Nagata Naoyoshi, Sakurai Toshiyuki, Moriyasu Shiori, Shimbo Takuro, Okubo Hidetaka, Watanabe Kazuhiro, Yokoi Chizu, Yanase Mikio, Akiyama Junichi, Uemura Naomi
Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan.
Ohta Nishinouchi Hospital, Koriyama, Fukushima, Japan.
PLoS One. 2017 Sep 1;12(9):e0183423. doi: 10.1371/journal.pone.0183423. eCollection 2017.
Anticoagulant management of acute gastrointestinal bleeding (GIB) during the pre-endoscopic period has not been fully addressed in American, European, or Asian guidelines. This study sought to evaluate the risks of rebleeding and thromboembolism in anticoagulated patients with acute GIB.
Baseline, endoscopy, and outcome data were reviewed for 314 patients with acute GIB: 157 anticoagulant users and 157 age-, sex-, and important risk-matched non-users. Data were also compared between direct oral anticoagulants (DOACs) and warfarin users.
Between anticoagulant users and non-users, of whom 70% underwent early endoscopy, no endoscopy-related adverse events or significant differences were found in the rate of endoscopic therapy need, transfusion need, rebleeding, or thromboembolism. Rebleeding was associated with shock, comorbidities, low platelet count and albumin level, and low-dose aspirin use but not HAS-BLED score, any endoscopic results, heparin bridge, or international normalized ratio (INR) ≥ 2.5. Risks for thromboembolism were INR ≥ 2.5, difference in onset and pre-endoscopic INR, reversal agent use, and anticoagulant interruption but not CHA2DS2-VASc score, any endoscopic results, or heparin bridge. In patients without reversal agent use, heparin bridge, or anticoagulant interruption, there was only one rebleeding event and no thromboembolic events. Warfarin users had a significantly higher transfusion need than DOACs users.
Endoscopy appears to be safe for anticoagulant users with acute GIB compared with non-users. Patient background factors were associated with rebleeding, whereas anticoagulant management factors (e.g. INR correction, reversal agent use, and drug interruption) were associated with thromboembolism. Early intervention without reversal agent use, heparin bridge, or anticoagulant interruption may be warranted for acute GIB.
美国、欧洲或亚洲的指南中均未充分涉及急性胃肠道出血（GIB）内镜检查前期的抗凝管理。本研究旨在评估急性GIB抗凝患者再出血和血栓栓塞的风险。
回顾了314例急性GIB患者的基线、内镜检查和结局数据：157例抗凝药物使用者和157例年龄、性别及重要风险匹配的非使用者。还比较了直接口服抗凝剂（DOACs）使用者和华法林使用者的数据。
在抗凝药物使用者和非使用者中，70%的患者接受了早期内镜检查，在内镜治疗需求率、输血需求率、再出血率或血栓栓塞率方面，未发现与内镜检查相关的不良事件或显著差异。再出血与休克、合并症、低血小板计数和白蛋白水平以及低剂量阿司匹林的使用有关，但与HAS - BLED评分、任何内镜检查结果、肝素桥接或国际标准化比值（INR）≥2.5无关。血栓栓塞的风险因素为INR≥2.5、内镜检查开始时与内镜检查前INR的差异、使用逆转剂和抗凝剂中断，但与CHA2DS2 - VASc评分、任何内镜检查结果或肝素桥接无关。在未使用逆转剂、肝素桥接或抗凝剂中断的患者中，仅发生1例再出血事件，无血栓栓塞事件。华法林使用者的输血需求显著高于DOACs使用者。
与非使用者相比，内镜检查对于急性GIB抗凝患者似乎是安全的。患者背景因素与再出血有关，而抗凝管理因素（如INR校正、使用逆转剂和药物中断）与血栓栓塞有关。对于急性GIB，可能有必要在不使用逆转剂、肝素桥接或抗凝剂中断的情况下进行早期干预。
