Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature

Table 1 Stratification of endoscopic procedures based on the risk of bleeding according to international guidelines

Procedure risk group	Practice guidelines
	ASGE[3]	ESGE/BSG[4]	APAGE/APSDE[5]
Low-risk	(1) Diagnostic (EGD, colonoscopy, flexible sigmoidoscopy) including mucosal biopsy; (2) ERCP with stent (biliary or pancreatic) placement or papillary balloon dilation without sphincterotomy; (3) Push enteroscopy and diagnostic balloon-assisted enteroscopy; (4) Capsule endoscopy; (5) Enteral stent deployment (controversial); (6) EUS without FNA; (7) Argon plasma coagulation and (8) Barrett’s ablation	(1) Diagnostic procedures +/– biopsy; (2) Biliary or pancreatic stenting; (3) Diagnostic EUS and (4) Device-assisted enteroscopy without polypectomy	(1) Diagnostic endoscopy with biopsy; (2) Endoscopic ultrasound without fine needle aspiration; (3) ERCP with biliary or pancreatic stenting; (4) Diagnostic push or device-assisted enteroscopy; (5) Video capsule endoscopy; (6) Oesophageal, enteral and colonic stenting and (7) Argon plasma coagulation
High-risk	(1) Polypectomy; (2) Biliary or pancreatic sphincterotomy; (3) Treatment of varices; (4) PEG/PEJ placement; (5) Therapeutic balloon-assisted enteroscopy; (6) EUS with FNA; (7) Endoscopic hemostasis; (8) Tumor ablation; (9) Cystgastrostomy; (10) Ampullary resection; (11) EMR; (12) Endoscopic submucosal dissection and (13) Pneumatic or bougie dilation	(1) Polypectomy; (2) ERCP with sphincterotomy; (3) Ampullectomy; (4) EMR; (5) ESD; (6) Dilation of strictures; (7) Therapy of varices; (8) PEG; (9) EUS with FNA and (10) Oesophageal, enteral or colonic stenting	(1) Polypectomy; (2) ERCP with sphincterotomy ± balloon sphincteroplasty; (3) Dilatation of strictures; (4) Injection or banding of varices; (5) PEG/PEJ placement; (6) EUS with FNA and (7) Ampullectomy
Ultra-high-risk	NA	NA	(1) ESD; (2) EMR of large (> 2 cm) polyps

ASGE: American society for gastrointestinal endoscopy; ESGE/BSG: European society of gastrointestinal endoscopy and British society of gastroenterology; APAGE/APSDE: Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy; EGD: Esophagogastroduodenoscopy; EUS: Endoscopic ultrasound; FNA: Fine-needle aspiration; ERCP: Endoscopic retrograde cholangiopancreatography; PEG: Percutaneous endoscopic gastrostomy; PEJ: Percutaneous endoscopic jejunostomy; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; NA: Not assessed.

Table 2 Stratification of thrombotic risk according to international guidelines

Thrombotic risk category	Practice guidelines
	ASGE[3]	ESGE/BSG[4]	APAGE/APSDE[5]
Low-risk	Anticoagulant therapy: (1) Bileaflet aortic valve prosthesis without AF and no other risk factors for CVA; (2) VTE > 12 mo previous and no other risk factors; and (3) Atrial fibrillation with CHA2DS2-VASc score < 2	Antithrombotic therapy: (1) Ischaemic heart disease without coronary stent; (2) Cerbrovascular disease; and (3) Peripheral vascular disease.	Antithrombotic therapy: (1) Acute coronary syndrome or percutaneous coronary intervention > 6 mo ago; and (2) Stable coronary artery disease.
		Anticoagulant therapy: (1) Prosthetic metal heart valve in aortic position; (2) Xenograft heart valve; (3) Atrial fibrillation without valvular disease; (4) > 3 mo after venous thromboembolism; and (5) Thrombophilia syndromes
			Anticoagulant therapy: (1) Non-valvular atrial fibrillation with a CHA2DS2-VASc score ≤ 5; (2) Prosthetic valve without atrial fibrillation; and (3) > 3 mo after venous thromboembolism
Moderate-risk	Anticoagulant therapy: (1) Bileaflet aortic valve prosthesis and one or more of the following risk factors: AF, prior CVA or TIA, hypertension, diabetes, congestive heart failure, age > 75 yr; (2) VTE within the past 3-12 monon-severe thrombophilia (heterozygous factor V Leiden or prothrombin gene mutation); and (3) Recurrent VTEactive cancer (treated within 6 mo or palliative)
High-risk	Anticoagulant therapy: (1) Any mitral valve prosthesis; (2) Any caged-ball or tilting disc aortic valve prosthesis; (3) Recent (within 6 mo) CVA or TIA; and (4) Atrial fibrillation with CHA2DS2-VASc score ≥ 2	Antithrombotic therapy: (1) Drug eluting coronary artery stents within 12 mo of placement; and (2) Bare metal coronary artery stents within 1 mo of placement.	Antithrombotic therapy: (1) Acute coronary syndrome or percutaneous coronary intervention 6 wk–6 mo.
			Anticoagulant therapy: (1) Non-valvular atrial fibrillation with a CHA2DS2-VASc score > 5; (2) Metallic mitral valve; (3) Prosthetic valve with atrial fibrillation; (4) < 3 mo after venous thromboembolism; and (5) Severe thrombophilia (protein C or protein S deficiency and (6) antiphospholipid syndrome)
		Anticoagulant therapy: (1) Prosthetic metal heart valve in mitral position; (2) Prosthetic heart valve and atrial fibrillation; (3) Atrial fibrillation and mitral stenosis; and (4) < 3 mo after venous thromboembolism
Very high-risk			Antithrombotic therapy: Acute coronary syndrome or percutaneous coronary intervention < 6 wk

ASGE: American society for gastrointestinal endoscopy; ESGE/BSG: European society of gastrointestinal endoscopy and British society of gastroenterology; APAGE/APSDE: Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy; AF: Atrial fibrillation; CVA: Cerebrovascular accident; VTE: Venous thromboembolism; TIA: Transient ischemic attack.