Upper GI Endoscopy in Heart Failure Patients
Upper GI endoscopy (UGIE) can be safely performed in patients with heart failure when clinically indicated, though these patients require careful cardiovascular monitoring and risk stratification, particularly those with concomitant coronary artery disease or congestive heart failure. 1, 2
Safety Profile and Feasibility
UGIE is feasible and safe in heart failure patients, with successful procedures reported even in high-risk populations including those with left ventricular assist devices (LVADs) and post-cardiac transplant patients 1, 3
In a series of 68 endoscopic procedures in LVAD patients, all procedures were completed successfully under deep sedation or general anesthesia without requiring invasive hemodynamic monitoring 1
Post-cardiac transplant patients have undergone upper endoscopy safely without complications, performed in standard GI suites without cardiac monitoring 3
Cardiovascular Risks and Monitoring
Patients with heart failure, especially those with coronary artery disease, have significantly higher cardiovascular risks during endoscopy that require heightened vigilance:
Patients with stable coronary artery disease undergoing emergency UGIE for upper GI bleeding had a 42% incidence of ventricular arrhythmias during the procedure compared to 16% in non-CAD patients 2
Concomitant congestive heart failure is associated with both higher frequency and more severe fluctuation of ventricular arrhythmias during endoscopy 2
Myocardial ischemia (ST changes) occurred in 18% of CAD patients versus 2% of non-CAD patients, though these were mostly subclinical without angina or MI 2
Hemodynamic Management During Procedure
Non-invasive monitoring (pulse oximetry and non-invasive blood pressure) can be reliably used in heart failure patients with residual cardiac function:
Transient hypotensive episodes during endoscopy respond well to fluids and/or vasopressors (phenylephrine, ephedrine) or inotropes (milrinone) 1
Management should be guided by plethysmographic waveform and non-invasive blood pressure rather than routinely requiring invasive monitoring 1
Resuscitation facilities must be immediately available during procedures in high-risk patients 4
Anticoagulation and Antiplatelet Management
The management of antithrombotic therapy is critical in heart failure patients undergoing UGIE, as 20% of acute heart failure patients develop GI bleeding: 5
For patients on dual antiplatelet therapy (DAPT), both agents should not be withheld simultaneously due to high risk of stent thrombosis 4
In patients on DAPT with aspirin and clopidogrel, continue aspirin and temporarily withhold clopidogrel during active bleeding 4
For high-risk endoscopic procedures (including therapeutic endoscopy, polypectomy, or variceal therapy), anticoagulants should be resumed within 48 hours after the procedure depending on bleeding and thrombotic risks 6, 7
Diagnostic upper endoscopy with or without biopsy is considered a low-risk procedure where anticoagulation management may be less restrictive 6
Risk Stratification
Higher-risk heart failure patients requiring special consideration include:
Those with elevated BNP levels (higher BNP correlates with increased GI bleeding risk) 5
Patients with concomitant coronary artery disease, particularly those with recent stent placement 4, 2
Those on anticoagulation (64% of heart failure patients with GI bleeding were on anticoagulants versus 42% without bleeding) 5
Elderly patients (median age 77 years in those with GI bleeding versus 70 years without) 5
Common Pitfalls to Avoid
Do not delay endoscopy unnecessarily in hemodynamically unstable patients, as early intervention (within 12 hours) is recommended for high-risk clinical features including persistent hypotension despite volume replacement 6
Avoid routine invasive hemodynamic monitoring in normotensive heart failure patients who respond to diuretics and vasodilators, as this is not recommended by ACC/AHA guidelines 6
Do not assume cross-sectional imaging will identify the bleeding source - only 25% of heart failure patients with GI bleeding had abnormal findings on CT imaging 5
Recognize that the most common endoscopic findings in heart failure patients with GI bleeding include esophagitis/gastritis, esophageal/gastric ulcers, diverticulosis, and polyps 5