trial. And what both of those showed was that bridging with low-molecular weight heparin actually increased the risk of post-procedural bleeding and did not reduce the risk of thromboembolism. But with that said, you should consider bridging in those super high-risk patients. And so that would be the patients with mechanical valves, those with atrial fibrillation that have a CHADS2 score over five, patients with a history of thromboembolism during temporary interruption of blood thinners, those who have had prior cardiovascular surgery, such as a cardiac valve replacement or a carotid endarterectomy. Your DOACs, again, those factor 10A inhibitors and those direct thrombin inhibitors, work differently than warfarin. They directly affect 10A or 2A. They are fast onset and fast offset, so you only have to hold them for one to three days before elective procedures. And that is really dependent on their renal function. Same recommendation that I have for these, you know, check with the prescribing provider. You're really looking at stratifying the patient's individual risk, both in sense of their own history as well as the procedure they're scheduled for, and have a plan for resumption in place. So when do we stop them? I included this here really just to give everybody a little bit of a visual of the differences in the timing for onset to action. And so depending on a patient's creatinine clearance, you can see that the recommendation to hold them is in general between one and three days, a little bit longer for Xarelto. I really like this graph that looks at the pharmacodynamics of warfarin and the DOACs because I think it's a really good visual that we can carry with us. So for the DOACs, the blue line, it shows that just after starting it, you are up to maximal effect very, very quickly within 10 hours. When you stop it, completely negate that effect within about 60 to 70 hours. With the warfarin though, it's a much more gradual onset, much more gradual offset. Your thiamine pyridines inhibit platelet aggregation. So these are things like your clopidogrel. The clopidogrel and the presagrel are both irreversible, and so they are inactive prodrugs. The half-lives are very different, but they inhibit platelets for about the same period of time. The berlinta only inhibits platelets for a couple of days, and so our recommendations for whether we're holding these, how long we hold them for, really are dependent on the mechanism of action and the duration of action. And so what do we do with these? We always recommend to continue aspirin. Aspirin is not considered an antithrombotic. It is not a medication that we're going to stop for this. You could consider holding your antiplatelets if the procedure is deemed to be high risk. And again, the duration depends upon which agent they're on, and you do want to resume this as soon as possible post-procedure. So some general guidelines, and this is going to differ depending on the endoscopist, and again depending on the patient. However, for diagnostic EGDs, typically you do not need to stop any blood thinners. For an EGD with dilation, I always suggest check with the provider who's performing the procedure. It may depend on the type of dilation or how significant the structure is. EGDs generally will hold for PEG-2 placements. Push enteroscopy, also say check with the provider depending on what intervention is planned. ERCP with sphincterotomy, definitely have to hold. ERCP just for stent change, in some circumstances you may be able to continue. For colonoscopy, if the patient has a history of stroke or they were started on a blood thinner within the last year, definitely check. Otherwise, request permission to hold. So the general idea for this is that if you're going to put a patient through the procedure, they're going to do the bowel prep, and then you go in there and you see there's a polyp, it's tough to take it out if it is a larger polyp and they're on the blood thinners. And so then you're looking at doing two procedures. Now, there is some growing acceptance to the recent guidelines, which suggest that polyps less than one centimeter in size can be safely removed without interrupting antithrombotic medications. And so I would strongly recommend that this be a discussion that you have with your collaborating physicians and have a plan in place for what they're doing and what they're most comfortable with. And when do we restart our anticoagulation? Well, this is really dependent on the intervention and the bleeding risk. There is not a specific guideline that exists and that talks about the reinitiation of them. So just to kind of provide some general guidance, if no intervention was done, resume on the same day. If there was minimal intervention or low risk of bleeding, you can resume on the same day or the next day. If there's a moderate risk of bleeding, resume in one to two days and high risk resume within three days. There are no studies that compare same day resumption of warfarin or the DOACs versus resumption one to seven days after elective procedures. And so you're looking at the risk of bleeding post-procedure versus the risk of thrombosis. And again, it's patient risk, procedure risk, and did you achieve endoscopic chemostasis? So what do we do if a patient's too high risk to stop the antithrombotic therapy? And we don't think that's going to change soon. So just some questions that we can ask and kind of a little bit of a schematic for you. First thing is what's the indication for the procedure? Is this a surveillance procedure? Because in that case, are there other non-procedural surveillance mechanisms that would be acceptable? What harm comes from not doing or delaying the procedure? Is the risk of endoscopic intervention predictably catastrophic and inevitable? Weighing the risks and benefits, share decision making with the patient, ensure that there's appropriate backup and support around the time of the procedure and post-procedure should a complication happen, and that might include interventional radiology and surgery. Patient may need 23-hour observation post-procedure, definitely need to communicate with other providers, and then close outpatient follow-up. So that patient and procedure risk assessment is critical. For patients who are on an antithrombotic, colonoscopy with polypectomy, again those small polyps, may be able to be performed. You might be able to do an endoscopic ultrasound with fine needle aspiration of solid lesions. You might be able to do endoscopic ablation, like radiofrequency ablation or cryoablation, eneral stenting, or an ERCP for biliary stent change. On the other side though, doing dilation or endoscopic mucosal resection, liver biopsy, aspirating a pancreatic cyst or pancreatic pseudocyst drainage, or having to perform a sphincterotomy are going to be very challenging to do on antithrombotics because the nature of those procedures is so high for bleeding. And so most of that's about elective. What do we do if a patient comes in with a GI bleed and they need an urgent procedure? The first thing is identify life-threatening hemorrhage, and that is really defined by hypovolemic shock, severe hypotension that requires pressure support, a drop in the hemoglobin, more than five grams per deciliter, or a transfusion requirement of five or more units of blood. For severe life-threatening bleeding, you can consider the use of reversal agents. Standard resuscitation protocols should be followed. Multidisciplinary consultation, urgent endoscopy, evaluation, and then angiographic embolization when needed. And so in a life-threatening GI bleed, consider holding your Warfarin. If the INR is over 2, they have severe bleeding, you can consider using four-factor prothrombin complex concentrate, that PCC. So PCC's factors 2, 7, 9, and 10. For your DOACs, consider reversal if it was taken within the last 24 hours. And there are reversal agents available. And then for your antiplatelet agents, which again, excluding aspirin from this discussion, but for the other antiplatelet agents, consider holding them and platelet transfusion if there's severe bleeding and thrombocytopenia. So to go back to the Warfarin for a second, previously, old guidelines had recommended that we use fresh frozen plasma. People have in the past used vitamin K. Again, vitamin K does not achieve rapid hemostasis. There's limited benefit in the acute setting. There's limited benefit on the elective setting as well, if it's to reverse Warfarin itself. And the reason for that is because it makes it difficult to re-anticoagulate the patients. Fresh frozen plasma is a large volume and it increases the risk of transfusion-associated pulmonary edema. And so that's not recommended any longer either. But that four-factor prothrombin complex would be your preferred agent. And so in conclusion, when we're looking at these patients, we really want to do a risk stratification that's looking at the patient risk, bleeding versus thromboembolism, looking at the procedure risk, high versus low bleeding risk, defer elective procedures in high-risk patients, continue aspirin if they're on it for secondary cardiovascular prophylaxis. Aspirin is no longer recommended for primary cardiovascular prophylaxis, so we shouldn't be seeing that very much anymore. Reversal agents for life-threatening GI bleeds, platelet transfusion for life-threatening GI bleed and thrombocytopenia. Restart your antithrombotic medications as soon as you can post-procedure, so day zero to three, and that patient-centered multidisciplinary approach is what's going to lead to the best outcomes. And then a couple of questions for you guys. All the following should be considered when stratifying risk of interrupting antithrombotic agents prior to an endoscopic procedure except. That's right, so patient fall risk, although, you know, we do care about that in the setting of antithrombotics, will not affect our decision-making in the endoscopic procedure. And the next one, which of the following agents should never be stopped for any endoscopic procedure? It's rare that we can use the word never in these. Yep, so exactly, aspirin. Warfarin and rivaroxaban will need to be stopped for any high-risk procedures. And the last one, the risk of bleeding is highest during which of the following endoscopic procedures? Yeah, so this was a good question, and I thought, so the answer is colonoscopy with polypectomy. That is the highest risk. APC is actually not considered a high-risk intervention, and ERCP, if you're just changing a stent, is not high risk. So I think I'm handing it back off to John now to start our question and answer.

bleeding risk

endoscopic procedures

antithrombotic agents

GI bleed

guidelines