Cold snare polypectomy with continuous anticoagulant

1. Cold snare polypectomy with continuous anticoagulant use does not increase bleeding risk compared with hot snare polypectomy and heparin bridging

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0026

Editorial: http://annals.org/aim/article/doi/10.7326/M19-1708

Free Summary for Patients: http://annals.org/aim/article/doi/10.7326/P19-0009

URLs go live when the embargo lifts

Patients who underwent cold snare polypectomy for small polyps while continuing to take anticoagulants did not experience increased incidence of severe bleeding compared with those who underwent hot snare polypectomy with heparin bridging. Findings from a multicenter, randomized, controlled trial are published in Annals of Internal Medicine.

Patients with polyps often have them removed to decrease their risk for colon cancer. If a patient is also taking blood thinners, it can increase their risk for bleeding. The type of polypectomy used may also have different risks for bleeding. Guidelines differ on how to manage anticoagulants for patients undergoing polypectomy.

Researchers from Osaka International Cancer Institute assigned 182 patients at 30 centers in Japan to two different treatment groups. The first group continued their anticoagulants and underwent cold snare polypectomy (CA+CSP), while the second group stopped taking their anticoagulant and were given heparin for a few days before and after undergoing hot snare polypectomy (HB+HSP). Patients in both groups were hospitalized for the procedure. The researchers found that the rate of bleeding in the CA+CSP group was lower than that in the HB+HSP group (approximately 5 percent versus 13 percent). The doctors did not observe poorly controlled bleeding during the procedure in either group. The HB+HSP group had a longer average procedure time and a longer hospital stay than the CA+CSP group. According to the authors, these findings show not only non-inferiority but also superiority of CA+CSP compared with HB+HSP.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Yoji Takeuchi, MD (@yojit1), please email directly at takeuti-yo@mc.pref.osaka.jp or yoji.endoscopy@oici.jp

2. Non-vitamin K oral anticoagulants best for early-stage chronic kidney disease

Data are insufficient to draw conclusions about oral anticoagulant therapy for advanced stages of CKD

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0087

Editorial: http://annals.org/aim/article/doi/10.7326/M19-1504

URLs go live when the embargo lifts

In early-stage chronic kidney disease (CKD) with atrial fibrillation, non-vitamin K oral anticoagulants (NOACs) had a benefit-risk profile superior to that of vitamin K antagonists (VKAs). There was insufficient evidence to establish benefits or harms of either anticoagulant for advanced CKD or end-stage kidney disease (ESKD). Findings from a systematic review and meta-analysis are published in Annals of Internal Medicine.

Patients with CKD and ESKD are at much greater risk for atrial fibrillation and venous thromboembolism (VTE). Anticoagulant therapy is an important intervention in the prevention of stroke and systemic embolism in atrial fibrillation and VTE events. However, patients with advanced stages of CKD and ESKD who have atrial fibrillation are prescribed oral anticoagulant therapy less frequently than those with normal kidney function. This may be due to the increased risk for bleeding, uncertainty about potential benefits in this population, warfarin-associated calciphylaxis, and warfarin-related nephropathy. Understanding the benefits and risks of oral anticoagulation therapy could help to guide treatment for these patients.

Researchers from The George Institute for Global health reviewed 45 trials comprising 34,082 participants to evaluate the benefits and harms of VKAs and NOACs in adults with CKD stages 3 to 5, including those with dialysis-dependent and ESKD. The data showed that NOACs had a benefit-risk profile superior to that of VKAs in patients with early-stage CKD, with significant reductions in stroke or systemic embolism and hemorrhagic stroke in atrial fibrillation. The data also showed a reduction in overall major bleeding risk that was not statistically significant in all trials combined, suggesting that these patients will derive similar or greater benefit compared with those who do not have CKD. However, evidence was insufficient to recommend widespread use of VKAs or NOACs to improve clinical outcomes in patients with advanced CKD and dialysis-dependent ESKD.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Sunil V. Badve, PhD, please contact Julia Timms at jtimms@georgeinstitute.org.au.

3. High-dose spironolactone may help to manage patients with acute decompensated heart failure and diuretic resistance

Abstract: http://annals.org/aim/article/doi/10.7326/M18-3285

URLs go live when the embargo lifts

High-dose spironolactone may be effective for managing patients with acute decompensated heart failure who are resistant to loop diuretics. Researchers suggest that it may be time for a randomized controlled trial to examine their role in treating these patients. A brief report describing a pilot study is published in Annals of Internal Medicine.

Resistance to loop diuretics occurs frequently in patients with acute decompensated heart failure. Aldosterone antagonists are a standard of care in heart failure, but they are commonly used at lower doses to avoid hyperkalemia.

Researchers from the University of Texas Health at San Antonio and South Texas Veterans Health Care System studied 19 patients hospitalized for heart failure with reduced or preserved ejection fraction and at least one symptom and sign of hypervolemia who were loop-diuretic resistant to examine whether high-dose spironolactone could be a safe and effective treatment option. They found that the addition of high-dose spironolactone was followed by clinically important weight loss and reduced shortness of breath and was not associated with worsening hyperkalemia or renal function. These results differ from those of previous studies where the addition of 100 mg of spironolactone to usual care for all participants did not lead to clinical improvement. In this study, the researchers used a higher dose of spironolactone and gave it only to those who did not respond to usual care.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Shweta Bansal, MD, please contact Will Sansom at SANSOM@uthscsa.edu.

Also new in this issue:

A Counterintuitive Tool for Connected Care

Zuzanna Czernik, MD; Robert Chang, MD; and Vineet Chopra, MD, MSc

Ideas and Opinions

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0589

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