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©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
Safety of gastrointestinal endoscopy in patients with acute coronary syndrome and concomitant gastrointestinal bleeding
Ahmed A Elkafrawy, Mohamed Ahmed, Mohammad Alomari, Ahmed Elkaryoni, Kevin F Kennedy, Wendell K Clarkston, Donald R Campbell
Ahmed A Elkafrawy, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Ahmed A Elkafrawy, Mohamed Ahmed, Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, MO 64108, United States
Mohammad Alomari, Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FL 33331, United States
Ahmed Elkaryoni, Division of Cardiovascular Medicine, Loyola University Medical Center and Stritch School of Medicine, Maywood, IL 60153, United States
Kevin F Kennedy, Mid America Heart Institute, Saint Luke's Health System, Kansas City, MO 64111, United States
Wendell K Clarkston, Donald R Campbell, Department of Gastroenterology, Saint Luke's Hospital/University of Missouri Kansas City, Kansas City, MO 64111, United States
Author contributions: Campbell DR and Clarkston WK were the study's senior authors; they contributed to interpreting the data, writing, critical reviewing, and editing of the manuscript; Elkafrawy AA contributed to the conception, study design, literature review, and drafting of the manuscript; Ahmed M and Alomari M performed the literature review and drafted the manuscript; Elkaryoni A contributed to the study design and to develop the analytic plan; Kennedy KF extracted the data and performed the statistical analysis; all authors reviewed and approved the final manuscript.
Institutional review board statement: The study population was identified from the Healthcare Cost and Utilization Project databases (HCUP). The HCUP databases are sponsored by the Agency for Healthcare Research and Quality. The Nationwide Inpatient Sample (NIS) database is the largest HCUP database, and it contains unweighted data from over 7 million hospital admission each year. The data represent a 20% random sample of participating hospital discharges from 46 states. The NIS database is de-identified and available to the public. Thus, it is not considered human subject research and is exempted from review by the institutional review board.
Informed consent statement: The study population was identified from the Healthcare Cost and Utilization Project databases (HCUP). The HCUP databases are sponsored by the Agency for Healthcare Research and Quality. The Nationwide Inpatient Sample (NIS) database is the largest HCUP database, and it contains unweighted data from over 7 million hospital admission each year. The data represent a 20% random sample of participating hospital discharges from 46 states. The NIS database is de-identified and available to the public. Thus, no informed consents were required or obtained.
Conflict-of-interest statement: The authors declare that they have no conflict-of-interest.
Data sharing statement: The study was conducted from the Nationwide Inpatient Sample Database (NIS). The NIS is a public database that contains de-identified data from hospitalized patients in the US. There is no risk of identification of patients.
STROBE statement: The authors have read the STROBE checklist, and the manuscript was prepared and revised according to the STROBE checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
http://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Ahmed A Elkafrawy, MD, Academic Fellow, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A50, Cleveland, OH 44195, United States.
ahmed.aly.kafrawy@gmail.com
Received: July 24, 2020
Peer-review started: July 24, 2020
First decision: September 14, 2020
Revised: October 1, 2020
Accepted: January 6, 2021
Article in press: January 6, 2021
Published online: February 16, 2021
Processing time: 189 Days and 15.7 Hours
BACKGROUND
Gastrointestinal bleeding (GIB) is a major concern in patients hospitalized with acute coronary syndrome (ACS) due to the common use of both antiplatelet medications and anticoagulants. Studies evaluating the safety of gastrointestinal endoscopy (GIE) in ACS patients with GIB are limited by their relatively small size, and the focus has generally been on upper GIB and esophago-gastroduod-enoscopy (EGD) only.
AIM
To evaluate the safety profile and the hospitalization outcomes of undergoing GIE in patients with ACS and concomitant GIB using the national database for hospitalized patients in the United States.
METHODS
The Nationwide Inpatient Sample database was queried to identify patients hospitalized with ACS and GIB during the same admission between 2005 and 2014. The International Classification of Diseases Code, 9th Revision Clinical Modification was utilized for patient identification. Patients were further classified into two groups based on undergoing endoscopic procedures (EGD, small intestinal endoscopy, colonoscopy, or flexible sigmoidoscopy). Both groups were compared regarding demographic information, outcomes, and comorbi-dities. Multivariate analysis was conducted to identify factors associated with mortality and prolonged length of stay. Chi-square test was used to compare categorical variables, while Student’s t-test was used to compare continuous variables. All analyses were performed using SAS 9.4 (Cary, NC, United States).
RESULTS
A total of 35612318 patients with ACS were identified between January 2005 and December 2014. 269483 (0.75%) of the patients diagnosed with ACS developed concomitant GIB during the same admission. At least one endoscopic procedure was performed in 68% of the patients admitted with both ACS and GIB. Patients who underwent GIE during the index hospitalization with ACS and GIB had lower mortality (3.8%) compared to the group not undergoing endoscopy (8.6 %, P < 0.001). A shorter length of stay (LOS) was observed in patients who underwent GIE (mean 6.59 ± 7.81 d) compared to the group not undergoing endoscopy (mean 7.84 ± 9.73 d, P < 0.001). Multivariate analysis showed that performing GIE was associated with lower mortality (odds ratio: 0.58, P < 0.001) and shorter LOS (-0.36 factor, P < 0.001).
CONCLUSION
Performing GIE during the index hospitalization of patients with ACS and GIB was correlated with a better mortality rate and a shorter LOS. Approximately two-thirds of patients with both ACS and GIB undergo GIE during the same hospitalization.
Core Tip: Less than 1% of hospitalized patients have concomitant acute coronary syndrome (ACS) and gastrointestinal bleeding (GIB). However, the combination of these two conditions is reported to be associated with increased morbidity and mortality. Studies evaluating the safety and hospitalization outcomes of gastrointestinal endoscopy (GIE) in patients with ACS and GIB are limited and conflicting. This analysis was designed to evaluate GIE safety and efficacy in patients with ACS and GIB. This study concluded that GIE in patients hospitalized with ACS and GIB is both safe and associated with lower mortality as well as a shorter hospital stay.
