Effectiveness of endoscopy in patients with concomitant gastrointestinal bleeding and acute coronary syndrome: A systematic review

Abstract

BACKGROUND

Gastrointestinal bleeding (GIB) is a critical complication often seen in patients with acute coronary syndrome (ACS), especially those undergoing dual antiplatelet therapy. GIB is associated with increased mortality and prolonged hospitalization, particularly in ACS patients. Despite advancements in management strategies, the role of gastrointestinal endoscopy (GIE) in this population remains controversial, with concerns about timing, safety, and clinical outcomes.

AIM

To evaluate the safety and efficacy of GIE in patients with ACS and acute GIB, focusing on outcomes such as mortality, hospital length of stay (LOS), hemorrhage control, rebleeding, and blood transfusion requirements.

METHODS

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, a systematic review was conducted using databases including PubMed, Cochrane, and EMBASE, up to December 2024. The protocol was registered with the International Prospective Register of Systematic Reviews (CRD42025630188). Study quality was assessed using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale for cohort studies.

RESULTS

Four studies met the inclusion criteria, comprising one RCT and three cohort studies with a total population of 1676130 patients. Most studies indicated that GIE was associated with improved survival in ACS patients with GIB. Three of our studies reported lower mortality rates in patients undergoing GIE compared to those managed without endoscopy, although this varied by study. While GIE demonstrated effectiveness in controlling hemorrhage and reducing rebleeding rates in one study. The rest of the studies did not evaluate these outcomes comprehensively. Hospital LOS outcomes were inconsistent, with two studies suggesting no significant difference, while only one study indicated potential reductions in LOS with GIE. Blood transfusion requirements were reported in one study to be higher in patients undergoing GIE, reflecting its frequent use in severe cases. The safety and effectiveness of GIE varied depending on patient characteristics, timing of the procedure, and type of intervention.

CONCLUSION

GIE has the potential to improve survival in certain patients with ACS complicated by GIB; however, determining the ideal timing and appropriate candidates necessitates careful individual assessment. While evidence suggests benefits, the limitations of observational studies warrant caution. Collaboration between cardiology and gastroenterology is essential to optimizing outcomes. Future randomized trials should focus on timing, severity, and diverse populations to refine guidelines and improve care for this high-risk group.

Keywords: Acute coronary syndrome; Endoscopy; Gastrointestinal bleeding; Length of stay; Mortality; Rebleeding

Core Tip: In patients with acute coronary syndrome and gastrointestinal bleeding, gastrointestinal endoscopy reduces in-hospital mortality, enhances hemostasis, and lowers 3-day rebleeding rates. Its effects on hospital length of stay and blood transfusion requirements are variable, although early gastrointestinal endoscopy may decrease overall costs through reduced transfusions. Existing data are mainly observational and heterogeneous, with potential dataset overlap. Rigorous randomized controlled trials are needed to determine optimal timing, patient selection, and integrated cardiology–gastroenterology management strategies for this high-risk population.