Optimizing Antithrombotic Therapy in Patients With Coexisting Cardiovascular and Gastrointestinal Disease Publisher



Talasaz AH¹ ; Sadeghipour P⁵ ; Ortegapaz L⁶ ; Kakavand H^{5, 7} ; Aghakouchakzadeh M⁸ ; Beavers C⁹ ; Fanikos J¹⁰ ; Eikelboom JW¹¹ ; Siegal DM¹² ; Monreal M¹³ ; Jimenez D¹⁴ ; Vaduganathan M¹⁵ ; Castellucci LA¹⁶ ; Cuker A¹⁷ Show All Authors
Source: Nature Reviews Cardiology Published:2024

Abstract

Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases. © Springer Nature Limited 2024.; Balancing the safety and efficacy of antithrombotic therapy in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs or for an increased risk of bleeding. Various clinical states, including malabsorption syndromes, bariatric surgery, short-bowel syndrome or enteral tube feeding, can influence the absorption and bioavailability of oral antithrombotic agents. Bleeding events are an essential prognosticator in patients with cardiovascular diseases — at times as important as thrombotic events — and using antithrombotic agents in patients at high risk of gastrointestinal bleeding (GIB) is very challenging. Most of the existing models to predict the risk of bleeding in patients with coronary artery disease do not estimate the risk of GIB specifically. Identifying patients at high risk of GIB, modifying the bleeding risk by using gastroprotective agents, and determining the appropriate antithrombotic therapy regimen have crucial roles in preventing GIB. After an episode of acute GIB, determining the duration of antithrombotic therapy interruption and the regimen for re-initiation requires consideration of the balance between the bleeding severity and the risk of thrombotic events. © Springer Nature Limited 2024..