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Amanda Jekowsky , American College of
Cardiology, 202-375-6645, ajekowsk@acc.org
October
6, 2008
Consensus Document Outlines Practical
Steps for Reducing Gastrointestinal Risks
of Antiplatelet and NSAID Use
Leading Medical Associations Collaborate to Improve Patient
Safety
The American College of Cardiology in collaboration
with the American College of Gastroenterology and the American
Heart Association today released consensus guidelines outlining
a stepwise approach for reducing the risk of ulcers and gastrointestinal
(GI) bleeding among patients using nonsteroidal anti-inflammatory
drugs (NSAIDs) along with antiplatelet agents.
Gastrointestinal bleeding is a major and potentially life-threatening
complication for patients taking antiplatelet and NSAID therapy,
according to Deepak L. Bhatt, M.D., document co-chair and
chief of cardiology, VA Boston Healthcare System. Patients
taking low-dose aspirin plus NSAIDs have a two- to four-fold
increased risk of gastrointestinal bleeding compared with
those not taking these medications.
NSAIDs – the most widely used class of medications
in the United States – can reduce fever, pain, and inflammation
(swelling and redness). Some are available over the counter
(OTC), while others require a prescription. The best-known
NSAID is aspirin (which also acts as an antiplatelet agent).
Other common NSAIDs are ibuprofen, ketoprofen and naproxen.
Antiplatelet drug treatment, which reduces the blood’s
ability to clot, is considered a cornerstone in cardiovascular
prevention – preventing an event (or subsequent event)
in people with atherosclerotic disease. This is usually accomplished
by prescribing daily low-dose aspirin. Antiplatelet agents
(usually aspirin plus clopidogrel) are also recommended for
patients after receiving coronary artery stents to prevent
dangerous clotting that could cause a heart attack.
As more Americans survive and live with heart disease in
addition to conditions that require them to take NSAIDs (e.g.,
arthritis, inflammation and related musculoskeletal pain),
managing GI risk will become an increasingly important part
of cardiovascular care.
“Doctors are uncertain about how best to prevent bleeding
complications in patients receiving antiplatelet therapy and
NSAIDs, which are both commonly used, and can cause erosions
in the stomach lining,” said Dr. Bhatt. “These
recommendations represent the collective expertise of leading
cardiologists and gastroenterologists, as well as an extensive
review of the literature, and provide specialists with practical
measures to manage competing risks and help improve patient
safety.”
“We must be more proactive in assessing individual
patient risk to be able to prevent gastrointestinal problems
as antiplatelet therapy is actually initiated,” said
David A. Johnson, M.D., immediate past president of the American
College of Gastroenterology and professor of medicine and
chief of gastroenterology at Eastern Virginia Medical School.
“Communication among cardiologists, gastroenterologists
and primary care physicians is critical. At the same time,
patients must tell their doctors about any and all medications
they are taking—prescription and over-the-counter medicines—so
appropriate measures can be taken to reduce risk.”
In fact, according to a recent survey, 18 percent of patients
failed to report recent use of non-prescription NSAIDs, which
greatly complicates attempts to manage risk. Since GI problems
may arise with few, if any, symptoms (e.g., blood in stool,
fatigue, abdominal pain), ongoing monitoring is also important.
“The recommendations will help physicians evaluate
the risk profile for each patient and either change medications
or provide appropriate therapies to help reduce GI complications,”
said Elliot Antman, M.D., a member of the writing group and
a professor of medicine at Harvard Medical School.
To reduce problems, providers must assess individual patient
risk factors for possible GI complications, including age,
previous history of ulcers or bleeding, presence of H. pylori
(a common bacteria that contributes to the development of
stomach ulcers), dyspepsia or GERD (gastroesophageal reflux
disease or “acid reflux”) symptoms, as well as
the simultaneous use of NSAIDs, anticoagulants and/or corticosteroids.
The presence of several risk factors further increases the
possibility of bleeding.
“We have an opportunity to work collaboratively to
reduce the risk of gastrointestinal problems to improve public
health,” says James Scheiman, M.D., document co-chair
and professor of medicine, Gastroenterology Division, University
of Michigan, Ann Arbor, Michigan. “There are strategies
to minimize or reverse GI injury, especially as many of the
medications become less costly as generics become available.”
These recommendations are part of an ongoing dialogue between
the three collaborating organizations and, according to the
authors, will be updated as more definitive data are accrued.
This document was developed by the American College of Cardiology
Foundation Task Force on Expert Consensus Documents, which
helps guide clinical practice in areas where rigorous evidence
may not be available or the evidence to date is not widely
accepted.
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About the American College of Cardiology
The American College of Cardiology is leading the way to optimal
cardiovascular care and disease prevention. The ACC is a 36,000-member
nonprofit medical society and bestows the credential Fellow
of the American College of Cardiology upon physicians who
meet its stringent qualifications. The College is a leader
in the formulation of health policy, standards and guidelines,
and is a staunch supporter of cardiovascular research. The
ACC provides professional education and operates national
registries for the measurement and improvement of quality
care. For more information, visit www.acc.org.
About the American College of Gastroenterology
Founded in 1932, the American College of Gastroenterology
(ACG) is an organization with an international membership
of more than 10,000 individuals from 80 countries. The College
is committed to serving the clinically oriented digestive
disease specialist through its emphasis on scholarly practice,
teaching and research. The mission of the College is to serve
the evolving needs of physicians in the delivery of high quality,
scientifically sound, humanistic, ethical, and cost-effective
health care to gastroenterology patients. To learn more, visit
www.acg.gi.org.
About the American Heart Association
Founded in 1924, the American Heart Association today is the
nation’s oldest and largest voluntary health organization
dedicated to building healthier lives, free of heart disease
and stroke. These diseases, America’s No. 1 and No.
3 killers, and all other cardiovascular diseases claim nearly
870,000 lives a year. In fiscal year 2006–07 the association
invested more than $554 million in research, professional
and public education, advocacy and community service programs
to help all Americans live longer, healthier lives. To learn
more, call 1-800-AHA-USA1 or visit americanheart.org.
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The American College of Cardiology is leading the way to optimal
cardiovascular care and disease prevention. The College is
a 36,000-member nonprofit medical society and bestows the
credential Fellow of the American College of Cardiology upon
physicians who meet its stringent qualifications. The College
is a leader in the formulation of health policy, standards
and guidelines, and is a staunch supporter of cardiovascular
research. The ACC provides professional education and operates
national registries for the measurement and improvement of
quality care. More information about the association is available
online at www.acc.org .
The American College of Cardiology (ACC) provides these news
reports of clinical studies published in the Journal of
the American College of Cardiology as a service to physicians,
the media, the public and other interested parties. However,
statements or opinions expressed in these reports reflect
the view of the author(s) and do not represent official policy
of the ACC unless stated so.
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