Antiplatelet therapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. Key messages for clinical practice

Should we interrupt antiplatelet therapy (acetylsalicylic acid [ASA] alone or in combination with clopidogrel) in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal (GI) procedures? The relevant evidence was critically appraised in a recent White Paper from the American College of Gastroenterology and the American College of Cardiology. Clinicians need to qualify and compare 2 competing risks: the increased risk of bleeding if antiplatelet therapy is maintained during the endoscopic GI procedure, vs. the increased risk of cardiovascular (CV) thrombosis if antiplatelet therapy is interrupted or modified in the periprocedural period. ASA treatment may be continued for all endoscopic GI procedures, provided that there is no pre‑existing bleeding disorder. Clopidogrel administration could be maintained for low-risk endoscopic GI procedures, such as diagnostic endoscopy of the upper or lower GI tract with or without biopsies. For patients on clopidogrel undergoing high-risk endoscopic GI procedures, such as polypectomy or phincterotomy, the individualized risk of CV complications from clopidogrel discontinuation should be assessed. During the first month following bare‑metal stent implantation or the first 6 (possibly 12) months following drug‑eluting stent placement the CV risk is particularly high, therefore elective high-risk endoscopic GI procedures should be deferred accordingly. In all other clinical situations requiring clopidogrel treatment, the risk of CV events is lower than above. Therefore, clopidogrel treatment could be interrupted for 7 to 10 days before the procedure (and restarted as soon as possible after the procedure), provided that ASA treatment is maintained.