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Stopping antithrombotic therapy after acute upper gastrointestinal bleeding is associated with reduced survival
Keith Siau1,2, Jack L Hannah3, James Hodson4
1Joint Advisory Group in Gastrointestinal Endoscopy, Royal College of Physicians, London.
Insights
Stopping antithrombotic therapy after acute upper gastrointestinal bleeding (AUGIB) increases mortality and thrombotic events. Restarting these crucial medications improves patient survival and reduces adverse outcomes.
Area of Science:
- Cardiology
- Gastroenterology
- Internal Medicine
Background:
- Antithrombotic drugs are frequently discontinued after acute upper gastrointestinal bleeding (AUGIB).
- The impact of this discontinuation practice on patient outcomes remains unclear.
- Restarting antithrombotic therapy post-AUGIB is a critical clinical question.
Purpose of the Study:
- To evaluate the clinical outcomes associated with restarting antithrombotic therapy before hospital discharge in patients with AUGIB.
- To determine if antithrombotic continuation impacts mortality, thrombotic events, or rebleeding rates.
Main Methods:
- Retrospective cohort study conducted at a university hospital.
- Analysis of 118 patients who underwent gastroscopy for AUGIB while on antithrombotic therapy.
- Comparison of outcomes between patients who continued and those who discontinued antithrombotic therapy at discharge, with a median follow-up of 259 days.
Main Results:
- Antithrombotic treatment was stopped in 49.2% of patients.
- Discontinuation was associated with significantly increased 1-year mortality (HR 3.32), thrombotic events (HR 5.77), and overall adverse events (HR 2.98).
- No significant difference in postdischarge bleeding rates was observed between groups.
Conclusions:
- Discontinuation of antithrombotic therapy following AUGIB is linked to poorer survival and higher thrombotic event rates.
- Continuation of antithrombotic therapy, particularly non-aspirin regimens, demonstrates a thromboprotective benefit.
- Clinical practice should consider the risks and benefits of antithrombotic therapy resumption after AUGIB.
Introduction:
Antithrombotic drugs are often stopped following acute upper gastrointestinal bleeding (AUGIB) and frequently not restarted. The practice of antithrombotic discontinuation on discharge and its impact on outcomes are unclear.
Objective:
To assess whether restarting antithrombotic therapy, prior to hospital discharge for AUGIB, affected clinical outcomes.
Design:
Retrospective cohort study.
Setting:
University hospital between May 2013 and November 2014, with median follow-up of 259 days.
Patients:
Patients who underwent gastroscopy for AUGIB while on antithrombotic therapy.
Interventions:
Continuation or cessation of antithrombotic(s) at discharge.
Main Outcomes Measures:
Cause-specific mortality, thrombotic events, rebleeding and serious adverse events (any of the above).
Results:
Of 118 patients analysed, antithrombotic treatment was stopped in 58 (49.2%). Older age, aspirin monotherapy and peptic ulcer disease were significant predictors of antithrombotic discontinuation, whereas dual antiplatelet use predicted antithrombotic maintenance. The 1-year postdischarge mortality rate was 11.3%, with deaths mainly due to thrombotic causes. Stopping antithrombotic therapy at the time of discharge was associated with increased mortality (HR 3.32; 95% CI 1.07 to 10.31, P=0.027), thrombotic events (HR 5.77; 95% CI 1.26 to 26.35, P=0.010) and overall adverse events (HR 2.98; 95% CI 1.32 to 6.74, P=0.006), with effects persisting after multivariable adjustment for age and peptic ulcer disease. On subgroup analysis, the thromboprotective benefit remained significant with continuation of non-aspirin regimens (P=0.016). There were no significant differences in postdischarge bleeding rates between groups (HR 3.43, 0.36 to 33.04, P=0.255).
Conclusion:
In this hospital-based study, discontinuation of antithrombotic therapy is associated with increased thrombotic events and reduced survival.
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