The utility of upper endoscopy in patients with concomitant upper gastrointestinal bleeding and acute myocardial
Sauyu Lin1, Richard Konstance, James Jollis
1Division of Gastroenterology, Department of Medicine, Durham, North Carolina, USA. lins@tmfhs.org
Insights
Upper gastrointestinal bleeding (UGIB) preceding acute myocardial infarction (AMI) indicates more severe lesions. Urgent endoscopy is most beneficial for patients with UGIB as the initial event, presenting with hematemesis and hemodynamic instability.
Area of Science:
- Gastroenterology
- Cardiology
- Internal Medicine
Background:
- Concomitant upper gastrointestinal bleeding (UGIB) and acute myocardial infarction (AMI) present diagnostic and therapeutic challenges.
- Determining the inciting event (UGIB or AMI) is crucial for patient management.
- Patients may experience UGIB secondary to AMI and anticoagulation, or AMI secondary to severe UGIB.
Purpose of the Study:
- To evaluate predictors for endoscopic therapy in patients with concomitant UGIB and AMI.
- To differentiate lesion severity based on the inciting event.
- To assess the impact of urgent endoscopy on clinical decision-making.
Main Methods:
- Retrospective single-center medical record review of 183 patients admitted between January 1, 1996, and December 31, 2002.
- Patients underwent esophagogastroduodenoscopy (EGD) within 7 days of AMI and UGIB.
- Comparison of high-risk upper gastrointestinal (UGI) lesions requiring endoscopic treatment between AMI and UGIB groups.
Main Results:
- A higher proportion of patients in the UGIB group (41%) had high-risk UGI lesions requiring endoscopic treatment compared to the AMI group (17%; P < 0.004).
- UGIB as the inciting event, hematemesis, and hemodynamic instability were significantly associated with requiring endoscopic therapy.
- Endoscopic findings altered cardiac catheterization decisions in 43% of the AMI group patients.
Conclusions:
- Urgent endoscopy is most beneficial in patients with UGIB as the initial event, presenting with hematemesis and hemodynamic instability.
- In patients without these features, urgent endoscopy can be delayed unless critical for cardiac management decisions.
- Severe complications from urgent endoscopy were rare (1%).
Abstract:
Patients who present with upper gastrointestinal bleeding (UGIB) in the setting of acute myocardial infarction (AMI) may have suffered an UGIB that subsequently led to an AMI or endured an AMI and subsequently suffered a UGIB as a consequence of anticoagulation. We hypothesized that patients in the former group bled from more severe upper tract lesions. The aim of this study was to evaluate predictors for endoscopic therapy in patients who suffer a concomitant UGIB and AMI. Retrospective, single center medical record abstraction of hospital admissions from January 1, 1996-December 31, 2002. During the study period, 183 patients underwent an esophagogastroduodenoscopy (EGD) within 7 days of suffering an AMI and UGIB (AMI group N=105, UGIB group N=78). A higher proportion of patients in the UGIB group (41%) was found to have high-risk UGI lesions requiring endoscopic treatment compared to patients in the AMI group (17%; P < 0.004). UGIB as the inciting event and patients suffering from hematemesis and hemodynamic instability were significantly associated with requiring endoscopic therapy. Although predominantly diagnostic, endoscopic findings in the AMI group did alter the decision to perform cardiac catheterization in 43% of patients. Severe complications occurred in 1% (95% confidence interval, 0%-4%) of patients. We conclude that in patients suffering from concomitant UGIB and AMI, urgent endoscopy was most beneficial in patients with UGIB as the initial event and those presenting with hematemesis and hemodynamic instability. In patients without these clinical features, urgent endoscopy may be delayed, unless cardiac management decisions are dependent on endoscopic findings.
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