Published online Apr 14, 2018. doi: 10.3748/wjg.v24.i14.1540
Peer-review started: February 21, 2018
First decision: March 9, 2018
Revised: March 15, 2018
Accepted: March 25, 2018
Article in press: March 25, 2018
Published online: April 14, 2018
Processing time: 50 Days and 0.4 Hours
To verify the validity of the endoscopy guidelines for patients taking warfarin or direct oral anticoagulants (DOAC).
We collected data from 218 patients receiving oral anticoagulants (73 DOAC users, 145 warfarin users) and 218 patients not receiving any antithrombotics (age- and sex-matched controls) who underwent polypectomy. (1) We evaluated post-polypectomy bleeding (PPB) risk in patients receiving warfarin or DOAC compared with controls; (2) we assessed the risks of PPB and thromboembolism between three AC management methods: Discontinuing AC with heparin bridge (HPB) (endoscopy guideline recommendation), continuing AC, and discontinuing AC without HPB.
PPB rate was significantly higher in warfarin users and DOAC users compared with controls (13.7% and 13.7% vs 0.9%, P < 0.001), but was not significantly different between rivaroxaban (13.2%), dabigatran (11.1%), and apixaban (13.3%) users. Two thromboembolic events occurred in warfarin users, but none in DOAC users. Compared with the continuing anticoagulant group, the discontinuing anticoagulant with HPB group (guideline recommendation) had a higher PPB rate (10.8% vs 19.6%, P = 0.087). These findings were significantly evident in warfarin but not DOAC users. One thrombotic event occurred in the discontinuing anticoagulant with HPB group and the discontinuing anticoagulant without HPB group; none occurred in the continuing anticoagulant group.
PPB risk was similar between patients taking warfarin and DOAC. Thromboembolism was observed in warfarin users only. The guideline recommendations for HPB should be re-considered.
Core tip: First, we found that anticoagulant (AC) users were at higher risk of post-polypectomy bleeding (PPB) than controls. Second, PPB risk was similar between warfarin users and direct oral anticoagulant users, whereas thromboembolism risk was observed only in warfarin users. Third, PPB risk was not significantly different between rivaroxaban, dabigatran, and apixaban users. Fourth, the strategy of discontinuing AC with heparin bridge as recommended in the endoscopy guidelines showed a higher bleeding rate than continuing AC alone and had one thrombotic event, thus indicating that heparin bridge increased bleeding and may not prevent thromboembolism.