Zullo Angelo, Hassan Cesare, Radaelli Franco
Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome (Angelo Zullo, Cesare Hassan).
Gastroenterology and Digestive Endoscopy, Valduce Hospital, Como (Franco Radaelli), Italy.
Ann Gastroenterol. 2017;30(1):7-14. doi: 10.20524/aog.2016.0096. Epub 2016 Oct 7.
Periprocedural management of antithrombotics for gastrointestinal endoscopy is a common clinical issue, given the widespread use of these drugs for primary and secondary cardiovascular prevention. For diagnostic procedures, with or without biopsy, no adjustments in antithrombotics are usually needed. For operative procedures, balancing the risk of periprocedural hemorrhage with the continuation of antithrombotics against the chance of recurrent thromboembolic events with their discontinuation may be challenging. Oral anticoagulants need to be temporarily withheld, and consideration must be given to whether a periendoscopic "bridge" therapy, typically a low-molecular-weight heparin, should be used in order to minimize the risk of thromboembolic events. Although some emerging evidence has shown that patients receiving heparin bridging appear to be at increased risk of overall and major bleeding and at similar risk of thromboembolic events compared to controls, bridging therapy is still recommended for patients on vitamin K antagonists who are at high thrombotic risk. Conversely, bridging therapy is usually not needed for patients taking new oral agents, which are characterized by shorter half-lives, and a rapid offset and onset of action. Management of antiplatelet therapy requires special care in patients on secondary prevention, especially those with coronary stents. This review is intended to summarize the recommendations of updated International Guidelines designed to help the decision-making process in such an intricate field.
鉴于抗血栓药物在心血管疾病一级和二级预防中的广泛应用，胃肠道内镜检查围手术期抗血栓药物的管理是一个常见的临床问题。对于诊断性操作，无论是否进行活检，通常都无需调整抗血栓药物。对于手术操作，权衡围手术期出血风险与继续使用抗血栓药物以及停用抗血栓药物后复发性血栓栓塞事件的发生几率可能具有挑战性。口服抗凝剂需要暂时停用，并且必须考虑是否应采用内镜检查期间的“桥接”治疗，通常是低分子量肝素，以尽量降低血栓栓塞事件的风险。尽管一些新出现的证据表明，与对照组相比，接受肝素桥接治疗的患者发生总体出血和大出血的风险似乎增加，而血栓栓塞事件的风险相似，但对于处于高血栓形成风险的维生素K拮抗剂使用者，仍建议进行桥接治疗。相反，对于服用新型口服抗凝剂的患者，通常不需要桥接治疗，这些药物的特点是半衰期较短、起效和失效迅速。在二级预防患者中，尤其是那些植入冠状动脉支架的患者，抗血小板治疗的管理需要特别注意。本综述旨在总结最新国际指南的建议，以帮助在这一复杂领域进行决策。
