Risk Factors For Gastrointestinal Bleeding Research Articles

Mo1285 – Recent Trends in Bleeding Location and Risk Factors for Gastrointestinal Bleeding in Patients Receiving Anticoagulation Therapy

Mo1285 – Recent Trends in Bleeding Location and Risk Factors for Gastrointestinal Bleeding in Patients Receiving Anticoagulation Therapy

Frequency of nonaspirin NSAID-relevant coexisting medical conditions in the primary-care setting: a retrospective database review.

BackgroundCoexisting medical conditions and concomitant medications contribute to treatment challenges primary-care professionals (PCPs) face daily. The current study assessed the extent and distribution of nonaspirin NSAID-relevant coexisting medical conditions of interest (CMCOI) in patients visiting PCPs.MethodsThis retrospective database review analyzed data from three large health-care claim databases to identify the frequency of nonaspirin NSAID-relevant CMCOI among adults aged ≥18 years with a PCP visit in 2013. Claim databases employed were the Truven Health MarketScan® Commercial Claims and Encounters database, representative of the privately insured (PI) population; Truven Health MarketScan Multi-State Medicaid, representative of the Medicaid population (Medicaid); and Truven MarketScan Medicare Supplemental, representative of the Medicare population with employer-based supplemental Medicare insurance (Medicare-Supplement). Nonaspirin NSAID-relevant CMCOI, asthma, cardiovascular risk factors, gastrointestinal bleeding risk factors, and renal insufficiency were chosen based on US NSAID over-the-counter Drug Facts label warnings. Frequency of CMCOI was determined for those without and with a musculoskeletal diagnosis.ResultsIn each database, ≥19% (19.0% PI, 29.9% Medicaid, 33.6% Medicare-Supplement) had a musculoskeletal diagnosis. A greater proportion of individuals with a musculoskeletal diagnosis had one or more CMCOI compared with those without a musculoskeletal diagnosis (61.3% vs 50.4% PI, 78.1% vs 66.8% Medicaid, 87.1% vs 82.3% Medicare-Supplement). The frequency of one or more CMCOI increased with age in each database. Across databases among CMCOI, cardiovascular risk factors were most common, followed by gastrointestinal bleeding risk factors, and proportions were higher among those with a musculoskeletal diagnosis.ConclusionThese data confirm the high frequency of nonaspirin NSAID-relevant CMCOI among patients presenting to PCPs for musculoskeletal diagnosis, as well as among older patients. These analyses reinforce the critical role health-care professionals can play in identifying patients with nonaspirin NSAID-relevant CMCOI, providing those patients with ongoing guidance on appropriate choice and use of over-the-counter analgesics, and educating patients about the impact aging, health status, concomitant conditions, and medicines have on selection of all medicines, including analgesics.

Meta analysis of risk factors for gastrointestinal bleeding in patients with cerebrovascular disease

Meta analysis of risk factors for gastrointestinal bleeding in patients with cerebrovascular disease

Appropriateness of Acid-suppressing Agents for Stress Ulcer Prophylaxis in Non-intensive Care Unit Setting in Saudi Arabia.

Objective:To investigate the appropriateness of acid-suppressive therapy (AST) for stress ulcer prophylaxis (SUP) in noncritically ill hospitalized patients.Materials and Methods:A prospective, observational study with 384 subjects was conducted between October and December 2017 in the emergency and internal medicine departments. The Herzig clinical risk scoring system and the guidelines of the American Society of Health-System Pharmacists guidelines were used to assess risk factors and determine risk scores for gastrointestinal (GI) bleeding.Results:The mean age of subjects was 51.9 ± 19.4 years, and 220 (57.3%) of them were males. Among the absolute risk factors, coagulopathy was observed in 2 (0.5%) patients, mechanical ventilation in 15 (3.9%), and a history of GI bleeding in 1 (0.3%). Of 384 patients with SUP, 370 (96.4%) had a clinical risk score ≤ 9 and 14 (3.6%) had a risk score between 10 and 12 for nosocomial GI bleeding. A statistically significant relationship was found between the risk factor indication and demographics.Conclusion:SUP is frequently administered to noncritically ill hospitalized patients lacking risk factors for GI bleeding. Proton pump inhibitors are the overwhelming first choice of AST among prescribers. Practitioners should follow international guidelines when prescribing ASTs outside the critical-care setting.

Mortality rate and risk factors for gastrointestinal bleeding in elderly patients

BackgroundGastrointestinal bleeding (GIB) is burdened by high mortality rate that increases with aging. Elderly patients may be exposed to multiple risk factors for GIB. We aimed at defining the impact of GIB in elderly patients. MethodsSince 2008, samples of elderly patients (age ≥ 65 years) with multimorbidity admitted to 101 internal medicine wards across Italy have been prospectively enrolled and followed-up (REPOSI registry). Diagnoses of GIB, length of stay (LOS), mortality rate, and possible risk factors, including drugs, index of comorbidity (Cumulative Illness Rating Scale [CIRS]), polypharmacy, and chronic diseases were assessed. Adjusted multivariate logistic regression models were computed. Results3872 patients were included (mean age 79 ± 7.5 years, F:M ratio 1.1:1). GIB was reported in 120 patients (mean age 79.6 ± 7.3 years, F:M 0.9:1), with a crude prevalence of 3.1%. Upper GIB occurred in 72 patients (mean age 79.3 ± 7.6 years, F:M 0.8:1), lower GIB in 51 patients (mean age 79.4 ± 7.1 years, F:M 0.9:1), and both upper/lower GIB in 3 patients. Hemorrhagic gastritis/duodenitis and colonic diverticular disease were the most common causes. The LOS of patients with GIB was 11.7 ± 8.1 days, with a 3.3% in-hospital and a 9.4% 3-month mortality rates. Liver cirrhosis (OR 5.64; CI 2.51–12.65), non-ASA antiplatelet agents (OR 2.70; CI 1.23–5.90), and CIRS index of comorbidity >3 (OR 2.41; CI 1.16–4.98) were associated with GIB (p < 0.05). ConclusionsA high index of comorbidity is associated with high odds of GIB in elderly patients. The use of non-ASA antiplatelet agents should be discussed in patients with multimorbidity.

Von Willebrand Disease and Gastrointestinal Bleeding: A National Inpatient Sample (NIS) Study

Background:Von Willebrand disease (VWD) is a common congenital bleeding disorder, caused by defective or deficient von Willebrand factor (VWF), and characterized by mucosal bleeding. Among these, recurrent gastrointestinal (GI) bleeding may be serious and life-threatening,requiring hospitalization in 30%. Diagnosis and management remain challenging, and the prevalence and correlates of GI bleeding in VWD are not well understood.Methods. We conducted a cross-sectional study using discharge data from the National Inpatient Sample (NIS) between January 1, 2009 and December 31, 2014 to identify factors associated with GI bleeding in VWD. NIS is the largest publicly available inpatient database in the U.S. developed by Healthcare Cost and Utilization Project (HCUP), containing a 20% stratified sample of U.S. hospital discharges. Discharges of individuals with and without VWD were evaluated by age, race, gender, primary and secondary diagnoses, length of stay, insurance, and discharge status. International Classification of Diseases, 9thedition, Clinical Modification (ICD9-CM) codes were used to classify de-identified discharge data by causes of GI bleeding, medications, blood products, and comorbidities. Discharge-level weights from the NIS database were used to produce estimates representative of all U.S. community hospitals. We compared GI bleeding prevalence between patients with and without VWD, and among those with VWD, the demographics (age, gender, race), length of stay, inpatient mortality, payor, medical comorbidities, and potential causes of and risk factors for GI bleeding. Categorical variables were compared by Rao-Scott chi-square test, and continuous variables by weighted simple linear regression. Independent factors associated with GI bleeding in VWD were determined by a weighted multivariable logistic regression model.Results:Individuals with VWD and GI bleeding were younger than those without GI bleeding, 58.5 yr vs 45.2 yr, and were more likely male, 42.3% vs 25.9%, and Black, 12.3% vs 7.5%, each p<0.0001. Overall, the prevalence of upper GI bleeding (UGI) was greater than lower GI bleeding (LGI) in VWD, 57.4% vs 44.4%; but these rates were significantly higher in non-VWD, 65.5% vs 35.6%, each p<0.001. The most common cause of GI bleeding in VWD was angiodysplasia, 36.5% (LGI 19.7%, UGI 16.3%) which was significantly more common than in non-VWD, 9.5% (LGI, 4.1%, UGI, 4.9%), p<0.0001. By contrast, the next most common causes of GI bleeding in VWD were ulcer disease, 10.8%; diverticulitis, 9.7%; and gastritis/ duodenitis, 8.9%, each less common than in non-VWD, 20.7%, 16.7%, and 12.5%, p<0.01. The most common ulcer type was gastric ulcer, 6.5% vs 14.1%, respectively, p<0.0001.Among VWD patients, those with GI bleeding were more likely than those without GI bleeding to receive aspirin, 3.3% vs 2.0% (p=0.030), platelet transfusion, 4.0% vs 2.1% (p=0.0012), and coagulation factor, 7.8% vs 4.6% (p=0.0003). Comorbidities were also more common in VWD with GI bleeding, including surgery, 73.4% vs 57.6%; hypertension, 36.7% vs 29.1%; hyperlipidemia, 24.6% vs 16.9%; GERD, 19.3% vs 16.1%; smoking, 17.1% vs 10.7%); diabetes, 15.0% vs 10.9%; chronic kidney disease, 12.2% vs 6.3%; hepatitis C, 9.2% vs 3.2%; thrombocytopenia, 7.6% vs 3.9%; liver disease, 7.5% vs 2.6%; aortic valve disease, 5.5% vs 2.0%; and vascular assist device, 2.2 vs 0.4%, each p<0.0001. Severity of illness, 1.5 vs 0.9, p<0.0001, and inpatient mortality, 2.4% vs 1.2%, p=0.011 were higher in VWD with GI bleeding than without GI bleeding.In a multivariable model, variables significantly associated with GI bleeding in VWD were angiodysplasia, OR=104.06 [95% CI: 75.14, 144.11]; diverticulitis, OR=16.66 [11.85, 23.42]; hepatitis C, OR=2.17 [1.40, 3.36]; Black race, OR=1.80 [1.31, 2.47]; male gender, OR=1.61 [1.29, 1.99]; and smoking, OR=1.40 [1.04, 1.88].Conclusion.The most significant correlates of GI bleeding in VWD are angiodysplasia, diverticulitis, hepatitis C, Black race, male gender, and smoking. Identification of VWD at high risk for GI bleeding with consideration for factor prophylaxis after the first GI bleed, may help reduce the morbidity of recurrent GI bleeding in VWD. [Display omitted] DisclosuresRagni:Bioverativ: Consultancy, Research Funding; CSL Behring: Research Funding; MOGAM: Membership on an entity's Board of Directors or advisory committees; Shire: Research Funding; SPARK: Consultancy, Research Funding; Alnylam: Membership on an entity's Board of Directors or advisory committees, Research Funding; Biomarin: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novo Nordisk: Research Funding; Sangamo: Research Funding.

Incidence of Bleeding in Patients with Sickle Cell Disease: A Population Based Study

Background:Bleeding in patients with sickle cell disease (SCD) occurs at a number of sites, often with significant morbidity and mortality. The increased risk of hemorrhagic stroke, hematuria, and vitreous hemorrhage in SCD patients is well known. However, the overall cumulative incidence of both major and clinically relevant, non-major bleeding events in SCD patients has not been well-described. Therefore, we determined the cumulative incidence of and risk factors for bleeding amongst patients with SCD. We also determined the association between bleeding and overall mortality.Methods:We utilized the California Patient Discharge Dataset (PDD) and Emergency Department (ED) Dataset to identify patients with SCD between 1991-2014. We then used specific ICD-9 CM codes to identify the first admission (PDD or ED) for bleeding events: intracranial hemorrhage (ICH), gastrointestinal (GI) bleeding, hemophthalmos, gross hematuria, and “other” bleeding (including hemopericardium, pulmonary bleed, and hemarthrosis). The cumulative incidence of bleeding was adjusted for the competing risk of death using age as the time scale and stratified by disease severity (severe disease was defined as requiring an average of ≥ 3 hospitalizations or ED visits per year). Cox proportional hazards regression models were used to determine factors associated with bleeding (all, ICH and GI) and the association of bleeding with mortality. Models included age, race, SCD related complications (ischemic stroke, venous thromboembolism [VTE], osteonecrosis of the femoral head [ONFH], renal failure, and liver failure) and disease severity. Complications and bleeding were included as time-dependent covariates.Results:Of the 6,423 SCD patients identified, 15.9% had an index bleeding event. Of these, 65.6% were GI bleeding, 14.2% were ICH, 7.1% were hemophthalmos, 4.3% were gross hematuria, and 8.8% were other types of bleeding. The top six diagnoses of GI bleeding were GI hemorrhage not otherwise specified, melena, hematemesis, rectal and anal hemorrhage, chronic gastric ulcer with hemorrhage, and Mallory-Weiss syndrome. Figure 1 shows the cumulative incidence of bleeding overall and by bleeding type. The incidence of all bleeding was 15.5% (95% confidence interval (CI) 14.4 - 16.6) at age 40 years and 33.6% (CI 31.5 - 35.8%) at age 60. The incidence of bleeding was higher among SCD patients with severe disease. For example, the cumulative incidence of GI bleeding at age 40 was 15.8% (CI 14.2-17.4%) among severe SCD patients compared to 4.8% (CI 3.9-5.8%) for those with less severe disease. In multivariable models, a higher risk of all bleeding was associated with severe SCD, VTE within 180 days prior to bleeding event, ONFH, ischemic stroke, renal failure and liver failure (Table 1). In multivariable models by bleeding type, there was a strong association between VTE and ischemic stroke with risk of ICH. In addition, ONFH was positively associated with risk of GI bleed. Bleeding was associated with a two-fold increased risk of death (hazard ratio =2.28; CI 1.97-2.64), adjusted for other SCD related complications. Bleeding had a similar negative effect on mortality as other complications.Conclusion:The findings from our study indicate that SCD patients have a high cumulative incidence of bleeding. While the increased incidence of intracranial, urological, and retinal bleeding has been previously described and are confirmed here, we present the novel finding that SCD patients also have a high incidence of GI bleeding, the majority of which are from an upper GI source. The association of hemorrhagic stroke with a history of ischemic stroke is also confirmed. The association of bleeding with VTE is likely due, at least in part, to anticoagulation. Further studies on the causes and risk factors for GI bleeding in patients with SCD are warranted, and possibilities include gastritis from increased use of non-steroidal anti-inflammatory drugs (hence the association of ONFH with GI bleeding) and stress ulcerations from frequent hospitalizations. Such data could inform preventive strategies. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Patients Prescribed Direct-Acting Oral Anticoagulants Have Low Risk of Postpolypectomy Complications

Use of direct-acting oral anticoagulants (DOACs) is increasing, but little is known about the associated risks in patients undergoing colonoscopy with polypectomy. We aimed to determine the risk of post-polypectomy complications in patients prescribed DOACs. We performed a retrospective analysis using Optum's de-identified Clinformatics Data Mart Database (2003-2016) (a de-identified administrative database from a large national insurance provider) to identify adults who underwent colonoscopy with polypectomy or endoscopic mucosal resection (EMR) from January 1, 2011, through December 31, 2015. We collected data from 11,504 patients prescribed antithrombotic agents (1590 DOAC, 3471 warfarin, and 6443 clopidogrel) and 599,983 patients not prescribed antithrombotics of interest (controls). We compared 30-day post-polypectomy complications, including gastrointestinal bleeding (GIB), cerebrovascular accident (CVA), myocardial infarction (MI), and hospital admissions, of patients prescribed DOACs, warfarin, or clopidogrel vs controls. Post-polypectomy complications were uncommon but occurred in a significantly higher proportion of patients receiving any antithrombotic vs controls (P < .001). The percentage of patients in the DOAC group with GIB was 0.63% (95% CI, 0.3%-1.2%) vs 0.2% (95% CI, 0.2%-0.3%) in controls. The percentage of patients with CVA in the DOAC group was 0.06% (95% CI, 0.01%-0.35%) vs 0.04% (95% CI, 0.04%-0.05%) in controls. After we adjusted for bridge anticoagulation, EMR, Charlson comorbidity index (CCI), and CHADS2 (congestive heart failure, hypertension, age over 75, diabetes, stroke [double weight]) score, patients prescribed DOACs no longer had a statistically significant increase in the odds of GIB (odds ratio [OR], 0.90; 95% CI, 0.44-1.85), CVA (OR, 0.45; 95% CI, 0.06-3.28), MI (OR, 1.07; 95% CI, 0.14-7.72), or hospital admission (OR, 0.86; 95% CI, 0.64-1.16). Clopidogrel, warfarin, bridge anticoagulation, higher CHADS2, CCI, and EMR were associated with increased odds of complications. In our retrospective analysis of a large national dataset, we found that patients prescribed DOACs did not have significantly increased adjusted odds of post-polypectomy GIB, MI, CVA, or hospital admission. Bridge anticoagulation, higher CHADS2 score, CCI, and EMR were risk factors for GIB, MI, CVA, and hospital admissions. Studies are needed to determine the optimal peri-procedural dose for high-risk patients.

Gastrointestinal Bleeding During Hospitalization for Transcatheter Aortic Valve Replacement

Introduction: Gastrointestinal bleeding (GIB) has been shown to be the most common bleeding complication post transcatheter aortic valve replacement (TAVR), likely due to multiple factors such as use of antiplatelets agents and anticoagulants, advanced age, chronic kidney disease, and prior history of GI disease. Yet there is a paucity of literature regarding the incidence and risk factors for GIB in this setting. The aim of this study was to determine the incidence and risk factors for GIB immediately following TAVR at UC Davis Medical Center (UCDMC). Methods: We retrospective reviewed medical records of 482 patients who were hospitalized for TAVR at UCDMC between January 1, 2012 to June 30, 2017. The incidence of both upper and lower GIB, and potential risk factors (age, antiplatelet use, chronic liver and kidney disease, Hb level, MCV, PPI use) during the same hospitalization were reviewed. The patterns of gastroenterology consultation, endoscopic findings and therapies were described. Multivariate regression analysis was done to identify independent risk factors for GIB. Results: Mean age was 81.5 years and 50% were males; 23% had CKD stage 3 or worse, 9.5% had history of prior GIB. Mean baseline Hb, MCV and platelet count were 11.9 g/dl, 91.6fl and 191000/ml, respectively. Dual antiplatelet therapy was used in 196 (40.6%) patients. Anticoagulation (mainly with warfarin) was used in 141 (29%) patients. PPIs and H2 receptor blockers were used in 167 (34.6%) and 20 (4%) patient, respectively. Incidence of GIB was 1.4% (7/482) with 5 cases of upper GIB, 1 small intestinal GIB and 1 lower GIB. Endoscopy (2 EGDs, 2 colonoscopies and one video capsule endoscopy) was performed in 5 patients, and showed esophagitis and angiodysplasia (1 in stomach, 1 in jejunum and 1 in cecum) in 2 and 3 patients respectively. Successful endoscopic intervention with argon plasma coagulation was performed in 3 patients with upper and lower angiodysplasia. 1 patient with a deep esophageal ulceration was not a candidate for endoscopic intervention. On multivariate regression, only a low hemoglobin level on admission was associated with increased likelihood of GIB (OR=1.53, CI 1.03-2.27). Conclusion: GIB is rare immediately post- TAVR. Angiodysplasia was the most common etiology in our series of 482 elderly patients, 23% of whom had advanced CKD. When indicated endoscopy is safe and successful in achieving hemostasis. Baseline anemia which is likely due to a preexisting GI lesion was a predictor of GIB in this setting.

Gastrointestinal Bleeding in Patients With Mechanical Ventilation: Insights From the Healthcare Utilization Project

Introduction: Stress ulceration of the gastrointestinal tract causes overt and clinically important bleeding in critically ill patients. It is suggested that Mechanical Ventilation (MV) is one of the most significant risk factors of Gastrointestinal Bleeding (GIB) in the intensive care unit. Very few studies have reported the incidence of GIB in MV patients. We aimed at analyzing data about this complication in MV patients in united states. Methods: We analyzed the National Inpatient Sample (NIS) database years 2002-2014 to identify hospitalizations in which MV was performed (ICD-9 CM code 96.70, 96.71 & 96.72). Hospitalizations complicated by GIB in this cohort were then identified. All primary admissions of GIB were excluded to minimize the bias. Prevalence of comorbidities was determined using Agency for Healthcare Research and Quality (AHRQ) comorbidity measures. Statistical significance of variation in the number of hospital discharges, demographics, cost of care, comorbidity measures and outcomes during the study period were determined using Cochran-Armitage trend test. Results: In 2002 there were 705806 hospitalizations with MV compared to 977560 in 2014. (P=<0.001). The percentage of MV hospitalizations complicated by GIB slightly increased from 7.43% in 2002 to 7.97% in 2014. The In-Hospital Mortality showed slightly improving trend from 46.7% in 2002 to 40.9% in 2014, but still the difference between the MV patients without GIB remains significant. The most commonly associated comorbidities in this cohort was alcoholism (14.1% Vs 8.8%, P=<0.001), congestive heart failure (24.6% Vs 22.6%, P=<0.001) coagulopathies (26.5% Vs 12.5%, P=<0.001), chronic liver disease (11.1% Vs 4.1%, P=<0.001), electrolytes disturbances (63.6% Vs 49.9%, P=<0.001) and chronic renal failure (21.3% vs 16.6%). There was a significant difference in median length of stay (8.22 Vs 11.89 days, P=<0.001) and median cost of care (73914 Vs 106740, P=<0.001) between MV hospitalizations without GIB than with GIB. Conclusion: In this analysis of inpatient sample of patients with MV, slight increase in incidence of GIB with associated high mortality is concerning, as there is more liberal use of proton pump inhibitors in these patients to prevent GIB. Further studies are needed to identify predictors of these trends and factors responsible for such outcomes to better elucidate and perhaps support our findings.

Gastrointestinal Bleeding Is Common in Children With Familial Dysautonomia: A Case-Control Study (1980-2017): Presidential Poster Award

Introduction: Familial dysautonomia (FD) is a rare hereditary disorder caused by mutations in the IKBKAP gene. The disease is characterized by sensory and afferent autonomic abnormalities. Clinical observations suggest that GI bleeds are not infrequent in patients with FD, but their actual frequency is unknown. We aimed to define the incidence of GI bleeding in patients with FD and its associated risk factors. Methods: Cases and age/sex matched controls were retrospectively identified using the NYU FD registry, which includes over 600 patients with genetically confirmed FD. Cases were defined as patients with FD with at least one episode of GI bleeding between January 1, 1980 and September 25, 2017. For each case we selected one to two age-matched controls with FD and no history of GI bleeding. Data on medication use, gastrostomy (G) tube placement, fundoplication, and ambulatory laboratory values obtained within one year before the GI bleed (or matched time period) were compared using univariate logistic regression models. Retinal fundus tortuosity scores (a noninvasive surrogate marker for the microcirculation) were collected from the most recent clinical visit. Continuous variables were evaluated with t-test and categorical variables by Chi squared test. Multivariate analysis was performed. Results: Thirty-nine FD patients with Gl bleeding and 52 controls were included. 62 GI bleeds occurred in 2,144 observed years (28.0 per 1000 person year) with a median age of bleeding at 11 years old (Figure 1). Fifty-three cases (85.5%) were upper GI bleeds from gastric and duodenal ulcers (Figure 2). Bleeds in patients with FD were more likely to occur in those with a G tube (p<0.01) or with a fundoplication (p<0.01) (Table 1). There were no differences in NSAID or SSRI use, age at fundoplication, or age of G tube placement. For a subset of the FD cohort with available ophthalmic fundus imaging (n=61), cases with GI bleeding had no difference in average arteriolar tortuosity score. Conclusion: The incidence of GI bleeding in FD is considerably higher than in the general pediatric population, which has been reported as 0.2 per 1000 person year. Rather than medications, G-tube and fundoplication appear to be the most important risk factors for gastrointestinal bleeding in patients with FD. Moreover, these procedures did not appear to be direct complications of these procedures. The potential role of other factors leading to mucosal injury remain important targets for study and potential interventions.1054_A Demographics. Bleeds in FD patients were more likely to occur in those with a G tube (p<0.01) and in those with a fundoplication (p<0.01). Statistical tests were not performed to compare medications given that zero cases had history of NSAID or SSRI use.1054_B Distribution of gastrointestinal bleed by age frequency. A total of 62 GI bleeds occurred with a median age of bleeding at 13.09 years old.1054_C Location of gastric ulcers. Fifty-three cases (85.5%) were upper GI bleeds from gastric and duodenal ulcers.

Predictive Factors for Gastrointestinal Bleeding Following Hemorrhagic Stroke: A Hospital-Based Cohort Study

Gastrointestinal bleeding is an important complication in the acute phase of hemorrhagic stroke. In this study, we aimed to identify the risk factors for gastrointestinal bleeding in patients with hemorrhagic stroke despite the administration of antiulcer drugs. We conducted a retrospective cohort study of our hemorrhagic stroke cases. We analyzed the background factors associated with gastrointestinal bleeding in the study population and their outcomes. The study included 837 patients: 598 with intracerebral hemorrhages and 239 with subarachnoid hemorrhages. Among them, 22 patients developed gastrointestinal bleeding. Intraventricular hemorrhage (P=0.0019) and ongoing oral anticoagulant use (P=0.0177) were significantly associated with gastrointestinal bleeding. Gastrointestinal bleeding was significantly associated with severe disability at discharge (P=0.0333) and number of days of hospitalization (P=0.0190). The risk factors of poorly controlled gastrointestinal bleeding during the acute phase of hemorrhagic strokes were intraventricular hemorrhage and use of anticoagulant drugs. Patients with a high risk for gastrointestinal bleeding need to be identified and to be given effective prophylactic therapy. (Received October 12, 2017; Accepted March 29, 2018; Published August 1, 2018).

Risk Factors of Gastrointestinal Bleeding After Continuous Flow Left Ventricular Assist Device.

This study aimed to compare von Willebrand factor (vWF) levels, ristocetin cofactor levels, platelet counts, aortic valve movements, and right heart failure (RHF) as risk factors of gastrointestinal (GI) bleeding in patients with continuous flow left ventricular assist device (cf-LVAD). In a single centre, 90 patients (mean age 52.0 ± 10.5 years), of which 59 were male and 31 were female, had cf-LVAD implantation from October 2010 to November 2012. Seventy-six (84.4%) patients had HeartWare (Medtronic, Mounds View, MN) and 14 (15.5%) had Heartmate II (Thoratec, Pleasanton, CA) implanted. vWF level, ristocetin cofactor level, and platelet count were measured before and after implantation to determine the presence of acquired von Willebrand Syndrome; aortic valve movement and postoperative RHF were evaluated to compare the difference in bleeding and nonbleeding patient groups. Fifteen patients (16.6%) suffered GI bleeding after cf-LVAD implantation. A statistically significant decrease was found in vWF and ristocetin cofactor levels from preoperative period to postoperative period in both bleeding and nonbleeding patient groups (p < 0.05). There was no significant difference in bleeding and nonbleeding groups regarding aortic valve movements (p ≥ 0.05). Postoperative RHF incidence was significantly high in the bleeding patient group compared with the nonbleeding group (p < 0.05). Therefore, depending on the findings of this study, acquired von Willebrand Syndrome was seen in all cf-LVAD patients, and postoperative RHF was an important risk factor for GI bleeding.

Design and rationale for the ASSOS study: Appropriateness of aspirin use in medical outpatients a multicenter and observational study.

Objective:The aim of this study was to describe the current status of aspirin use and the demographic characteristics of patients on aspirin for primary and secondary prevention of cardiovascular diseases.Methods:The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study (ASSOS) trial was a multicenter, cross-sectional, and observational study conducted in Turkey. The study was planned to include 5000 patients from 14 cities in Turkey. The data were collected at one visit, and the current clinical practice regarding aspirin use was evaluated (ClinicalTrials.gov number NCT03387384).Results:The study enrolled all consecutive patients who were admitted to the outpatient cardiology clinics from March 2018 until June 2018. Patients should be at least 18 years old, have signed written informed consent, and on aspirin (80–325 mg) therapy within the last 30 days. Cardiologists from the hospital participates in the study. Patients were divided into 2 categories according to presence or absence of atherosclerotic cardiovascular disease, namely secondary prevention group and primary prevention group, respectively. The appropriate use of aspirin in the primary and secondary prevention groups was assessed according to the European Society of Cardiology guidelines and US Preventive Services Task Force. The patients’ gastrointestinal bleeding risk factors and colorectal cancer risk were evaluated.Conclusion:The ASSOS registry will be the most comprehensive and largest study in Turkey evaluating the appropriateness of aspirin use. The results of this study help understand the potential misuse of aspirin in a real-world setting.

Risk Factors of Gastrointestinal Bleeding in Patients Receiving New Oral Anticoagulants

Risk Factors of Gastrointestinal Bleeding in Patients Receiving New Oral Anticoagulants

Gastrointestinal Bleeding after Continuous Flow Left Ventricular Assist Device Implantation: Analysis of the INTERMACS Registry

Continuous flow left ventricular assist devices (CF-LVADs) are associated with increased gastrointestinal bleeding (GIB) when compared with pulsatile devices. The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS), the national registry of patients with FDA-approved durable devices, was analyzed to characterize GIB in CF-LVAD recipients. Median time from implantation to GIB, frequency of GIB-related rehospitalization, transfusion and death, and risk factors for GIB were determined. Adult patients older than18 years, with primary CF-LVAD implantation between 2006 and 2014, were included. Exclusion criteria were previous or concurrent placement of RVAD or total artificial heart. The primary outcome of interest was incidence of GIB in CF-LVAD recipients. Multivariable Cox proportional hazards model was used to examine associations of GIB with potential risk factors. Of 10,470 patients, 2,717 (26%) experienced GIB, with 1,316 (12.6%) experiencing >1 GIB. Median time to first GIB was 3.1 months (Q1 0.9, Q3 10.2). Rehospitalization occurred in 49.2% of GIB events, with 88.7% requiring transfusion and 0.7% resulting in death. Identified risk factors in multivariable analysis included older age, female sex, ischemic etiology, low pre-operative hemoglobin and elevated creatinine, longer cardiopulmonary bypass time, and lower INR after implantation. The majority of GIB events occur early after CF-LVAD implantation and are primarily associated with older age. Patients in their fifth decade of life have 4.6 times the risk of GIB compared with those in their second decade. Nearly half of patients with GIB experience >1 GIB, and GIB is a significant driver of rehospitalization and transfusion, but rarely results in death.

E‐Poster Presentations – A2) Gastric and Duodenal

E‐Poster Presentations – A2) Gastric and Duodenal

Su1124 - Prevalence and Risk Factors for Gastrointestinal Bleeding in Novel Oral Anticoagulant Users

Su1124 - Prevalence and Risk Factors for Gastrointestinal Bleeding in Novel Oral Anticoagulant Users

Correction to: Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association.

HomeCirculationVol. 135, No. 10Correction to: Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection to: Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association Originally published7 Mar 2017https://doi.org/10.1161/CIR.0000000000000493Circulation. 2017;135:e647This article corrects the followingManagement of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart AssociationIn the article by Raval et al, “Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association,” which published ahead of print February 6, 2017, and appeared in the March 7, 2017, issue of the journal (Circulation. 2017;135:e604–e633. DOI: 10.1161/CIR.0000000000000477), several corrections were needed.On page e604, in the author byline, the fellowship designation “FAHA” has been added for Dr. Allyson R. Zazulia.On page e617, in Figure 3, in the left-hand panel, the following changes have been made:In the box that read, “Stop NOAC based on CrCl* (see Table 3 for timing), NO Bridge,” the parenthetical phrase that mentioned Table 3 has been deleted.In the box that read, “Stop NOAC based on CrCl* (see Table 3 for timing),” the parenthetical phrase that mentioned Table 3 has been deleted.These corrections have been made to the current online version of the article, which is available at http://circ.ahajournals.org/content/135/10/e604.FootnotesCirculation is available at http://circ.ahajournals.org. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Bhattacharya B and Davis K (2021) Geriatric Trauma Systems, Current Trauma Reports, 10.1007/s40719-020-00210-w, 7:1, (8-14), Online publication date: 1-Mar-2021. Kadyseva E, Nigmedzyanova A, Kulagina L and Maksimov M (2020) Clinical use of direct oral anticoagulants in modern practice. Efficiency and safety, Vrač skoroj pomoŝi (Emergency Doctor), 10.33920/med-02-2011-01:11, (26-36), Online publication date: 1-Nov-2020. Stasko J, Stasko J, Janickova M, Mikuskova K, Malachovsky I, Gengelova P, Kasaj M, Smatanova M and Statelova D (2017) Direct Oral Anticoagulant Drugs in Dental Clinical Practice, Acta Medica Martiniana, 10.1515/acm-2017-0008, 17:2, (20-27), Online publication date: 28-Aug-2017., Online publication date: 28-Aug-2017. Bakulina N, Tikhonov S, Lishchuk N and Karaya A (2021) Management of risk factors for gastrointestinal bleeding in patients receiving anticoagulant therapy, Russian Journal of Cardiology, 10.15829/1560-4071-2021-4635, 26:8, (4635) Related articlesManagement of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart AssociationAmish N. Raval, et al. Circulation. 2017;135:e604-e633 March 7, 2017Vol 135, Issue 10 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIR.0000000000000493PMID: 28264900 Originally publishedMarch 7, 2017 PDF download Advertisement

Characterizing Potentially Inappropriate Prescribing of Proton Pump Inhibitors in Older People in Primary Care in Ireland from 1997 to 2012.

To characterize prescribing of proton pump inhibitors (PPIs) and medicines that increase gastrointestinal bleeding risk (ulcerogenic) in older people from 1997 to 2012 and assess factors associated with maximal-dose prescribing in long-term PPI users. Repeated cross-sectional study of pharmacy claims data. Eastern Health Board region of Ireland. Individuals aged 65 and older from a means-tested health plan in 1997, 2002, 2007, and 2012 (range 78,489-133,884 individuals). PPI prescribing prevalence was determined per study year, categorized according to duration (≤8 or >8 weeks), dosage (maximal or maintenance), and co-prescribed drugs. Logistic regression in long-term PPI users was used to determine whether age, sex, polypharmacy, and ulcerogenic medicine use were associated with being prescribed a maximal dose rather than a maintenance dose. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) are presented. Half of this older population received a PPI in 2007 and 2012. Long-term use (>8 weeks) of maximal doses rose from 0.8% of individuals in 1997 to 23.6% in 2012. Although some ulcerogenic medicines and polypharmacy were significantly associated with maximal PPI doses, any nonsteroidal anti-inflammatory drug use was significantly associated with lower odds of maximal PPI dose (adjusted OR = 0.87, 95% CI = 0.85-0.89), as were aspirin use and older age. Adjusting for medication and demographic factors, odds of being prescribed a maximal PPI dose were significantly higher in 2012 than in 1997 (adjusted OR = 6.30, 95% CI = 5.76-6.88). Long-term maximal-dose PPI prescribing is highly prevalent in older adults and is not consistently associated with gastrointestinal bleeding risk factors. Interventions involving prescribers and patients may promote appropriate PPI use, reducing costs and adverse effects of PPI overprescribing.