Continuous Anticoagulation and Cold Snare Polypectomy

Abstract

TO THE EDITOR: Clinicians need data on perioperative anticoagulant therapy (especially direct-acting oral anticoagulants), and we congratulate Takeuchi and colleagues (1) on their contribution to this vital area of research. However, we have some questions about their methods. The authors state, On the basis of previous reports about warfarin and HB [heparin bridging] we hypothesized that the incidence of severe bleeding would be 10% in the HB+HSP [HB and hot snare polypectomy] group and 3% in the CA+CSP [continuous administration of anticoagulants and cold snare polypectomy] group. Given this hypothesis, why was a noninferiority trial performed rather than a superiority trial? The control group used in this study underwent HB, but use of this intervention for endoscopic procedures is not standard of care in patients receiving anticoagulant therapy for prevention of embolic events. These patients are usually told the risks of stopping anticoagulation, and therapy is interrupted in those with CHA2DS2-VASc (Congestive heart failure, Hypertension, Age 75, Diabetes mellitus, Stroke, Vascular disease, Sex female) scores of 2 or lower. For patients at high risk for a thromboembolic event (that is, those with CHA2DS2-VASc scores between 3 and 9 and a 2.2% annual risk for cerebrovascular accident), a more extensive discussion is probably warranted before stopping this therapy. Nevertheless, anticoagulant therapy is usually interrupted for gastroenterological procedures and restarted after the procedure when it is safe to do so (2). We contend that a comparison group using HB is not a good control group. This intervention does not represent conventional care, and patients may have had bleeding events simply from administration of heparin (3). A recent meta-analysis found that patients who received perioperative HB had a 3-fold higher risk for major bleeding than those who did not (4).