Table 3.

Clinical summary

Conclusion	Recommendations
Limited quality of published evidence limits our existing knowledge regarding risk.	Future studies focused on the antithrombotic population are required that include methodologic attention to standardized polypectomy techniques, clearly defined outcomes, and approach to temporary interruption and hemostatic clipping.
Estimates of immediate and delayed PPB vary widely in the literature. Variation in the definition of immediate and delayed PPB and lack of standardization in polypectomy technique (hot vs cold snare) limit accurate assessment of overall, immediate, and delayed PPB at this time.	With the temporary interruption of antithrombotic agents and prompt resumption of the drug, overall PPB is 1.8% to 7.0% (anticoagulant or antiplatelet agent). Nonthermal polypectomy of lesions <1 cm may be favorable when combined with temporary interruption; future studies are required to test this hypothesis. Without temporary interruption of antithrombotic agents, delayed PPB is slightly higher than with brief interruption (ie, up to 11%) with a trend toward higher immediate PPB (5.7% with continuous anticoagulant and 3.8%-8.5% with continuous antiplatelet use).
Cold- vs hot-snare polypectomy.	At this time, there is insufficient high-quality evidence in the antithrombotic population to unequivocally endorse cold-snare polypectomy as a technique to reduce PPB; however, the literature is promising in this regard. Future studies should focus on the polypectomy technique using an appropriate definition of PPB while considering a standardized approach to antithrombotic temporary interruption and resumption.
The risk of adverse cardiac events associated with temporary interruption of antithrombotic agents is low.	In endoscopic studies, the risk of adverse cardiac thromboembolic is <1%-3% at 30 days postprocedure, with appropriate temporary interruption of antiplatelet or anticoagulant drugs.
The timing of temporary interruption of antiplatelet agents is related to the drug’s half-life.	See Table 1.
Do not discontinue cardiac ASA (81 mg/day) among patients with a prior heart attack or stroke (ie, ASA for secondary prophylaxis).	Discontinuation of cardiac ASA is associated with an increased risk of postprocedural major adverse cardiac events (including myocardial infarction and drug-eluting stent occlusion) and all-cause mortality.
Temporary interruption of warfarin before polypectomy.	Hold 5 days before the procedure with the resumption of the drug after achieving immediate hemostasis. Patients prescribed warfarin for nonvalvular atrial fibrillation (only) do not require pre- or postbridge therapy.
Bridge therapy.	Heparin bridge therapy is an independent risk factor for PPB with an attributable rate as high as 20%. Preprocedural and postprocedural bridge therapy is necessary with warfarin discontinuation in all patients with mechanical heart valves. You can consider using bridge therapy in patients with atrial fibrillation and a CHA2DS2-VASC score ≥5, venous thromboembolism, or stroke within 3 months of a planned colonoscopy if prescribed warfarin; however, risk-benefit of this approach is unknown. Future studies in these particular populations will inform future recommendations.
DOAC temporary interruption.	Current best practice recommendations recommend brief interruption based on the patient’s creatinine clearance, risk of postendoscopic procedure bleeding, and specific DOAC agent (see Table 2). A simplified regimen that discontinues the DOAC 1 day before the endoscopy and resumes the DOAC the day after endoscopy has been shown to have favorable bleeding and cardiac outcomes. In the simplified regimen, no DOAC patients underwent a heparin bridge, and all endoscopic procedures (including polypectomy) are considered low risk. It is unknown whether similar favorable outcomes are associated with endoscopic surgeries causing significant mucosal defects (EMR or endoscopic submucosal dissection).
Prophylactic hemostatic clip use.	Data are mixed with regard to efficacy of prophylactic mechanical hemostasis after polypectomy in antithrombotic patients. Prophylactic clipping may be favorable if the PPB rate is ≥3.4% (anticoagulant bleeding risk) or ≥2.5% (antiplatelet bleeding risk). However, cost-effectiveness declines when more than 1 clip is placed. Clip closure of large, proximal EMR defects >2 cm (4 clips used per defect) may decrease delayed PPB (number needed to treat, 16). However, failure of randomization to balance antithrombotic drug use between control and clip groups may have introduced unmeasured confounding variables and favored the clip group outcome.
Documentation and procedural consent considerations.	Advise patients of the risk of antithrombotic-related PPB bleeding, document this risk, and educate them about PPB symptoms and how to seek emergency attention.

PPB, Postpolypectomy bleeding; ASA, acetylsalicylic acid; CHA₂DS₂-VASC, Congestive heart failure, Hypertension, Age (≥65 = 1 point, ≥75 = 2 points), Diabetes, and Stroke/transient ischemic attack (2 points), Vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), and Sex Category (female gender); DOAC, direct oral anticoagulant agent.