To Do or Not to Do: Whether to Hold or Continue Antithrombotics before Endoscopy

摘要

Antithrombotics comprise antiplatelets (i.e., aspirin, clopidogrel) and anticoagulants (i.e., warfarin, apixaban). They are widely used for primary as well as secondary prevention of cardiovascular and cerebrovascular diseases. This translates to a large number of patients using antithrombotics before their endoscopic procedure. Physicians frequently consider the risks of continuing or stopping antithrombotics as well as the risks of thrombotic events or bleeding. Practice guidelines from the European Society of Gastrointestinal Endoscopy and the American Society of Gastrointestinal Endoscopy exist. Most recently, the Asian Pacific Association of Gastroenterology and the Asian Pacific Society for Digestive Endoscopy published a joint official statement regarding the management of antithrombotics undergoing endoscopy. These guidelines recommend management of antithrombotics based on two types of risks: bleeding risk and thrombotic risk. A diagnostic endoscopy with or without biopsy are considered procedures with low bleeding risk and cessation of antithrombotics are generally not required. A colonoscopy with polypectomy is a procedure with high bleeding risk. Management of antithrombotics depends on the type of antithrombotic (i.e., aspirin, warfarin) and the patient’s risk of thrombosis. Endoscopic submucosa dissection (ESD) and endoscopic mucosal resection of polyps ≥2 cm are classified as ultrahigh risk procedures, and cessation of all antithrombotic is generally recommended.