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Guías: endoscopia del tracto digestivo en los pacientes que reciben anticoagulantes

21.04.2023
Título original: Endoskopia przewodu pokarmowego u chorych przyjmujacych leki przeciwzakrzepowe
Autores: Ewa Nowakowska‑Duława (MD, PhD), Małgorzata Szczepanek (MD, PhD)
Consultado por: prof. Anetta Undas (MD, PhD)

Siglas y abreviaturas: AAS — ácido acetilsalicílico, ACOD — anticoagulantes orales de acción directa, ACV — accidente cerebrovascular, AIT — accidente isquémico transitorio, ASH — American Society of Hematology, AVK — antagonista de vitamina K, BSG — British Society of Gastroenterology, CCP — concentrado del complejo de protrombina, CPRE — colangiopancreatografía retrograda endoscópica, CrCl — aclaramiento de creatinina, DES — disección endoscópica de la submucosa, ECA — ensayo controlado aleatorizado, ESC — European Society of Cardiology, ESGE — European Society of Gastrointestinal Endoscopy, EST (endoscopic sclerotherapy) — escleroterapia endoscópica, ETV — enfermedad tromboembólica venosa, GEP — gastrostomía endoscópica percutánea, HBPM — heparina de bajo peso molecular, HNF — heparina no fraccionada, ICP — intervención coronaria percutánea, INR (international normalised ratio) — índice internacional normalizado, PEJ (percutaneous endoscopic jejunostomy) — yeyunostomía endoscópica percutánea, PFC — plasma fresco congelado, TAD — terapia antiplaquetaria dual, VBL (variceal band ligation) — ligadura de varices con banda

Introducción

En 2021 la British Society of Gastroenterology (BSG) y la European Society of Gastrointestinal Endoscopy (ESGE) actualizaron sus guías de 2016, relativas al manejo perioperatorio de los enfermos que reciben anticoagulantes y que se someten a la endoscopia diagnóstica o terapéutica.1,2

Existen numerosas indicaciones de la terapia anticoagulante y aumenta la frecuencia de uso de antiagregantes y anticoagulantes, sobre todo del grupo de anticoagulantes orales de acción directa (ACOD), también llamados anticoagulantes orales no antagonistas de la vitamina K (NACO). Por eso, los datos relativos a la eventual discontinuación y reanudación del tratamiento en el período perioperatorio, así como las reglas de la denominada terapia puente con heparina tras la discontinuación de anticoagulantes orales son esenciales no solo para los endoscopistas, sino también para los médicos de otras especialidades. Esto se debe tanto al riesgo de sangrado asociado a las intervenciones endoscópicas, como al riesgo de complicaciones tromboembólicas que pueden presentarse incluso después de una corta discontinuación de la terapia anticoagulante y conducir a la incapacidad permanente o incluso a la muerte. También es muy importante conocer las reglas de manejo ante la aparición de las manifestaciones de sangrado gastrointestinal durante el tratamiento anticoagulante, así como los métodos para revertir la acción de los fármacos.

En la elaboración de las guías participaron no solo gastroenterólogos, sino también hematólogos que representaron la Thrombosis and Haemostasis Task Force British Society of Haematology, cardiólogos y cardiocirujanos de la British Cardiovascular Intervention Society y representantes de las asociaciones de pacientes.

Las recomendaciones fueron elaboradas según los principios de AGREE II y NICE (National Institute for Health and Care Excellence), mediante la metodología GRADE (Grading of Recommendations, Assessment, Development and Evaluations). Las recomendaciones se han clasificado como fuertes [F] o débiles [D], mientras que la calidad de los datos en los que se han basado se ha clasificado en alta [A], moderada [M], baja [B] o muy baja [MB]. Vale la pena subrayar que la mayoría de las recomendaciones comentadas, al igual que las recomendaciones relativas al mismo tema publicadas en 2022 por el American College of Gastroenterology y la Canadian Association of Gastroenterology3, así como por el American College of Chest Physicians4, se basó en datos de calidad baja o muy baja.

En las guías se comentaron los principios de manejo de los enfermos que reciben antiagregantes —ácido acetilsalicílico (AAS) o inhibidores del receptor de la P2Y12— o anticoagulantes orales —antagonistas de la vitamina K (AVK) o ACOD—.

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