Comment from the EditorNovel Oral Anticoagulants and Gastrointestinal Bleeding: a Case for Cardiogastroenterology
Section snippets
Post–Acute Coronary Syndrome Antithrombotic Prescription: A Clinical Dilemma at the Intersection of 2 Medical Subspecialties—Cardiology and Gastroenterology
Although the ischemic risk tends to diminish with time, longer treatment duration exacerbates the risk of bleeding.12 Evidence on the efficacy of secondary cardiac protection and safety with triple antithrombotic therapy (combination ASA, clopidogrel, and warfarin) is limited; but data from a national registry13 and population-based cohorts14, 15, 16, 17 suggest a high risk of bleeding, including GI, proportional to the number of antithrombotic drugs used, with an NNH of 12.5.13, 17 Currently,
Case Example: Mr H
Mr H is a 66-year-old man with a history of coronary artery disease and ACS with percutaneous coronary implantation of 3 drug-eluting stents (2010) and re-implantation of 2 stents after primary stent occlusion. He has been on ASA and clopidogrel since 2010 and has experienced persistent, occult GI bleeding (iron-deficiency anemia despite iron supplementation) and occasional overt GI bleeding. To date, he has had 5 balloon-assisted enteroscopy examinations, guided by results of video capsule
Summary of Gastrointestinal Bleeding Risk Associated With New Oral Anticoagulant Agents After Acute Coronary Syndrome
The risk of GI bleeding associated with use of new oral anticoagulants in the post-ACS setting is still poorly understood. The raw data from pivotal trials (Table 1) suggest that the number needed to result in one additional clinically significant GI bleed (NNH) ranges from as few as 20 patients, with apixaban at the lowest dose, to 91 patients with dabigatran. The risk of dabigatran-related GI bleeding is increased further in elderly people and in those on doses of 150 mg twice a day. The
Cardiogastroenterology: A New Intersection of Ideas and Medicine
To solve the clinical dilemma of patients such as Mr H, for whom the best answer may be unclear, we need new approaches that help to arrive at the best answer for individual patients. In the book The Medici Effect,20 Frans Johansson refers to the space between fields as the intersection. Intersectional innovation changes the way we think, by taking leaps in new directions not previously considered, and paves the way for a new approach to a vexing problem, supported by sound science and a new,
References (20)
- et al.
Heart disease and stroke statistics–2011 update: a report from the American Heart Association
Circulation
(2011) - et al.
ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents
Circulation
(2010) - et al.
ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non–ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol
(2012) - et al.
Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE)
BMJ
(2006) - et al.
Ticagrelor versus clopidogrel in patients with acute coronary syndromes
N Engl J Med
(2009) - et al.
Prasugrel versus clopidogrel in patients with acute coronary syndromes
N Engl J Med
(2007) - et al.
Use of new-generation oral anticoagulant agents in patients receiving antiplatelet therapy after an acute coronary syndrome: systematic review and meta-analysis of randomized controlled trials
Arch Intern Med
(2012) Collaborative overview of randomised trials of antiplatelet therapy–I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patientsAntiplatelet Trialists' Collaboration
BMJ
(1994)- et al.
Long-term oral anticoagulant therapy in patients with unstable angina or suspected non-Q-wave myocardial infarction: organization to assess strategies for ischemic syndromes (OASIS) pilot study results
Circulation
(1998) - et al.
Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic qjattack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial
Lancet
(2004)
Cited by (10)
Management of Antiplatelet Agents and Anticoagulants in Patients with Gastrointestinal Bleeding
2015, Gastrointestinal Endoscopy Clinics of North AmericaCitation Excerpt :Rebleeding rates are similar with and without anticoagulant reversal. NOACs include direct thrombin inhibitor, dabigatran etexilate (Pradaxa), and direct oral factor Xa inhibitors, rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Lixiana).29 These agents, developed to overcome the limitations of warfarin with their rapid and predictable pharmacodynamic response and fixed once or twice daily dosing regimens, have quickly become popular with physicians and patients alike.
Novel oral anticoagulants in gastroenterology practice
2013, Gastrointestinal EndoscopyCitation Excerpt :In a subgroup of post-acute coronary syndrome patients (ie, those with both coronary stent placement and concurrent AF and substantial risk of stroke) “triple” antithrombotic therapy is recommended. Patients with AF who develop acute coronary syndrome are difficult to manage because the use of an anticoagulant in addition to dual antiplatelet therapy confers an increased risk of bleeding, including major GI bleeding.74 To reduce this risk, clinicians should attempt to limit the duration of exposure to triple therapy.
How much does the specialist know about cardiogastroenterology?
2018, Revista de Gastroenterologia de MexicoPrevention of gastrointestinal bleeding in patients receiving oral anticoagulants: Focus on proton pump inhibitors
2019, Cardiovascular Therapy and Prevention (Russian Federation)To bleed or not to bleed: That is the question. The side effects of Apixaban
2018, Current Drug Targets
Conflicts of interest The author discloses no conflicts.
Funding Supported in part by the Houston Veterans Affairs Health Services Research & Development Center of Excellence (HFP90-020).
The views expressed are those of the author and not necessarily those of the Department of Veterans Affairs and/or Baylor College of Medicine.