Acute GI Bleeding After Percutaneous Coronary Intervention
Acute GI Bleeding After Percutaneous Coronary Intervention
Patients who suffer a GI bleed after PCI are a challenging group. They may have multiple comorbidities and are often medically unstable; treatment must balance the need to prevent ischemic post-procedure complications against the risk that GI hemorrhage in the anticoagulated patient represents. Close liaison between cardiologists and gastroenterologists is paramount, as a number of difficult risk–benefit decisions are required.
There are well-established guidelines for the management of nonvariceal upper GI bleeding, much of which are valid for post-PCI bleeding and will not be discussed here, such as resuscitation, disposition and endoscopic techniques. However, certain aspects of management need careful consideration in these patients, including use of blood transfusions, timing and safety of endoscopy, PPI use, interruption, reversal and reintroduction of anticoagulant and antiplatelet therapy and consideration of surgery.
A consensus statement for use of blood transfusion from 1988 still rings true today. It advocates that the decision to transfuse should not based be upon one sole marker, such as a low hemoglobin, but instead rely upon the patient's clinical situation and the need for oxygen delivery. The clinical practice of the authors is to transfuse to hemoglobin of 100 g/l following a significant GI bleed in the setting of PCI. We consider transfusion to be of greatest importance when bleeding has been accompanied by hemodynamic compromise, a significant fall in hemoglobin (e.g., >30 g/l) or by the finding of high-risk endoscopic stigmata for rebleeding.
The issues surrounding the use of PPI as a prophylactic measure have been discussed above. To the best of our knowledge, there are no data regarding the effect of a PPI infusion on clopidogrel efficacy in the setting of a GI bleed post PCI. We recommend that PPI is administered in accordance with current guidelines. This will involve a bolus followed by an infusion prior to endoscopy then continuing either as an infusion or as a regular oral or intravenous dose depending upon the endoscopic findings.
Gastroscopy is safe post PCI provided patients are hemodynamically stable, which should be the goal of resuscitation. Early and intensive resuscitation of patients who have had a GI bleed improves mortality. In a retrospective study of 5673 patients who underwent PCI at a single center, 70 patients suffered an upper GI hemorrhage within 30 days, 65 of whom underwent gastroscopy during that same admission. There were no significant complications in this cohort. An earlier case–control study of 200 patients who underwent gastroscopy a median of 9.1 days after MI had a significantly higher rate of serious complications than the control group (7.5 vs 1.5%). However, those with complications typically had hemodynamic instability and higher APACHE II scores, highlighting the need for adequate resuscitation pregastroscopy.
Accordingly, patients who have a GI bleed should undergo diagnostic and therapeutic gastroscopy within 24 h, ideally after adequate resuscitation and hemodynamic stabilization. Given its safety, the threshold for performing gastroscopy should be low. An early gastroscopy allows the clinician to potentially control the source of bleeding and arrest hemorrhage, as well as providing information that assists in the estimation of mortality and risk of further bleeding.
In those considered high risk for rebleeding or those suffering ongoing bleeding, a repeat endoscopy may be considered within days after the index bleed, which will allow further endoscopic attempts at arresting hemorrhage and a re-assessment of rebleeding risk. This may allow the appropriate reintroduction of an antiplatelet agent, thereby reducing ischemic risk.
The authors recommend standard therapeutic endoscopic techniques to control bleeding, as they are safe to use in patients post-PCI. Theoretically, intramural adrenaline may be absorbed systemically and potentially reach the myocardium, producing unwanted sympathetic stimulation. A small study of patients undergoing therapeutic endoscopy for bleeding ulcers demonstrated that adrenaline does reach the systemic circulation; however, there were no cardiac complications.
Perhaps the most difficult decision to be made in the management of a patient with a GI bleed after PCI is how to manage their antiplatelet and anticoagulant regimen. There are no data that look specifically at this issue, and thus the management of these patients will rely heavily on the experience of the managing cardiologist and gastroenterologist. Recommendations made here will not be applicable to all cases and aim to serve as a guide only.
The decision to modify an antiplatelet or anticoagulant regimen will be based upon the competing risks of ongoing hemorrhage versus that of further ischemic coronary events, in particular in-stent thrombosis. The approach will differ by patient characteristics, timing of the bleed (i.e., early vs late), the severity of the bleed and the perceived risk of rebleeding after endoscopic therapy. Furthermore, coronary factors such as the location of the stent, extent of disease and other findings at coronary angiography must be considered. Factors associated with being high risk for mortality and further bleeding, and for in-stent thrombosis are summarized in Table 4.
Management of a GI Bleed Post PCI
Patients who suffer a GI bleed after PCI are a challenging group. They may have multiple comorbidities and are often medically unstable; treatment must balance the need to prevent ischemic post-procedure complications against the risk that GI hemorrhage in the anticoagulated patient represents. Close liaison between cardiologists and gastroenterologists is paramount, as a number of difficult risk–benefit decisions are required.
There are well-established guidelines for the management of nonvariceal upper GI bleeding, much of which are valid for post-PCI bleeding and will not be discussed here, such as resuscitation, disposition and endoscopic techniques. However, certain aspects of management need careful consideration in these patients, including use of blood transfusions, timing and safety of endoscopy, PPI use, interruption, reversal and reintroduction of anticoagulant and antiplatelet therapy and consideration of surgery.
Blood Transfusion
A consensus statement for use of blood transfusion from 1988 still rings true today. It advocates that the decision to transfuse should not based be upon one sole marker, such as a low hemoglobin, but instead rely upon the patient's clinical situation and the need for oxygen delivery. The clinical practice of the authors is to transfuse to hemoglobin of 100 g/l following a significant GI bleed in the setting of PCI. We consider transfusion to be of greatest importance when bleeding has been accompanied by hemodynamic compromise, a significant fall in hemoglobin (e.g., >30 g/l) or by the finding of high-risk endoscopic stigmata for rebleeding.
Proton-pump Inhibitors
The issues surrounding the use of PPI as a prophylactic measure have been discussed above. To the best of our knowledge, there are no data regarding the effect of a PPI infusion on clopidogrel efficacy in the setting of a GI bleed post PCI. We recommend that PPI is administered in accordance with current guidelines. This will involve a bolus followed by an infusion prior to endoscopy then continuing either as an infusion or as a regular oral or intravenous dose depending upon the endoscopic findings.
Timing & Safety of Endoscopy After PCI
Gastroscopy is safe post PCI provided patients are hemodynamically stable, which should be the goal of resuscitation. Early and intensive resuscitation of patients who have had a GI bleed improves mortality. In a retrospective study of 5673 patients who underwent PCI at a single center, 70 patients suffered an upper GI hemorrhage within 30 days, 65 of whom underwent gastroscopy during that same admission. There were no significant complications in this cohort. An earlier case–control study of 200 patients who underwent gastroscopy a median of 9.1 days after MI had a significantly higher rate of serious complications than the control group (7.5 vs 1.5%). However, those with complications typically had hemodynamic instability and higher APACHE II scores, highlighting the need for adequate resuscitation pregastroscopy.
Accordingly, patients who have a GI bleed should undergo diagnostic and therapeutic gastroscopy within 24 h, ideally after adequate resuscitation and hemodynamic stabilization. Given its safety, the threshold for performing gastroscopy should be low. An early gastroscopy allows the clinician to potentially control the source of bleeding and arrest hemorrhage, as well as providing information that assists in the estimation of mortality and risk of further bleeding.
In those considered high risk for rebleeding or those suffering ongoing bleeding, a repeat endoscopy may be considered within days after the index bleed, which will allow further endoscopic attempts at arresting hemorrhage and a re-assessment of rebleeding risk. This may allow the appropriate reintroduction of an antiplatelet agent, thereby reducing ischemic risk.
The authors recommend standard therapeutic endoscopic techniques to control bleeding, as they are safe to use in patients post-PCI. Theoretically, intramural adrenaline may be absorbed systemically and potentially reach the myocardium, producing unwanted sympathetic stimulation. A small study of patients undergoing therapeutic endoscopy for bleeding ulcers demonstrated that adrenaline does reach the systemic circulation; however, there were no cardiac complications.
Interruption, Reversal & Recommencement of Antiplatelets & Anticoagulants
Perhaps the most difficult decision to be made in the management of a patient with a GI bleed after PCI is how to manage their antiplatelet and anticoagulant regimen. There are no data that look specifically at this issue, and thus the management of these patients will rely heavily on the experience of the managing cardiologist and gastroenterologist. Recommendations made here will not be applicable to all cases and aim to serve as a guide only.
The decision to modify an antiplatelet or anticoagulant regimen will be based upon the competing risks of ongoing hemorrhage versus that of further ischemic coronary events, in particular in-stent thrombosis. The approach will differ by patient characteristics, timing of the bleed (i.e., early vs late), the severity of the bleed and the perceived risk of rebleeding after endoscopic therapy. Furthermore, coronary factors such as the location of the stent, extent of disease and other findings at coronary angiography must be considered. Factors associated with being high risk for mortality and further bleeding, and for in-stent thrombosis are summarized in Table 4.
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