Anti-platelet therapy and endoscopic procedures: eyes wide shut?

That the decision-making process in medicine is generally complex is comprehensible. Indeed, several factors need be considered when a medical procedure is performed or a therapeutic approach is used, such as the patient's characteristics, the complexity of the procedure, the drugs to be administered, the physician’s skill, and the setting. The difficulty is further increased when the available scientific data for a specific topic are incomplete or controversial. In this scenario, the existence of official guidelines is surely an advantage for physicians wishing to minimize clinical errors. The management of antiplatelet agent (APA) therapy before gastrointestinal endoscopy is a typical situation requiring complex analysis in that several factors need to be considered. Fortunately, in 2009, the American Society of Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee delivered recommendations on the management of antithrombotic agents in patients undergoing endoscopic procedures [1]. Basically, the endoscopic examinations were subgrouped as procedures associated with a “low risk” or a “high risk” for bleeding. The recommendations advised that the discontinuation of APA therapy before diagnostic procedures (low risk), as well as before polypectomy, endoscopic retrograde pancreatography (ERCP) with sphincterotomy, stent placement (without dilation), and percutaneous endoscopic gastrostomy (PEG), is not required because no data have consistently demonstrated a significant increase in risk for bleeding [1]. Moreover, no bleeding-related deaths occurred in patients on APA therapy after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) [2, 3]. Nevertheless, the question of how these guidelines are followed in clinical practice must be asked. A specific, pretested questionnaire was administered to 400 gastroenterologists attending an ASGE endoscopy course, and 239 of them (60%) completed the survey [4]. Surprisingly, as many as 26% of the endoscopists stated that they withhold all APAs before any endoscopic procedure. Such an approach raises some relevant concerns, which deserve consideration. As in a movie, we alternately look at a case with the eyes of an endoscopist and with those of a patient. The endoscopist is required to perform an endoscopic procedure in a patient at increased risk for bleeding because of ongoing APA therapy. What are the endoscopist's eyes looking at? Surely, procedure-related bleeding. Therefore, the endoscopist stops the APA therapy for 5 to 7 days before the endoscopic procedure (and for 1 to 5 days afterward) in all patients, particularly when he or she considers that an unplanned operative procedure (e.g., a polypectomy) may be necessary. Although such a cautious approach is also advantageous for the patient, the endoscopist is marginalizing the potential risk to the patient related to the interruption of APA therapy. Indeed, the patient is taking long-term APA therapy for either the primary or the secondary prevention of cardiovascular events. Prevention is primary when a patient has cardiovascular risk factors but has previously had no cardiovascular event, whereas it is secondary when a patient has previously had a myocardial infarction or stroke. What are the patient's eyes are looking at when the interruption of preventive therapy is suggested? Surely, they are imagining a serious cardiovascular event. Most likely, the patient is unaware of the increased risk for bleeding during endoscopy that is related to the ongoing APA therapy. How to balance the caution of the endoscopist and the safety of the patient? Considering that the ideal situation (a zero risk for bleeding and a zero risk for a cardiovascular event) is impossible, a wise approach should be chosen. Fortunately, consistent data are available on the role of APA therapy in the prevention of cardiovascular events. There is clear evidence that the cardiovas-