Periprocedural and long-term gastrointestinal bleeding in patients undergoing percutaneous coronary intervention
- David R Holmes, Jr, MD
David R Holmes, Jr, MD
- Professor of Medicine
- Mayo Clinic College of Medicine
- Paul Sorajja, MD
Paul Sorajja, MD
- Director, Center for Valve and Structural Heart Disease
- Minneapolis Heart Institute
- Section Editors
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- John R Saltzman, MD, FACP, FACG, FASGE, AGAF
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
- Section Editor — Therapeutic and Diagnostic Endoscopy
- Professor of Medicine
- Harvard Medical School
Periprocedural and long-term antithrombotic (anticoagulant or antiplatelet) therapy is an integral part of percutaneous coronary intervention (with either coronary artery stenting or percutaneous transluminal coronary angioplasty). Antithrombotic therapy has been shown to prevent periprocedural and long-term cardiovascular events such as stent thrombosis and recurrent myocardial infarction. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients" and "Antithrombotic therapy for elective percutaneous coronary intervention: General use".)
Current antithrombotic regimens have the potential to result in either new gastrointestinal (GI) bleeding or to exacerbate chronic episodic GI bleeding. For those with GI bleeding, there is significant attributable morbidity and mortality. However, in many such patients, alternatives to percutaneous coronary intervention (PCI) may be limited. Given the fact that over one million PCI procedures are performed annually, and that antithrombotic therapy has become more aggressive, there is a need to understand the unique challenges in the prevention and management of GI bleeding in this patient population. Furthermore, with the increasing adoption of a radial as compared to femoral artery approach, GI bleeding may be the most common type of bleeding associated with PCI.
This topic focuses on periprocedural and long-term GI bleeding in patients undergoing PCI. Issues of GI bleeding in patients on chronic anticoagulant or nonsteroidal antiinflammatory therapy are discussed elsewhere. (See "Triple antithrombotic therapy in patients with cardiovascular disease" and "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity".)
Periprocedural bleeding not related to the GI tract in patients undergoing PCI is discussed separately. (See "Periprocedural bleeding in patients undergoing percutaneous coronary intervention".)
While strict definitions of peri-procedural bleeding in percutaneous coronary intervention (PCI) patients have been adopted, there is less consensus on what constitutes clinically significant gastrointestinal (GI) bleeding. (See "Periprocedural bleeding in patients undergoing percutaneous coronary intervention".)
- Abbas AE, Brodie B, Dixon S, et al. Incidence and prognostic impact of gastrointestinal bleeding after percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol 2005; 96:173.
- Chin MW, Yong G, Bulsara MK, et al. Predictive and protective factors associated with upper gastrointestinal bleeding after percutaneous coronary intervention: a case-control study. Am J Gastroenterol 2007; 102:2411.
- Nikolsky E, Stone GW, Kirtane AJ, et al. Gastrointestinal bleeding in patients with acute coronary syndromes: incidence, predictors, and clinical implications: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. J Am Coll Cardiol 2009; 54:1293.
- Yasuda H, Yamada M, Sawada S, et al. Upper gastrointestinal bleeding in patients receiving dual antiplatelet therapy after coronary stenting. Intern Med 2009; 48:1725.
- Mehta SK, Frutkin AD, Lindsey JB, et al. Bleeding in patients undergoing percutaneous coronary intervention: the development of a clinical risk algorithm from the National Cardiovascular Data Registry. Circ Cardiovasc Interv 2009; 2:222.
- Gaglia MA Jr, Torguson R, Gonzalez MA, et al. Correlates and consequences of gastrointestinal bleeding complicating percutaneous coronary intervention. Am J Cardiol 2010; 106:1069.
- Koskinas KC, Räber L, Zanchin T, et al. Clinical impact of gastrointestinal bleeding in patients undergoing percutaneous coronary interventions. Circ Cardiovasc Interv 2015; 8.
- Kelly JP, Kaufman DW, Jurgelon JM, et al. Risk of aspirin-associated major upper-gastrointestinal bleeding with enteric-coated or buffered product. Lancet 1996; 348:1413.
- Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med 2002; 346:2033.
- Sørensen HT, Mellemkjaer L, Blot WJ, et al. Risk of upper gastrointestinal bleeding associated with use of low-dose aspirin. Am J Gastroenterol 2000; 95:2218.
- Lanas A, Scheiman J. Low-dose aspirin and upper gastrointestinal damage: epidemiology, prevention and treatment. Curr Med Res Opin 2007; 23:163.
- Lanas A, Fuentes J, Benito R, et al. Helicobacter pylori increases the risk of upper gastrointestinal bleeding in patients taking low-dose aspirin. Aliment Pharmacol Ther 2002; 16:779.
- Grove EL, Würtz M, Schwarz P, et al. Gastrointestinal events with clopidogrel: a nationwide population-based cohort study. J Gen Intern Med 2013; 28:216.
- Fork FT, Lafolie P, Tóth E, Lindgärde F. Gastroduodenal tolerance of 75 mg clopidogrel versus 325 mg aspirin in healthy volunteers. A gastroscopic study. Scand J Gastroenterol 2000; 35:464.
- Cryer B. Reducing the risks of gastrointestinal bleeding with antiplatelet therapies. N Engl J Med 2005; 352:287.
- Ng FH, Wong SY, Chang CM, et al. High incidence of clopidogrel-associated gastrointestinal bleeding in patients with previous peptic ulcer disease. Aliment Pharmacol Ther 2003; 18:443.
- Ma L, Elliott SN, Cirino G, et al. Platelets modulate gastric ulcer healing: role of endostatin and vascular endothelial growth factor release. Proc Natl Acad Sci U S A 2001; 98:6470.
- Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007; 357:2001.
- Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009; 361:1045.
- Harrington RA, Stone GW, McNulty S, et al. Platelet inhibition with cangrelor in patients undergoing PCI. N Engl J Med 2009; 361:2318.
- Bhatt DL, Stone GW, Mahaffey KW, et al. Effect of platelet inhibition with cangrelor during PCI on ischemic events. N Engl J Med 2013; 368:1303.
- Alli O, Smith C, Hoffman M, et al. Incidence, predictors, and outcomes of gastrointestinal bleeding in patients on dual antiplatelet therapy with aspirin and clopidogrel. J Clin Gastroenterol 2011; 45:410.
- Berger PB, Bhatt DL, Fuster V, et al. Bleeding complications with dual antiplatelet therapy among patients with stable vascular disease or risk factors for vascular disease: results from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial. Circulation 2010; 121:2575.
- Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005; 293:2126.
- Ho PM, Peterson ED, Wang L, et al. Incidence of death and acute myocardial infarction associated with stopping clopidogrel after acute coronary syndrome. JAMA 2008; 299:532.
- Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2008; 52:1502.
- Hall P, Nakamura S, Maiello L, et al. A randomized comparison of combined ticlopidine and aspirin therapy versus aspirin therapy alone after successful intravascular ultrasound-guided stent implantation. Circulation 1996; 93:215.
- Urban P, Macaya C, Rupprecht HJ, et al. Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the multicenter aspirin and ticlopidine trial after intracoronary stenting (MATTIS). Circulation 1998; 98:2126.
- Schömig A, Neumann FJ, Kastrati A, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med 1996; 334:1084.
- Leon MB, Baim DS, Popma JJ, et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N Engl J Med 1998; 339:1665.
- Bertrand ME, Legrand V, Boland J, et al. Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (fantastic) study. Circulation 1998; 98:1597.
- Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial. Ann Intern Med 2010; 152:1.
- Bhatt DL, Cryer BL, Contant CF, et al. Clopidogrel with or without omeprazole in coronary artery disease. N Engl J Med 2010; 363:1909.
- Charlot M, Ahlehoff O, Norgaard ML, et al. Proton-pump inhibitors are associated with increased cardiovascular risk independent of clopidogrel use: a nationwide cohort study. Ann Intern Med 2010; 153:378.
- Vaduganathan M, Bhatt DL, Cryer BL, et al. Proton-Pump Inhibitors Reduce Gastrointestinal Events Regardless of Aspirin Dose in Patients Requiring Dual Antiplatelet Therapy. J Am Coll Cardiol 2016; 67:1661.
- Abraham NS, Hlatky MA, Antman EM, et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation 2010; 122:2619.
- Agewall S, Cattaneo M, Collet JP, et al. Expert position paper on the use of proton pump inhibitors in patients with cardiovascular disease and antithrombotic therapy. Eur Heart J 2013; 34:1708.