Abstract and Introduction
Abstract
Direct oral anticoagulants (DOACs) are recommended for the prevention of thromboembolism in patients with atrial fibrillation (AF), and are now preferred over vitamin K antagonists due to their beneficial efficacy and safety profile. However, all oral anticoagulants carry a risk of gastrointestinal (GI) bleeding. Although the risk is well documented and acute bleeding well codified, there is limited high-quality evidence and no guidelines to guide physicians on the optimal management of anticoagulation after a GI bleeding event. The aim of this review is to provide a multidisciplinary critical discussion of the optimal management of GI bleeding in patients with AF receiving oral anticoagulants to help physicians provide individualized treatment for each patient and optimize outcomes. It is important to perform endoscopy when a patient presents with bleeding manifestations or hemodynamic instability to determine the bleed location and severity of bleeding and then perform initial resuscitation. Administration of all anticoagulants and antiplatelets should be stopped and bleeding allowed to resolve with time; however, anticoagulant reversal should be considered for patients who have life-threatening bleeding or when the bleeding is not controlled by the initial resuscitation. Anticoagulation needs to be timely resumed considering that bleeding risk outweighs thrombotic risk when anticoagulation is resumed early after the bleeding event. To prevent further bleeding, physicians should prescribe anticoagulant therapy with the lowest risk of GI bleeding, avoid medications with GI toxicity, and consider the effect of concomitant medications on potentiating the bleeding risk.
Introduction
Atrial fibrillation (AF) is the most common type of cardiac arrhythmia that increases the risk of cardiovascular events such as stroke, systemic embolism, and heart failure and promotes the worsening of cardiac and noncardiac conditions.[1,2] According to the Global Burden of Disease Study, there were 37.57 million [95% uncertainty interval (UI) 32.55–42.59] prevalent cases of AF and 3.05 million (95% UI 2.61–3.51) incident cases of AF worldwide in 2017.[2] The prevalence of AF has nearly doubled between 1990 and 2017, and rates are expected to keep increasing due to the aging population.[2]
European guidelines recommend the use of direct oral anticoagulants (DOACs) such as dabigatran, rivaroxaban, apixaban, or edoxaban for the prevention of stroke and systemic embolism in AF.[3,4] Their mechanism of action is based on the direct inhibition of activated coagulation factors; dabigatran inhibits thrombin (factor IIa), while rivaroxaban, apixaban, and edoxaban inhibit factor Xa.[5–10] Overall, DOACs are preferred over vitamin K antagonists (VKA) such as warfarin in adult patients, except in the context of pregnancy and in patients with mechanical valve prosthesis, triple-positive antiphospholipid syndrome, or end-stage kidney disease.[3,11] DOACs are being increasingly used due to their improved efficacy/safety ratio, predictable anticoagulant effect without need for routine coagulation monitoring, fixed dose regimens, and fewer food and drug interactions compared with VKAs.[12] However, gastrointestinal (GI) bleeding remains a serious and challenging complication of any anticoagulant medication.[13] The management of acute major bleeding in patients treated with anticoagulants is well codified,[14] but there is a lack of standardized protocols as to how and when to resume anticoagulant therapy after GI bleeding. As such, international guidelines recommend the development of a hospital-based multidisciplinary approach including cardiologists, gastroenterologists, emergency physicians/intensive care specialists, hemostasis experts, and others to optimally treat patients with GI bleeding.[3]
This article aims to critically discuss the optimal approach to the multidisciplinary management of GI bleeding in patients with AF receiving anticoagulants.
Am J Cardiovasc Drugs. 2023;23(4):407-418. © 2023 Adis Springer International Publishing AG
