Risk assessment in UGIB:

recent PCI & ACS

Dr Martin James PhD FRCP

October 20th 2016

Nottingham Endoscopy Masterclass

Clinical scenario

65 yr male

Previous smoker, hyperlipidaemia, DM

PCI < 48 hours

Dual antiplatelet therapy & LMWH

Active bleeding – melaena, hypotension,

tachycardia

GBS 12; pre-endo Rockall score 5

ECG

Glasgow-Blatchford Bleeding Score

Requires FBC, U&E and basic

clinical assessment

Simple

Ready within 1 hour

Assessed against composite

end-point of:

Clinical intervention

(transfusion, endoscopic

treatment or surgery)

Death 30d

Rockall et al 1996

Glasgow-Blatchford Bleeding Score

Stanley Lancet 2009

Stanley Lancet 2009

Rockall Score

Risk Score Rebleed % Mortality %

0 5 0

1 3 0

2 5 0.2

3 11 3

4 14 5

5 24 11

6 33 17

7 44 27

8+ 42 41

Rockall et al 1996

Key questions

How common & what causes GI bleeding after

ACS/PCI?

Efficacy & risks of conservative measures?

Likelihood of therapeutic intervention?

What is the clinical outcome?

Risks associated with endoscopy post ACS?

Should antiplatelets/anticoagulation be stopped?

Key questions

How common & what causes GI bleeding after

ACS/PCI?

Efficacy & risks of conservative measures

Likelihood of therapeutic intervention?

What is the clinical outcome?

Risks associated with endoscopy post ACS?

Should antiplatelets/anticoagulation be stopped?

Secondary prevention - evidence

Study Year n Follow up Drugs CVS event Bleeding

COGENT

(dual therapy)

2010 NEJM 3800 6m ASA/Clopi

+Omeprazole

4.9% 1.1%

ASA/Clopi

+placebo

5.7% 2.9%

CHARISMA

(ACS pts)

2010 NEJM 15,600 28m Aspirin 75 7.3% 1.7%

Aspirin 75/

Clopi 75

6.8% 1.3%

OASIS-7

(PCI)

2010 NEJM 25,000 30d Clopi HD/

Aspirin 75

4.2% 2.5%

Clopi LD

/aspirin

4.4% 2.0%

PROFESS

(CVA)

2008 NEJM 20,000 2.5y Aspirin/

dipyridamole

9.0% 4.1%

Clopidogrel 8.8% 3.6%

Bleeding events post PCI

Koscinas ; Circ Cardiovent Intervent 2015

Causes of UGIB after ACS/PCI

COMMON (90%):

Peptic ulceration

Gastritis, duodenitis

Oesophagitis

UNCOMMON (10%):

Variceal haemorrhage

UGI malignancy

Dieulafoy Lesion

Mallory Weiss tear

Shalev Int J Cardiol 2012

Ng Am J Gastro 2008

Yachimski Dig Dis Sci 2011

Key questions

How common & what causes GI bleeding after

ACS/PCI?

Efficacy & risks of conservative measures

Likelihood of therapeutic intervention?

What is the clinical outcome?

Risks associated with endoscopy post ACS?

Should antiplatelets/anticoagulation be stopped?

Rebleed rates

Rebleed <5 days; PPI alone

11-34%

Rebleed <5 days; following endoscopic therapy

9% in high risk lesion

3% in low risk lesion

Khurooo NEJM 1997

Jung AM J Gastro 2002

Bleau GIE 2002

Bini GIE 2003

Yachimski Dig Dis Sci 2011

0

20

40

60

80

100

Active

bleeder

NBVV Clot Dot Clean

base

bleeder

7%NBVV

8%

clot

13%dot

23%

Clean base

49%

Stigmata of Bleeding Risks of Re-bleeding and Prevalence

Key questions

How common & what causes GI bleeding after

ACS/PCI?

Efficacy & risks of conservative measures

Likelihood of therapeutic intervention?

What is the clinical outcome?

Risks associated with endoscopy post ACS?

Should antiplatelets/anticoagulation be stopped?

Clinical outcomes – UGIB in ACS

Findings in acute severe overt GI bleeding:

Identify bleeding source 90%

Need for endoscopic intervention:

39%

Procedure related mortality 1%

30d mortality in ACS and UGIB 10-33%

Cappell Am J Med 1999

Cappell Dig Dis Sci 2005

Lin Dig Dis Sci 2005

Yachimski Dig Dis Sci 2011

Haemoglobin targets?

Villaneuva NEJM 2013

NEJM; VILLANAEUVA NEJM 2013

TRIGGER STUDY;

Jairath LANCET 2015

TRIGGER Subgroup analyses – Hb <12 g/dL

Outcome Liberal

(n=383)

Restrictive

(n=257)

Difference and

95% CI

P-value

Ischaemic heart disease

Further bleeding (Day 28) – no. (%)

6/66 (9) 3/46 (7) -2.7 (-20.8 to 15.4) 0.85

Mortality – no. (%) 2/67 (3) 6/49 (12) -10.7 (-9.8 to 31.2) 0.11

Variceal bleeding

Further bleeding (Day 28) – no. (%)

7/51 (14) 4/22 (18) -0.7 (-40.2 to 41.6) 0.73

Mortality – no. (%) 6/55 (11) 1/23 (4) -7.1 (-20.3 to 6.0 0.18

Anaesthetic Support in Major Upper

Gastrointestinal Bleeding?

NICE 2012

• Cardio-respiratory support

not specifically addressed

SIGN 2008

• Highlights risk of airway

compromise and need for

appropriately trained staff

but no specific guidelines

regarding use of

anaesthetic support

BSG 2006

• Anaesthetic support

recommended for large

UGIB where there is

depressed LOC or reduced

patient co-operation. Also

considers those who may

be at risk of oversedation

and aspiration pneumonia

Current NUH Algorithm

Initial patient assessment indicates urgent

endoscopy is required

• Exsanguinating (ongoing

haemodynamic compromise after

initial resuscitation)

• Active fresh haematemesis

with haemodynamic compromise

• Risk of airway compromise

(reduced consciousness,

vomiting, agitation,

uncooperative)

• Urgent endoscopy needed out

of office hours

Yes to any

No

Perform endoscopy in

emergency theatre

Stabilise and endoscopy

<12 hours

Principal recommendations:

• Hospitals must provide 24/7 access to on-site

endoscopy, IR, GI surgery and critical care

anaesthesia

• Patients with major GIB should be discussed

with duty on-call endoscopist within 1 hour

• GIB + haemodynamic instability require OGD

within 2 hours of optimal resuscitation

• Ongoing management of major bleeds rests with

named consultant Gastroenterologist

• Clearly documented re-bleed plans

Patient Characteristics –

NUH UGIB GA cases 2015

Gender

Male:Female ratio 60:35

Age (years) mean ± SD

Males 59.2 ± 19.1

Females 55.2 ± 28.4

ASA (%)

Grade 1 7.4

Grade 2 10.5

Grade 3 44.2

Grade 4 34.7

Grade 5 3.2

Urgency Code (%)

1 64.2

3 25.3

6 4.2

12 4.2

24 2.1

GBS Score

Yes (%) 17 (18%)

Median (range) 12 (1 – 19)

Post-OGD complications

• MI: n=5 (5.3%)

• ARF: n=24 (25%)

• Respiratory failure: n=15 (15.8%)

• Heart failure: n= 11 (11.6%)

• Sepsis: n=22 (23.2%)

• Mortality: n=20 (21 %)

Key questions

How common & what causes GI bleeding after

ACS/PCI?

Efficacy & risks of conservative measures

Likelihood of therapeutic intervention?

What is the clinical outcome?

Risks associated with endoscopy post ACS?

Should antiplatelets/anticoagulation be stopped?

Risks of endoscopy post ACS/MI

Overall 30%

Mostly self-limiting

Hypotension

arrhythmia

16% evidence of myocardial ischaemia

Procedure related mortality 1%

Key questions

How common & what causes GI bleeding after

ACS/PCI?

Efficacy & risks of conservative measures

Likelihood of therapeutic intervention?

What is the clinical outcome?

Risks associated with endoscopy post ACS?

Should antiplatelets/anticoagulation be stopped?

Methods

Patients on aspirin for secondary prophylaxis

Bleeding controlled endoscopically

All had 72h PPI then po pantoprazole 40mg

Randomised to aspirin 80mg or placebo for 8 weeks

RCDBT 2003-2006

Single institution

Follow-up at 30 and 56 days

No Hp eradication

Primary outcome

Aspirin re-bleeding (n=8):

1 GU/ 7DU

Same site as index bleed

6 within 10 days

Placebo (n=4)

4 DU re-bleeds

(2 others likely re-bleed but

too unwell for OGD)

3 within 10 days

Secondary Outcomes

NICE UGIB 2012

Conclusions

2% ACS/PCI patients have acute UGIB & are high risk

90% will have OGD findings

Mostly UGI ulceration or inflammatory changes

40% require endo therapy

Monitoring & anaesthetic support

Blood transfusion targets?

Post-procedure monitoring & re-bleed plans

Algorithmic approach? PCI/ACS & significant UGIB bleed

Resuscitate & stabilise

– Hb 10g/L

Risk assess GBS/

Pre-endo Rockall

Upper GI endoscopy

-identify source

-dual endo therapy

Anaesthetic support

and monitoring

Post endoscopy PPI, anti-platelets, monitoring

Close liaison with cardiologists & patient