From the Guidelines
Anticoagulant therapy can be resumed as soon as possible after 7 days of anticoagulant interruption in patients at low thrombotic risk, while in those at high-thrombotic risk, an earlier resumption of anticoagulation with heparin bridging, preferably within 3 days, is recommended. When considering the resumption of anticoagulant therapy after an upper GI endoscopy, it is crucial to weigh the risks of bleeding against the risks of thrombotic events. The decision should be made in consultation with a consultant cardiologist/haematologist, taking into account the severity of haemorrhage and the patient’s thrombotic risk 1.
Key Considerations
- For patients with an indication for long-term anticoagulation, restarting anticoagulation following acute GI haemorrhage is recommended, with the timing dependent on the patient's thrombotic risk 1.
- In patients at low thrombotic risk, anticoagulation can be restarted as soon as possible after 7 days of anticoagulant interruption, while those at high thrombotic risk may require earlier resumption with heparin bridging 1.
- The management of anticoagulation in the context of GI endoscopy should consider the type of anticoagulant, the procedure's risk level, and the patient's individual risk factors for bleeding and thrombosis 1.
Procedure-Specific Guidance
- For low-risk endoscopic procedures, warfarin therapy can be continued, ensuring the INR does not exceed the therapeutic range in the week prior to the procedure 1.
- For high-risk procedures in patients at low thrombotic risk, warfarin should be discontinued 5 days before the procedure, with INR checked prior to the procedure to ensure it is <1.5 1.
- For patients at high thrombotic risk undergoing high-risk procedures, warfarin should be temporarily discontinued and substituted with low-molecular-weight heparin (LMWH) 1.
Monitoring and Bridging
- Patients should be monitored for signs of bleeding after resuming anticoagulation, including black stools, vomiting blood, dizziness, or abdominal pain.
- For patients with high thrombotic risk, consider bridging with heparin or LMWH while waiting to restart oral anticoagulants, with the specific approach guided by the patient's condition and the endoscopist's recommendations 1.
From the Research
Resuming Anticoagulant Therapy After Upper GI Endoscopy
- The decision to resume anticoagulant therapy after an upper GI endoscopy depends on the risk of thromboembolism and the risk of bleeding associated with the procedure 2.
- For low-risk procedures such as upper endoscopy with biopsy, anticoagulation does not need to be adjusted 2.
- Warfarin therapy may generally be resumed on the night of the procedure and may be supplemented by heparin in patients with a high risk of thromboembolism 2.
- The optimal time to resume anticoagulation after gastrointestinal bleeding is unknown, but resuming therapy between 7 and 14 days after bleeding has stopped may be considered 3.
- Resuming anticoagulation therapy is recommended to reduce the risk of thromboembolic complications, but the decision should be individualized based on the patient's risk factors and the type of anticoagulant used 3, 4.
Considerations for Resuming Anticoagulant Therapy
- The risk of rebleeding and thromboembolism should be weighed when deciding when to resume anticoagulant therapy 5, 6.
- The type of anticoagulant used, such as warfarin or direct oral anticoagulants (DOACs), may influence the decision to resume therapy 3, 4.
- Clinical prediction guides, such as the Glasgow-Blatchford bleeding score, may be used to stratify the risk of upper GI bleeding and guide management decisions 5.
- Anticoagulant reversal agents, such as prothrombin complex concentrates or target-specific DOAC reversal agents, may be considered in patients with life-threatening GI bleeding 4.