Dual Antiplatelet Therapy and Upper Gastrointestinal Bleeding Risk

Do PPIs Make Any Difference?

Inamul Haq; Fazal-ur-rehman Ali; Shakeel Ahmed; Steven Lindsay; Sudantha Bulugahapitiya

Disclosures

Br J Cardiol. 2013;20(4) 

In This Article

Abstract and Introduction

Abstract

Dual antiplatelet therapy (DAT) with aspirin and clopidogrel is recommended for up to one year following acute coronary syndrome (ACS). Gastrointestinal bleeding is the main hazard of this treatment and proton pump inhibitors (PPIs) are often prescribed in selected patients to reduce this risk. The main purpose of this study was to analyse the effect of PPIs in reducing the subsequent risk of gastrointestinal bleeding.

The medical records of 177 consecutive patients treated with DAT following ACS, were specifically reviewed for the study parameters over a 12-month period.

The mean age was 66 years (range 24–96) with a median value of 68 years; 67% were males and 33% females, 74% Caucasians and 26% Asians. Patients were divided into two groups: the PPI group (patients on DAT and PPIs, n=91) and the control group (patients on DAT only, n=86). In the PPI group, 55% were on lansoprazole, 34% on pantoprazole and 11% on omeprazole.

Out of the 177 patients, evidence of upper gastrointestinal bleeding was found in 10 patients, with the mean age of these patients being 77 years in the PPI group and 53 years in the control group. In the PPI group, endoscopy findings from six patients (6.6%) revealed gastritis in four, bleeding angiodysplasia in one, and bleeding oesophagitis in one; while the findings for the four patients in the control group (4.6%) showed gastritis in two, gastric ulcer in one and Mallory Weiss tear in one (odds ratio: 1.45, 95% confidence interval 0.39–5.32, p=0.58). None of these patients had a previous history of gastrointestinal bleeding.

In conclusion, empirical prophylactic prescription of PPIs for patients on DAT following ACS is of no significant benefit in reducing their predisposition to upper gastrointestinal bleeding. However, studies utilising larger populations are warranted to confirm this conclusion.

Introduction

Dual antiplatelet therapy (DAT) with aspirin and clopidogrel is recommended for up to one year following acute coronary syndrome (ACS) in order to reduce the risk of further cardiac events.[1,2] Gastrointestinal bleeding is the main hazard of this treatment; however, although the incidence of bleeding is low, it results in significantly increased morbidity and mortality in these patients,[3–5] and proton pump inhibitors (PPIs) are often prescribed to selective patients to reduce this risk. PPIs act by reducing the secretion of gastric acid, neutralising gastric pH, increasing clot formation and decreasing the lysis of blood clots.

There are no formal guidelines concerning the initiation and continuation of PPIs for such patients. In addition, evidence regarding the treatment effect of this group of medications in lowering the risk of subsequent gastrointestinal bleeding is absent. Therefore, the main purpose of this study was to analyse the effect of PPIs in reducing the subsequent risk of gastrointestinal bleeding in patients on DAT with aspirin and clopidogrel following ACS.

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