The effects of anticoagulant therapy re-initiation after gastrointestinal bleeding: A systematic review and meta-analysis.

Long-term anticoagulant/antithrombotic therapy is widely used for the management of thromboembolic conditions. Gastrointestinal bleeding is a common collateral manifestation of anticoagulant/antithrombotic therapy that complicates its administration. The continuation or discontinuation of anticoagulant/antithrombotic therapy after an episode of gastrointestinal bleeding has been a matter of debate. Despite recent positive reports from retrospective cohort studies suggesting a reduction in morbidity- and mortality-related outcomes with continued administration of anticoagulant/antithrombotic agents (even after gastrointestinal bleeding), no consensus or comparisons about the efficacies of continued or discontinued antithrombotic administration exist. Therefore, we developed this current state-of-evidence analysis evaluating the comparative effects of continuation and discontinuation of anticoagulant/antithrombotic drugs after gastrointestinal bleeding on the overall incidences of gastrointestinal bleeding, thromboembolic events and mortality events. We performed a systematic academic literature search according to the PRISMA guidelines across five databases: Web of Science, Embase, CENTRAL, Scopus and MEDLINE. Moreover, we conducted a random effect meta-analysis to compare the effects of continuation and discontinuation of anticoagulant/antithrombotic drugs after an event of gastrointestinal bleeding on the overall incidences of gastrointestinal bleeding, thromboembolic events and mortality events. We found seven eligible studies (from 1397 candidates) with 2532 participants (mean age, 73.1 ± 4.1 years). Our meta-analysis revealed lower odds of thromboembolic events (OR, -0.21), mortality outcomes (OR, -0.39) and an increase in the incidence of gastrointestinal bleeding (OR, 2.4) in the group with continued anticoagulant/antithrombotic therapy than in the group discontinuing the therapy. We provide an updated evidence on the comparative effects between continuation and discontinuation of anticoagulant/antithrombotic drugs after gastrointestinal bleeding events based on the overall incidences of gastrointestinal bleeding, thromboembolic events and mortality events. This study reports confirm an overall lower incidence of thromboembolic events and mortality outcomes for the continuation group than for the discontinuation group.

Bingzheng X ，Jingnan R ，Ligang B ，Jianping C ... -  《-》

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines.

Kaye AD ，Manchikanti L ，Novitch MB ，Mungrue IN ，Anwar M ，Jones MR ，Helander EM ，Cornett EM ，Eng MR ，Grider JS ，Harned ME ，Benyamin RM ，Swicegood JR ，Simopoulos TT ，Abdi S ，Urman RD ，Deer TR ，Bakhit C ，Sanapati M ，Atluri S ，Pasupuleti R ，Soin A ，Diwan S ，Vallejo R ，Candido KD ，Knezevic NN ，Beall D ，Albers SL ，Latchaw RE ，Prabhakar H ，Hirsch JA ... -  《-》

Assessment of bleeding risk of interventional techniques: a best evidence synthesis of practice patterns and perioperative management of anticoagulant and antithrombotic therapy.

Manchikanti L ，Falco FJ ，Benyamin RM ，Caraway DL ，Kaye AD ，Helm S 2nd ，Wargo BW ，Hansen H ，Parr AT ，Singh V ，Swicegood JR ，Smith HS ，Schultz DM ，Malla Y ，Hirsch JA ... -  《-》

Management of Antithrombotic Agents During Surgery or Other Kinds of Medical Procedures With Bleeding: The MARK Study.

Gotoh S ，Yasaka M ，Nakamura A ，Kuwashiro T ，Okada Y ... -  《Journal of the American Heart Association》

Effects of antithrombotic therapy on bleeding after endoscopic submucosal dissection.

Bleeding is the most common adverse event after endoscopic submucosal dissection (ESD). Although several studies have reported on the use of antithrombotic agents and post-ESD bleeding, many issues remain controversial. We conducted a meta-analysis and systematic review to evaluate the effects of antithrombotic therapy on post-ESD bleeding. The published literature was searched on online databases, and all studies were included up to January 2017. Standard forms were used to extract data by 2 independent reviewers. The Newcastle-Ottawa Scale score was used to assess the quality of studies. The pooled odds ratio (OR) was computed for the effect of antithrombotic agents. Publication bias was assessed by funnel plots. Heterogeneity was assessed by the Cochran Q test and I2 statistic. Sixteen retrospective articles were included. Regardless of discontinuation (OR, 1.66; 95% confidence interval [CI], 1.15-2.39; P = .007) or continuation (OR, 8.39; 95% CI, 4.64-15.17; P < .00001), antithrombotic therapy was significantly associated with post-ESD bleeding, particularly for delayed bleeding (OR, 2.66; 95% CI, 1.42-4.98; P = .002). The bleeding rate was higher in the discontinued multiple antithrombotics group (OR, 5.17; 95% CI, 3.13-8.54; P < .00001) than in the discontinued a single antithrombotic group (OR, 2.23; 95% CI, 1.29-3.85; P = .004) and single antiplatelet group (OR, 2.08; 95% CI, 0.93-4.63; P = .07). In the subgroup analysis, resuming antithrombotics within 1 week (OR, 2.46; 95% CI, 1.54-3.93; P = .0002) and using heparin replacement (OR, 4.20; 95% CI, 1.94-9.09; P= .0003) significantly increased post-ESD bleeding risk. Continued use of low-dose aspirin (OR, 1.22; 95% CI, 0.17-8.61; P = .84) did not significantly increase the bleeding risk. Antithrombotic therapy is a risk factor for post-ESD bleeding, especially for delayed bleeding. Using multiple antithrombotic drugs, resuming antithrombotics within 1 week, and heparin replacement were significantly associated with post-ESD bleeding; but continuous low-dose aspirin was not. However, much larger prospective studies are required.

Dong J ，Wei K ，Deng J ，Zhou X ，Huang X ，Deng M ，Lü M ... -  《-》