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Endoscopic procedures in patients under clopidogrel/dual antiplatelet therapy: to do or not to do?
Ahmed Abdel Samie1, Lorenz Theilmann
1Department of Gastroenterology, Pforzheim Hospital, Kanzlerstr 2-6, 75175 Pforzheim, Germany. abdelsamie@ngi.de
Insights
Current guidelines suggest stopping clopidogrel before high-risk endoscopy, but this study found minimal bleeding risk with uninterrupted dual antiplatelet therapy. Individual patient assessment is recommended over routine cessation.
Area of Science:
- Cardiology
- Gastroenterology
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) is crucial after coronary stent placement (bare metal: ≥1 month; drug-eluting: ≥1 year).
- Guidelines recommend discontinuing clopidogrel 7 days before high-risk endoscopy due to bleeding concerns.
- Premature cessation of DAPT increases the risk of adverse cardiovascular events.
Purpose of the Study:
- To evaluate the bleeding risk of gastrointestinal endoscopic procedures in patients maintained on uninterrupted clopidogrel/dual antiplatelet therapy.
- To assess the safety of continuing DAPT during endoscopic procedures.
Main Methods:
- A systematic literature search was conducted for clinical trials up to October 2012.
- Included studies focused on bleeding risk in patients undergoing endoscopy while on uninterrupted clopidogrel/DAPT.
- Analyzed data from six identified studies involving 1,245 endoscopic procedures.
Main Results:
- A total of 1,245 endoscopic procedures were performed with uninterrupted clopidogrel.
- A low bleeding complication rate of 1% (13 cases) was observed.
- No patients required angiographic or surgical intervention, and no long-term sequelae were reported.
Conclusions:
- Published data on this topic are limited and of variable quality.
- Current evidence does not support routine clopidogrel cessation before high-risk endoscopic procedures.
- Clinical decisions regarding DAPT and endoscopy should be individualized based on patient risk factors.
Background:
Dual antiplatelet therapy has to be used for at least one month after placement of bare metal coronary stents and for a minimum of one year after placement of drug eluting stents. Because of the higher risk of bleeding, guidelines recommend cessation of clopidogrel seven days prior to high-risk endoscopic procedures and to delay elective surgery/endoscopy until dual antiplatelet therapy is ended. Premature cessation of clopidogrel however, may lead to catastrophic cardiovascular sequelae.
Methods:
We searched the MEDLINE database, EMBASE, and the Cochrane Library for English-language literature up to October 2012 to identify clinical trials on the bleeding risk of gastrointestinal endoscopic procedures in patients on uninterrupted clopidogrel/dual antiplatelet therapy.
Results:
Six studies (high-risk endoscopic procedures: 5, low-risk endoscopic procedures: 1) on this issue were identified through the literature search. A total of 1,245 endoscopic procedures were performed under clopidogrel. Thirteen bleeding complications occurred (1%). None of the patients required angiographic or surgical intervention and there were no long-term sequelae.
Conclusion:
To date, data published on this issue are scarce and of poor quality. Nevertheless, there is no evidence to support the recommendations of the current guidelines to stop clopidogrel for at least one week prior to high-risk endoscopic procedures. In this setting, the clinical decision making should take place on an individual basis.
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