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

Table 1 Characteristics of included studies and participant demographics, n (%)

Ref.	Elkafrawy et al[8], 2021	Hoffman et al[9], 2020	Chung et al[7], 2022	Modi et al[10], 2017
Country	United States	United States	Taiwan	United States
Study design	Cohort	Cohort	RCT	Cohort
Number of patients included (total)	269483	1281749	43	124855
Number of patients intervention group	183248	53035	22	9138
Number of patients control group	86235	1228714	21	115717
Mean ± SD age (endoscopy group)	72.32 ± 11.72	71.1	63.55 ± 12.19	Colonoscopy: 70.78 ± 24.5; EGD: 69.56 ± 25.3
Mean ± SD age (non-endoscopy group)	71.27 ± 12.29	68.9	70.67 ± 12.82	67.13 ± 33.8
Gender distribution (endoscopy group)	F = 63369 (34.6); M = 120040 (65.4)	F: 23610; M: 29425	F: 4; M: 18	F = 43.13; M = 56.87
Gender distribution (non-endoscopy group)	F = 28003 (32.5); M = 58070 (67.5)	F: 523345; M: 704785	F: 8; M: 13	F = 38.7; M = 61.3
Severity of GIB	Higher transfusion requirement (55.9% vs 50.5%)	Severity inferred via mortality outcomes	Improved hemorrhage control (4.55% vs 23.81%), significantly lower 3-day rebleeding rate (4.55% vs 28.57%)	Severity inferred via mortality outcomes
Type of endoscopy	EGD, small intestinal endoscopy, colonoscopy, or flexible sigmoidoscopy	Esophagogastroduodenoscopies (EGDs)	EGD	Colonoscopy, with or without EGD
Type of ACS	Acute myocardial infarction, subendocardial infarction, and acute coronary occlusion without infarction	Non-ST elevation myocardial infarction (NSTEMI): 58.9; demand ischemia (NSTEMI type II): 32.5; ST elevation myocardial infarction (STEMI): 8.7	Unstable angina, STEMI, NSTEMI	Acute coronary syndrome STEMI
Mortality cases	7027 (3.8)	9.9 (95%CI: 9.3-10.5)	1	33
Mortality control	7421 (8.6)	Lower: 0.80, P < 0.001	0	6941 (no endoscopy group), 384 (EGD only)
Hospital stay cases mean ± SD	6.59 ± 7.81	11.8 days (95%CI: 11.5-12.2)	ITT: 13.64 ± 10.99, PP: 13.14 ± 11.01	12.53 days (CI: 11.43-13.63)
Hospital stay controls mean ± SD	7.84 ± 9.73	5.6 days (95%CI: 5.5-5.6)	ITT: 11.57 ± 5.67; PP: 11.05 ± 5.66	10.44 days (CI: 10.30-10.58)
Blood transfusion requirement (endoscopy group) mean ± SD	102484 (55.9)	N/A	ITT: 0.77 ± 1.23, PP: 0.62 ± 1.02	N/A
Blood transfusion requirement (non-endoscopy group) mean ± SD	43455 (50.5)	N/A	ITT: 2.76 ± 2.86, PP: 2.63 ± 2.99	N/A
Key points	Patients who underwent endoscopy had a lower mortality, hospital length, and mechanical ventilation rate compared to the control group	Endoscopy reduced adjusted mortality despite sicker patients	EE had a higher rate of hemorrhage control, lower 3-day rebleeding rate	Patients undergoing endoscopy showed a lower mortality rate

RCT: Randomized controlled trial; EGD: Esophagogastroduodenoscopy; F: Female; M: Male; GIB: Gastrointestinal bleeding; ACS: Acute Coronary Syndrome; NSTEMI: Non-ST elevation myocardial infarction; STEMI: ST elevation myocardial infarction; CI: Confidence interval; ITT: Intention to treat; PP: Per protocol; N/A: Not Applicable.

Table 2 The Newcastle-Ottawa Scale risk of bias

Ref.1	Study design	Selection	Comparability	Exposure	Total (maximum 9)
Hoffman et al[9], 2020	Cohort	3	2	3	8
Modi et al[10], 2017	Cohort	4	1	3	7
Elkafrawy et al[8], 2021	Cohort	4	1	2	8

¹The summary of the review authors’ judgments about the Newcastle Ottawa Scale item for included studies.