What are the ACC/ACG/AHA guidelines on concomitant use of proton pump inhibitors (PPI) and thienopyridines in acute coronary syndrome (ACS)?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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A 2010 consensus statement issued by the ACC, American College of Gastroenterology (ACG), and AHA addressed the issue of concomitant use of proton pump inhibitors (PPIs) and thienopyridine antiplatelet drugs. [117] The recommendations are summarized below.

Clopidogrel reduces major cardiovascular (CV) events compared with placebo or aspirin.

Dual antiplatelet therapy with clopidogrel and aspirin, compared with aspirin alone, reduces major cardiovascular events and coronary stent thrombosis, but it is not routinely recommended for patients with prior ischemic stroke because of the risk of bleeding.

Clopidogrel alone, aspirin alone, and their combination are all associated with increased risk of GI bleeding.

Patients with prior GI bleeding are at highest risk for recurrent bleeding on antiplatelet therapy. Other clinical characteristics that increase the risk of GI bleeding include advanced age; concurrent use of anticoagulants, steroids, or NSAIDs including aspirin; and Helicobacter pylori infection. The risk of GI bleeding increases as the number of risk factors increases.

Use of a PPI or histamine H2 receptor antagonist (H2RA) reduces the risk of upper GI bleeding compared with no therapy. PPIs reduce upper GI bleeding to a greater degree than do H2RAs.

PPIs are recommended to reduce GI bleeding among patients with a history of upper GI bleeding. PPIs are appropriate in patients with multiple risk factors for GI bleeding who require antiplatelet therapy.

Routine use of either a PPI or an H2RA is not recommended for patients at a lower risk of upper GI bleeding.

Clinical decisions regarding concomitant use of PPIs and thienopyridines must balance overall risks and benefits, considering both cardiovascular and GI complications.

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