What are the cardiac clearance guidelines for patients undergoing endoscopy?

Cardiac Clearance Guidelines for Endoscopy

Cardiac clearance for endoscopy should be based on both the thrombotic risk of the patient and the bleeding risk of the specific endoscopic procedure, with management strategies tailored accordingly. 1

Risk Stratification

Endoscopic Procedure Risk Classification

High-Risk Procedures:

• Endoscopic polypectomy
• ERCP with sphincterotomy
• Ampullectomy
• Endoscopic mucosal resection (EMR) or submucosal dissection (ESD)
• Endoscopic dilatation of strictures
• Endoscopic therapy of varices
• Percutaneous endoscopic gastrostomy (PEG)
• Endoscopic ultrasound (EUS) with sampling or interventional therapy
• Oesophageal or gastric radiofrequency ablation 1

Low-Risk Procedures:

• Diagnostic procedures with or without biopsy sampling
• Biliary or pancreatic stenting
• Device-assisted enteroscopy without polypectomy
• Oesophageal, enteral or colonic stenting
• EUS without sampling or interventional therapy 1

Thrombotic Risk Classification

Very High Risk:

• Acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) <6 weeks ago 1

High Risk:

• ACS or PCI 6 weeks–6 months ago
• Prosthetic metal heart valve
• Atrial fibrillation with mitral stenosis
• AF with previous stroke/TIA
• <3 months after venous thromboembolism (VTE)
• Severe thrombophilia 1

Moderate to Low Risk:

• ACS or PCI >6 months ago
• Stable coronary artery disease
• Xenograft heart valve
• AF without high risk factors (CHADS₂<4) 1

Management Recommendations

For Very High Thrombotic Risk Patients:

• Defer elective endoscopic procedures until at least 6 weeks after cardiac event 1
• If endoscopy must be performed on the day of MI, be aware of significantly increased risk of complications (p=0.02) 2

For High Thrombotic Risk Patients:

Antiplatelet Management:

• Continue aspirin for all procedures
• For high-risk procedures: Consult with interventional cardiologist regarding P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor)
• For drug-eluting stents: Consider temporary cessation of P2Y12 inhibitors only after 6-12 months post-insertion
• For bare metal stents: Consider temporary cessation of P2Y12 inhibitors only after >1 month post-insertion 1

Anticoagulant Management:

• For warfarin:

  • High-risk procedures: Temporarily discontinue warfarin 5 days before procedure and substitute with LMWH
  • Check INR prior to procedure to ensure <1.5
  • Restart warfarin evening of procedure with usual daily dose
  • Check INR one week later 1

• For DOACs:

  • Last dose should be taken 3 days before high-risk procedures
  • For dabigatran with CrCl 30–50 mL/min: Last dose 5 days prior
  • Consult hematologist for patients with rapidly deteriorating renal function 1

For Moderate to Low Thrombotic Risk Patients:

Antiplatelet Management:

• Continue aspirin for all procedures
• Withhold P2Y12 inhibitors 5-7 days before high-risk procedures
• Resume P2Y12 inhibitors 1-2 days after procedure 1

Anticoagulant Management:

• For warfarin:

  • Withhold 5 days before high-risk procedures
  • Check INR prior to procedure to ensure <1.5
  • Resume after adequate hemostasis
  • No heparin bridging needed 1

• For DOACs:

  • Withhold 2-3 days before high-risk procedures
  • Resume after adequate hemostasis
  • No heparin bridging needed 1

Post-Procedure Considerations

• Resume antiplatelet or anticoagulant therapy 2–3 days after the procedure depending on hemorrhagic and thrombotic risks 1
• For patients with drug-eluting coronary stents, early resumption of P2Y12 receptor inhibitor is recommended, preferably within 5 days 1
• Advise all patients on antiplatelets or anticoagulants about increased risk of post-procedure hemorrhage 1

Special Considerations

• Endoscopy can be safely performed in patients with recent MI if necessary, though timing affects risk 2
• Evidence suggests that ST elevation MI, depressed ejection fraction, or elevated troponin levels do not independently increase endoscopic risk 2
• Women may be at higher risk for periprocedural ischemia during endoscopy (31% vs 11% in men) 3
• The risk of cardiovascular complications during hospital-based endoscopy may be higher than previously reported, with male gender and use of propofol being independent risk factors 4

Acute GI Hemorrhage Management

• Consider permanent discontinuation of aspirin if used for primary prophylaxis
• Continue aspirin for secondary prevention; if stopped, recommence as soon as hemostasis is achieved
• For patients with coronary stents, continue DAPT if possible, in liaison with interventional cardiologist
• If P2Y12 inhibitor must be interrupted due to major hemorrhage, continue aspirin 1