Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease

Azita H Talasaz; Parham Sadeghipour; Luis Ortega-Paz; Hessam Kakavand; Maryam Aghakouchakzadeh; Craig Beavers; John Fanikos; John W Eikelboom; Deborah M Siegal; Manuel Monreal; David Jimenez; Muthiah Vaduganathan; Lana A Castellucci; Adam Cuker; Geoffrey D Barnes; Jean M Connors; Eric A Secemsky; Benjamin W Van Tassell; Raffaele De Caterina; Jacob E Kurlander; Ali Aminian; Gregory Piazza; Samuel Z Goldhaber; Lisa Moores; Saskia Middeldorp; Ajay J Kirtane; Mitchell S V Elkind; Dominick J Angiolillo; Stavros Konstantinides; Gregory Y H Lip; Gregg W Stone; Mary Cushman; Harlan M Krumholz; Roxana Mehran; Deepak L Bhatt; Behnood Bikdeli

doi:10.1038/s41569-024-01003-3

Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease

Nat Rev Cardiol. 2024 Mar 20. doi: 10.1038/s41569-024-01003-3. Online ahead of print.

Authors

Azita H Talasaz^{1

2

3}, Parham Sadeghipour⁴, Luis Ortega-Paz⁵, Hessam Kakavand^{4

6}, Maryam Aghakouchakzadeh⁷, Craig Beavers⁸, John Fanikos⁹, John W Eikelboom¹⁰, Deborah M Siegal¹¹, Manuel Monreal¹², David Jimenez¹³, Muthiah Vaduganathan¹⁴, Lana A Castellucci¹⁵, Adam Cuker¹⁶, Geoffrey D Barnes¹⁷, Jean M Connors¹⁸, Eric A Secemsky^{19

20

21}, Benjamin W Van Tassell³, Raffaele De Caterina^{22

23}, Jacob E Kurlander^{24

25

26}, Ali Aminian²⁷, Gregory Piazza^{14

28}, Samuel Z Goldhaber^{14

28}, Lisa Moores²⁹, Saskia Middeldorp³⁰, Ajay J Kirtane^{31

32}, Mitchell S V Elkind^{33

34}, Dominick J Angiolillo⁵, Stavros Konstantinides³⁵, Gregory Y H Lip^{36

37}, Gregg W Stone³⁸, Mary Cushman³⁹, Harlan M Krumholz^{40

41

42}, Roxana Mehran³⁸, Deepak L Bhatt³⁸, Behnood Bikdeli^{43

44

45}

Affiliations

¹ Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA.
² Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA.
³ Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA.
⁴ Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.
⁵ Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA.
⁶ Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran.
⁷ Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
⁸ University of Kentucky College of Pharmacy, Lexington, KY, USA.
⁹ Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁰ Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.
¹¹ Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
¹² Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain.
¹³ Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain.
¹⁴ Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁵ Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada.
¹⁶ Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
¹⁷ Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
¹⁸ Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁹ Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
²⁰ Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
²¹ Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
²² Cardiology Division, Pisa University Hospital, Pisa, Italy.
²³ Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy.
²⁴ Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
²⁵ Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
²⁶ VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
²⁷ Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA.
²⁸ Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
²⁹ F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
³⁰ Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands.
³¹ Cardiovascular Research Foundation, New York, NY, USA.
³² Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.
³³ Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.
³⁴ Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
³⁵ Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany.
³⁶ Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK.
³⁷ Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
³⁸ Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
³⁹ University of Vermont Medical Center, Burlington, VT, USA.
⁴⁰ Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
⁴¹ Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.
⁴² Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
⁴³ Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. bbikdeli@bwh.harvard.edu.
⁴⁴ VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA. bbikdeli@bwh.harvard.edu.
⁴⁵ Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA. bbikdeli@bwh.harvard.edu.

PMID: 38509244
DOI: 10.1038/s41569-024-01003-3

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.

Publication types

Review