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• W4206650854 abstract "We are heartened by the interest of Drs Zhu and Xu1Zhu H. Xu H. Warfarin should be switched to heparin bridging for patients with high thromboembolic risk.Gastrointest Endosc. 2020; 92: 796-797Abstract Full Text Full Text PDF Scopus (1) Google Scholar in our work.2Tien A. Kwok K. Dong E. et al.Impact of direct-acting oral anticoagulants and warfarin on postendoscopic GI bleeding and thromboembolic events in patients undergoing elective endoscopy.Gastrointest Endosc. 2020; 92: 284-292Abstract Full Text Full Text PDF Scopus (6) Google Scholar Regarding bridging, the medical decision making behind bridging off warfarin comes from active comanagement by our region-wide anticoagulation service. Their current guidelines are aligned with the 2017 American College of Cardiology (ACC) Expert Consensus Decision Pathway, which recommends the consideration of bridging for patients with a moderate to high thrombotic risk (CHA2DS2-VASc of 5 to 6, or 7+).3Doherty J.U. Gluckman T.J. Hucker W.J. et al.2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force.J Am Coll Cardiol. 2017; 69: 871-898Crossref PubMed Scopus (208) Google Scholar In our methods, we stated that we excluded patients who were receiving single-agent therapy with heparin, clopidogrel, and low-molecular-weight heparin. However, we would like to clarify that patients who were bridged were not included as being in that single-agent therapy group with the listed agents. In our cohort, 16.0% (829/5178) of the warfarin cohort were at moderate risk, with CHA2DS2-VASc 5 to 6, and 2.5% (132/5178) were at high risk, with CHA2DS2-VASc 7+. The decision to bridge is mainly based on clinical judgement depending on the patient’s risk factors such as prior stroke, prior transient ischemic attack, and bleeding risk. For example, high-risk patients (CHA2DS2-VASc 7+) who have had a recent thromboembolic event within 3 months of a planned endoscopy and have no increased risk for bleeding would likely be bridged. In these cases, our anticoagulation clinic’s agent of choice for outpatient procedures would be enoxaparin. Although patients with CHA2DS2-VASc 1 to 4 are at increased risk for a thromobolic event, they are classified in the low-risk group per the ACC guidelines and are not recommended to be bridged.3Doherty J.U. Gluckman T.J. Hucker W.J. et al.2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force.J Am Coll Cardiol. 2017; 69: 871-898Crossref PubMed Scopus (208) Google Scholar Regarding the suggestion on reclassification, we agree it may be a worthwhile consideration to reclassify procedures into “low risk” and “high risk” in future analyses as these medications become more widely used.2Tien A. Kwok K. Dong E. et al.Impact of direct-acting oral anticoagulants and warfarin on postendoscopic GI bleeding and thromboembolic events in patients undergoing elective endoscopy.Gastrointest Endosc. 2020; 92: 284-292Abstract Full Text Full Text PDF Scopus (6) Google Scholar,4Acosta R.D. Abraham N.S. Chandrasekhara V. et al.The management of antithrombotic agents for patients undergoing GI endoscopy.Gastrointest Endosc. 2016; 83: 3-16Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar For the present analysis, owing to the low numbers of patients in the high-risk bleeding subgroups, we wanted to focus our analysis on procedures that were more commonly performed in routine clinical practice. Nevertheless, this is definitely an area ripe for ongoing investigation, the results of which will be pertinent to interventional endoscopists across the world. All authors disclosed no financial relationships. Warfarin should be switched to heparin bridging for patients with high thromboembolic riskGastrointestinal EndoscopyVol. 92Issue 3PreviewWe read with great interest the article by Tien et al.1 The authors presented some new findings indicating that direct oral anticoagulants (DOAC) did not increase the risk of postendoscopic GI bleeding and thromboembolic (TE) events when compared with warfarin, as per the data of a large integrated healthcare system. Endoscopists need to continually strike a balance between bleeding and thromboembolism in patients taking anticoagulants. Notably, this research provided evidence for endoscopists regarding anticoagulant management in the preoperative stage, especially for DOAC. Full-Text PDF" @default.
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• W4206650854 title "Response" @default.
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