Management of Anticoagulation and Antithrombotics

Management of Anticoagulation and Antithrombotics

Arjun R. Sondhi, MD

An increasing number of patients require antithrombotics (antiplatelets and/or anticoagulants), which are also increasing in number and complexity, requiring endoscopists to understand the indications, metabolism, bleeding risk, and thrombosis risk surrounding the use and interruption of these medications in low- and high-bleeding-risk procedures. This provides a summary of multiple guidelines, recognizing many of these are based on observational studies or the expert opinion.1,2,3,4 With the growing interest in improving the knowledge base and accessibility to antithrombotic management resources, consider use of a free, validated online tool ( to assist in real-time management of antithrombotics.5,6 This decision support is based on the 2016 American Society of Gastrointestinal Endoscopy (ASGE).


While antithrombotics increase the risk of gastrointestinal (GI) bleeding, there is a large body of evidence supporting their use in a variety of conditions. There are competing interests—maintaining vascular patency with use of these medications but avoiding procedure-related GI bleeding by interrupting the medication. These competing interests have been stratified as low risk and high risk.1,4 An ultra-high-risk category has also been described.3 The main risk factor for periprocedural bleeding is the type of procedure.2 The bleeding risk of endoscopy without biopsy or intervention is very low, even in the setting of antithrombotics, but the risk significantly increases with interventions, especially with more invasive endoscopic approaches (e.g., large lesion endoscopic mucosal resection [EMR], per-oral endoscopic myotomy [POEM], and endoscopic submucosal dissection [ESD]). Table 4.1 stratifies procedural bleeding risk.

TABLE 4.1 Bleeding Risk Stratification of Procedures3,4

Low Risk

High Risk

Ultra High Risk

Upper or lower endoscopy with or without cold forceps biopsy


Endoscopic submucosal dissection (ESD)

Endoscopic ultrasound (EUS) without fine needle aspiration (FNA)

ERCP with sphincterotomy

Endoscopic mucosal resection (EMR) of polyps >2 cm

Endoscopic retrograde cholangiopancreatography (ERCP) with or without pancreatobiliary stenting or papillary dilation but without sphincterotomy

Pneumatic or bougie dilation

Per-oral endoscopic myotomy (POEM)

Push or diagnostic balloon-assisted enteroscopy (BAE)

Therapeutic BAE

Video capsule endoscopy

Variceal sclerotherapy or band ligation

Esophageal, enteral, or colonic stenting

Percutaneous endoscopic gastrostomy or jejunostomy

Argon plasma coagulation

EUS with FNA

Barrett’s ablation

Endoscopic hemostasis

Tumor ablation

Cyst gastrostomy



From Chan FKL, Goh KL, Reddy N, et al. Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines. Gut. 2018;67(3):405-417. doi:10.1136/gutjnl-2017-315131. Epub January 13, 2018. Review. PMID: 29331946 and Acosta RD, Abraham NS, Chandrasekhara V, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3-16. doi:10.1016/j.gie.2015.09.035. Epub November 24, 2015. PMID: 26621548.


Conditions carrying risk of thrombosis or requiring antithrombotics include atrial fibrillation (AF), cardiac valvular replacements, deep vein thrombosis and venous thromboembolism, cerebral artery thrombosis, percutaneous coronary intervention (PCI) or other vascular stenting, acute coronary syndromes, cerebrovascular accident (CVA), transient ischemic attack (TIA), and a genetic or acquired (e.g., malignancy) hypercoaguable state.2 Complicating this, the objective measurement of severity of bleeding is difficult.2 For example, a 2002 ASGE guideline designated a
procedure as low risk of bleeding if the rate was ≤1.5%,7 but this definition is not standardized and has not appeared in later iterations of the ASGE’s antithrombotic guidelines.

Of particular mention is AF, as this is one of the most common reasons for anticoagulation, and the prevalence of this condition increases with age. The CHA2DS2-VASc (C2V) score quantifies the risk of AF-related CVA. The C2V score is calculated as a sum of points associated with the below patient attributes:

  • Congestive heart failure = 1 point

  • Hypertension = 1 point

  • Age 75 years or greater = 2 points

  • Diabetes = 1 point

  • Stroke or TIA = 2 points

  • Vascular disease = 1 point

  • Age 65 to 74 years = 1 point

  • Sex category (female gender) = 1 point

The annual risk of AF-related CVA generally increases with an increasing C2V score.4 A C2V score of ≥2 portends a high risk of stroke and usually warrants systemic anticoagulation.


Procedure-Related Factors

Table 4.2 provides the risk of bleeding in the absence of antithrombotics.8

Patient-Related Factors

In addition to the binary factor of presence versus absence of use of anticoagulant, HAS-BLED is a validated multivariable score in AF patients that was developed to determine the 1-year risk of significant bleeding (intracranial bleeding, hospitalization, hemoglobin decrease >2 grams/deciliter (g/dL), or transfusion) while on anticoagulation9 and, compared to other bleeding scoring systems, is the best predictor of bleeding in AF patients.10 The HAS-BLED score is calculated as a sum of points associated with the below patient attributes, each of which is assigned an equal weight of 1 point9:

  • Hypertension: systolic blood pressure >160 millimeters (mm) of mercury

  • Abnormal renal function (dialysis, status post renal transplant, or serum creatinine >2.25 milligrams [mg]/dL) or abnormal hepatic function (cirrhosis, total bilirubin >2 times the upper limit of normal [ULN]; or aspartate aminotransferase, alanine aminotransferase, or alkaline phosphatase >3 times the ULN)

  • Stroke: prior history of CVA

    TABLE 4.2 Procedure-Related Hemorrhage Risk in Patients Not on Antithrombotics8


    Hemorrhage Risk (%)

    Colonic polypectomy


    Colon EMR of lesion >10 mm


    Esophageal EMR


    Duodenal EMR


    Endoscopic submucosal dissection


    ERCP with sphincterotomy


    ERCP with sphincteroplasty




    Esophageal dilation


    Esophageal, duodenal, enteral stent


    Colonic stent


    Percutaneous endoscopic gastrostomy


    EUS with FNA


    EUS with brushing of pancreas cyst


    EMR, endoscopic mucosal resection; ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; FNA, fine needle aspiration.

    Reprinted by permission from Springer: Veitch AM. Endoscopy in patients on antiplatelet agents and anticoagulants. Curr Treat Options Gastroenterol. 2017;15(2):256-267. Copyright © 2017 Springer Science+Business Media, LLC.

  • Bleeding: prior major bleeding or other predisposition to bleeding

  • Labile international normalized ratio (INR): unstable or high INR or INR in the therapeutic range <60% of the time

  • Elderly: age >65 years

  • Drug use: prior alcohol use (≥8 drinks per week), prior drug use, antiplatelet agents, or nonsteroidal anti-inflammatory drugs

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May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on Management of Anticoagulation and Antithrombotics

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