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Management of antithrombotic agents for endoscopic procedures

Published:November 04, 2009DOI:https://doi.org/10.1016/j.gie.2009.09.040
      This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. This guideline combines and updates 2 previously issued guidelines, “Guideline on the management of antithrombotic and antiplatelet therapy for endoscopic procedures”
      • Eisen G.M.
      • Baron T.H.
      • Dominitz J.A.
      • et al.
      American Society for Gastrointestinal Endoscopy. Guideline on the management of antithrombotic and antiplatelet therapy for endoscopic procedures.
      and “ASGE guideline: the management of low-molecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures.”
      • Zuckerman M.J.
      • Hirota W.K.
      • Adler D.G.
      • et al.
      Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. ASGE guideline: the management of low-molecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures.
      To prepare this guideline, a search of the medical literature was performed using PubMed. Studies or reports that described fewer than 10 patients were excluded from analysis if multiple series with more than 10 patients addressing the same issue were available. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and were graded on the strength of the supporting evidence (Table 1).
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.”
      Table 1GRADE system for rating the quality of evidence for guidelines
      Quality of evidence Definition Symbol
      High quality Further research is very unlikely to change our confidence in the estimate of effect ⊕⊕⊕⊕
      Moderate quality Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate ⊕⊕⊕○
      Low quality Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate ⊕⊕○○
      Very low quality Any estimate of effect is very uncertain ⊕○○○
      Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.”
      Adapted from Guyatt et al.
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.

      Abbreviations:

      ACC (American College of Cardiology), ACS (acute coronary syndrome), AHA (American Heart Association), DAT (dual antiplatelet therapy), DES (drug-eluting stent), DVT (deep venous thrombosis), FFP (fresh frozen plasma), GIB (GI bleeding), INR (international normalized ratio), LMWH (low molecular weight heparin), MI (myocardial infarction), NSAID (nonsteroidal anti-inflammatory drug), UFH (unfractionated heparin)
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