Antikoagülan ve Antiplatelet Kullanan Hastada Endoskopi
Özet
Antikoagülan ve antiplatelet (antiagregan) ilaçlar; atriyal fibrilasyon, mekanik kalp kapağı, venöz tromboembolizm, koroner arter hastalığı ve stent, geçirilmiş inme gibi durumlarda tromboembolik olayları önlemek için yaygın kullanılır. Endoskopik işlem öncesinde bu ilaçların yönetimi, işleme bağlı kanama riski ile ilacın kesilmesine bağlı tromboz riskinin dengelenmesini gerektiren, bireyselleştirilmiş bir karardır. Yönetim üç değişkene dayanır: (1) işlemin kanama riski (düşük/yüksek), (2) hastanın tromboembolik riski (düşük/yüksek) ve (3) kullanılan ilacın farmakokinetiği (yarı ömür, böbrek atılımı, geri dönüşlülük). Bu bölümde antitrombotik ilaçların sınıflandırması ve farmakokinetiği; işlemlerin kanama riskine ve hastanın tromboz riskine göre sınıflaması; aspirin, P2Y12 inhibitörleri, varfarin ve doğrudan oral antikoagülanların (DOAK) kesilme ve yeniden başlama zamanlaması; köprüleme (bridging) endikasyonları; acil kanamada geri çevirme ajanları ve özel durumlar (koroner stent/DAPT, mekanik kapak, böbrek yetmezliği) ele alınır. Öneriler ESGE/BSG 2021, ACG-CAG 2022 ve ACCP 2022 güncel kılavuzlarına dayanır. Ayrıca standart hasta bilgilendirme metni, sık sorulan sorular ve yanlış inanışların düzeltilmesine yer verilmiştir.
Anticoagulant and antiplatelet agents are widely used to prevent thromboembolic events in atrial fibrillation, mechanical heart valves, venous thromboembolism, coronary artery disease and stents, and prior stroke. Their peri-endoscopic management is an individualized decision balancing procedure-related bleeding risk against thrombotic risk from interruption, and rests on three variables: (1) procedure bleeding risk (low/high), (2) patient thrombotic risk (low/high), and (3) drug pharmacokinetics (half-life, renal clearance, reversibility). This chapter covers classification and pharmacology of antithrombotic agents; stratification of procedures by bleeding risk and patients by thrombotic risk; timing of cessation and resumption of aspirin, P2Y12 inhibitors, warfarin and direct oral anticoagulants (DOACs); indications for bridging; reversal agents for emergency bleeding; and special situations (coronary stent/DAPT, mechanical valve, renal impairment), in accordance with current ESGE/ BSG 2021, ACG-CAG 2022 and ACCP 2022 guidelines, together with standardized patient information, FAQs and correction of misconceptions.
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