| Part OneThe demographic characteristics, epidemiology, management of antithrombotic agents and peri-endosopic adverse events in 3747 patients receiving endoscopyproceduresAim:to investigate the demographic characteristics, epidemiological characteristics of cardiovascular disease and related risk factors, characteristics of gastrointestinal endoscope, management of antithrombotic agents and peri-endosopic adverse events in patients receiving endoscopy proceduresMaterials and methods:The electronic medical records system was applied to screen available patients. Between January 1st 2008 and December 31st 2014, in-patient patients receiving gastrointestinal endoscopic procedures were suitable for inrollment. Patients must be hospitalized for at least 7days. The peri-endoscopy was defined as between 7 days before endoscopic procedure and 30 days after procedure. Patients who were admitted for emergency gastrointestinal endoscopy were ruled out. Totally 3747 patients (aged 46-99 years) were enrolled in our study. The study population was predominately male(3601,96.1%).3458 (92.3%)patients were older than 60 years. The admission time, discharging time, and time of endoscopic procedure were recorded. Patients’demographic characteristics, clinical diagnosed disease, current medication, characteristics of gastrointestinal endoscopy, management of antithrombotic agents and peri-endosopic adverse events were collected.Results:In 3747 patients, the first five common diseases were hypertension(66.9%), coronary heat disease(CHD)(53.6%), diabetes(45.9%), peripheral vascular disease(41.6%), and ischemic stroke(25.0%). The prevalence of atrial fibrillation was up to 9.2%. On admission,98.9% of 2031 patients receiving antrthrombotic agents were on antiplatelet drugs. After endoscopic procedure,98.6% of 1986 patients receiving antrthrombotic agents were on antiplatelet drugs.99%(2011/2031) of the 2031 patients’ antithrombotic therapy were ceased before procedure. Before endoscopic procedure, the management of 29.20%,29.20%,28.29%, and 32.50% of the 2031 patients on antithrombic agents were in adherence to the British Society of Gastrointerology(BSG) 2008 guideline, the American Society of Gastrointestinal Endoscopy (ASGE) 2009 guideline, the European Society of Gastrointestinal Endoscopy (ESGE) 2011 guideline, and Japan Gastroenterological Endoscopy Society (JGES) 2014 guideline respectively.. After endoscopic procedure, the management of 26.78%,26.78%、25.08%, and 30.06% of the 1986 patients on antithrombic agents were in adherence to BSG, ASGE, ESGE, and JGES guidelines respectively. During peri-endoscopy, the incidenc of total thromboembolism was 2.24%(84 cases):incidences of ACS, ischemic stroke, and other system embolism were 1.59%(63 cases),0.43%(16 cases),0.13%(5 cses) respectively. The incidence of total bleeding was 1.89%(71 case):incidences of major bleeding and minor bleeding were 0.29%(11cases) and 1.6%(60 cases) respectively. The incidence of all-causes death was 0.11%(4 cases). The median time (interquartile range)(day) for ACS ischemic stroke, other system embolism, major bleeding and minor bleeding were 7(3-12),8(-1-15),13(12-13),7 (3-16) and 4 (1-13).Conclussion:Our study was a retrospective study which focused on the elderly male patients with multiple cardiovascular diseases and mainly on anti platelet therapy. The rates of adherence of management of the peri-endoscopic antithrombotic agents to current 4 international guidelines were low. The peri-endoscopic incidence of ischemic stroke and other system embolism were relatively low, while the peri-endoscopic incidence of ACS was relatively high. The adverse events including thromboembolism and bleeding mainly occurred in the first two weeks after endoscopic procedure,.Part TwoInvestigation of the predictive ability of current 4 international guidelines on peri-endoscopic adverse events in elderly patientsAim:to investigate the predictive ability of current 4 international guidelines in peri-endoscopic adverse events in elderly patientsMaterials and methods:receiver operator characteristic (ROC) curve was used to evaluate the predictive ability of current 4 international guidelines’risk stratificaiton of thromboembolism and bleeding on peri-endoscopic adverse events in this study populationResults:According to the JGES, ASGE, BSG, and ESGE guidelines, patients categorized into high risk of bleeding were 248 cases (6.6%),468 cases (12.5%),468 cases (12.5%),78 (2.1%) repectively. As far as risk stratification of thromboembolism after cessation of antithrombotic agents during per-endoscopy was concerned, high risk of thromboembolism after discontinuation of antiplatelet were 76 cases(2.0%) and 50 cases (1.3%) according to JGES guidelines and ASGE_BSG_ESG guidelines respectively. High risk of thromboembolism after discontinuation of anticoagulation were 366 cases (9.8%) and 330 cases (8.8%) according to JGES guidelines and ASGE_BSG guidelines respectively. For the first time, we discussed the predictive ability of current 4 international guidelines’thromboembolic risk stratification and bleeding risk stratification on peri-endoscopic thromboembolic and bleeding events in Chinese elderly patients. Sadly, the predictive ability of current 4 international guidelines for peri-endoscopic thromboembolic events in elderly patients were low. When total thromboembolic events were discussed separately, the predictive ability of JGES and ASGE_BSG guidelines’thromboembolic risk stratification after discontinuation of anticoagulation was only median for other system embolism (JGES: area under ROC 0.836[p=0.024,95%CI:0.578-1.000]; ASGE_BSG:area under ROC 0.831 [p=0.022,95%CI:0.582-1.000]). The predictive ability of JGES and ASGE_BSG_ESGE guidelines’ thromboembolic risk stratification after discontinuation of antiplatelet was only low for ACS in our study population. Moreover, only JGES guideline’s bleeding risk stratification held a low predictive ability for total bleeding and minor bleeding events for Chinese elderly patients, the other three guidelines had no predictive ability.Conclusion:the predictive ability of current 4 international guidelines’thromboembolic risk stratification were all relatively low for elderly patients, while only JGES guidelines held a low predictive ability for total bleeding risk and minor bleeding risk for Chinese elderly patients.Part ThreeMultimobidity and peri-endoscopic adverse events in elderly patientsAims:to investigate the relationship between multimorbidity and and peri-endoscopic adverse events, and also to screen out the risk factors for peri-endoscopic adverse events.Materials and methods:Multimorbidity was defined as one paitents with>1 following disease:hypertension, CHD, peripheral vascular disease, diabetes, ischemic stroke, maliglnancy, chronic obstructive pulmonary disease, renal dysfunction, atrial fibrillation, heart failure, and anemia. R×C tables were used to compare the differences of peri-endoscopic adverse events between patients with different number of multimobidities.Results:In 3747 patients, the percentage of patients with 0 multimorbidity,1 multimorbidity,2 multimorbidity,3 multimorbidity,4 multimorbidity, and≥5 multimorbidity were4.62%(173 cases),13.66%(512 cases),20.44%(766 cases), 23.33%(874 cases),18.31%(686 cases), and 19.64%(736 cases). In patients with 0 multimorbidity,1 multimorbidity,2 multimorbidity,3 multimorbidity,4 multimorbidity and ≥5 multimorbidity:the incidence of total thromboembolic events rate were 0.00%, 0.20%,1.04%,1.49%,2.19%, and 6.39%(p<0.001) respectivley; the incicdence of ACS were 0.00%,0.00%,0.78%,1.26%,1.60%, and 4.76% respectively (p<0.001); the incidence of ischemic stroke were 0.00%,0.00%,0.26%,0.23%,0.58%, and 1.08% respectively (p=0.023); the incidence of other system embolism were 0.00%,0.20%, 0.00%,0.00%,0.00%, and 0.54% respectively (p=0.034); the incidence of peri-endocsopic total bleeding were 0.00%,0.59%,0.78%,1.729%,1.75%, and 4.76% respectively (p<0.001); the incidence of major bleeding were 0.00%,0.00%,0.13%, 0.46%,0.29%, and 0.54% respectively (p=0.232); the incidence of minor bleeding were 1.16%,0.59%,0.65%,1.26%,1.17%, and 4.21% respectively (p<0.001).Conclusion:We first introduce the conception of multimorbidity into the investigation of peri-endoscopic adverse events in elderly patients. Our results revealed that, as increasing of the number of multimorbidity, peri-endoscopic incidence of thromboembolism and bleeding increased. All events were found to be highest in patients with ≥5 multimorbidity.Part FourInvestigation on the risk factors of peri-endoscopic adverse eventsAim:to investigate the risk factors of peri-endoscopic adverse events in elderly patients with multimorbidity.Materials and methods:Multivariate regression analysis was uses to determine risk factors for peri-endoscopic adverse events including thromboembolic events and bleeding events.Results:Multivariate regression analysis revealed that CHD (OR5.58,95%CI 1.81-17.23, p=0.003), hypertension (OR3.51,95%CI 1.28-9.62, p=0.015), and atrial fibrillation (OR1.58,95%CI 1.01-5.88, p=0.021) were independent risk factors for peri-endoscopic thromboembolic events. Past history of major bleeding (OR10.15, 95%CI 1.37-75.36, p=0.024) and atrial fibrillation (OR3.82,95%CI 1.36-10.72, p=0.011) were independent risk factors for peri-endoscopic bleeding events. D-dimer and C-reactive protein (CRP) were independent risk factors for both peri-endoscopic thromboembolic events (D-dimer:HR1.49,95%CI 1.13-1.97, p=0.045; CRP:HR1.15, 95%CI 1.02-1.31, p=0.024) and bleeding events (D-Ddimer:HR1.55,95%CI 1.18-2.05, p=0.002; CRP:OR 1.15,95%CI 1.02-1.29, p-0.022). Total Bleeding rate in patients with gastric polyp> 0.5cm are significantly higher than those with gastric polyp<0.5cm (9.09% vs 1.05%, p=0.031). Total Bleeding rate in patients with colonic/rectal polyp≥0.5cm are significantly higher than those with colonic/rectal polyp<0.5cm (4.13% vs 1.37%, p=0.014).Conclusion:CHD, hypertension, and atrial fibrillation were independent risk factors for peri-endoscopic thromboembolic events. Past history of major bleeding and atrial fibrillation were independent risk factors for peri-endoscopic bleeding events. D-dimer and CRP were independent risk factors for both peri-endoscopic thromboembolic events and bleeding events. In elderly patients, bleeding risk increases when gastrointestinal polyp≥0.5cm.Part FiveInvestigation on the management of peri-endoscopic antithrombotic therapy inelderly patients with multimorbidityAim:to investigate the management of peri-endoscopic antithrombotic therapy in 3747 patients in order to provide actual clinical data for management of peri-endoscopic antithrombotic agents in elderly patients with multimorbidity.Materials and methods:R×C tables were used to compare the differences of peri-endoscopic adverse events between patients with different management strategies of peri-endoscopic antithrombotic therapy.Results:In 3747 paitents, before endoscopic procedure, the incidence of peri-endoscopic thromboembolism in patients with non-discontinuation of antithrombotic therapy, in patients with cessation of antithrombotic therapy 0-7 days, and in patients with cessation of antithrombotic therapy≥7 days were 0.00%,1.87%, and 8.12% respectively (p<0.001). After endoscopic procedure, the incidence of peri-endoscopic thromboembolism in patients with resuming antithrombotic therapy≤2 days, in patients with resuming antithrombotic therapy 2-7 days, in patients with resuming antithrombotic therapy>7 days, and in patients without esuming antithrombotic therapy were 0.73%,2.07%,7.56%, and 7.27% repectively(p<0.001). When discontinuation of antithrombotic therapy, the difference of peri-endoscopic thromboembolic events between patients receiving low-molecular-weight heparin (LMWH) bridging therapy and those without LMWH bridging therapy was not significant (3.08%VS3.85%,p=0.569). As for peri-endoscopic bleeding events, before procedure, the incidence in patients with non-discontinuation of antithrombotic therapy, in patients with cessation of antithrombotic therapy 0-7 days, and in patients with cessation of antithrombotic therapy≥7 days were 0.00%,2.38%, and 1.68% respectively (p=0.678). After endoscopic procedure, the incidence of peri-endoscopic bleeding in patients with resuming antithrombotic therapy≤2 days, in patients with resuming antithrombotic therapy 2-7 days, in patients with resuming antithrombotic therapy>7 days, and in patients without esuming antithrombotic therapy were 3.15%, 0.63%,3.91%, and 6.36% repectively(p<0.001). When discontinuation of antithrombotic therapy, the difference of peri-endoscopic bleeding events between patients receiving LMWH bridging therapy was higer than those without LMWH anticoagulation bridging therapy, but the differenc was not significant (2.83%VS2.03%,p=0.343). The same trends were observed in patients with multimorbidity≥2 and in patients with multimorbidity≥5.Conclusion:the reason that the bleeding rates of patients with resuming antithrombotic therapy>7 days, and without esuming antithrombotic therapy were higher than those with resuming antithrombotic therapy 2-7 days was that the occurrence of bleeding events caused clinical physician to postpone the resuming of antithrombotic therapy or cancel the resumption. Our results showed that cessation of antithrombotic therapy<7 days before endoscopic procedure and resumption of antithrombotic therapy in 2-7days were reasonable strategy for elderly patients with multimorbidity. Bridging therapy of LMWH when cessation of antithrombotic therapy couldn’t provide protection from peri-endoscopic thromboembolic events. On the other hand, bridging therapy seemed to increase peri-endoscopic bleeding. |
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