Proton Pump Inhibitor, Dual Antiplatelet Therapy, and Bleeding

Jul 01, 2019
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Authors:
Sehested TS, Carlson N, Hansen PW, et al.
Citation:
Reduced Risk of Gastrointestinal Bleeding Associated With Proton Pump Inhibitor Therapy in Patients Treated With Dual Antiplatelet Therapy After Myocardial Infarction. Eur Heart J 2019;40:1963-1970.
Summary By:
Bina Ahmed, MD, FACC

Study Questions:

How effective are proton pump inhibitors (PPIs) in preventing upper gastrointestinal (UGI) bleeding in patients on dual antiplatelet therapy (DAPT) after acute myocardial infarction (AMI) based on clinical risk of UGI bleeding?

Methods:

This was a retrospective analysis from the Danish nationwide registries of patients who were taking DAPT 7 days after hospital discharge for an AMI. High UGI bleeding risk was established based on a prior history of GI bleed, chronic nonsteroidal anti-inflammatory drug use, chronic corticosteroid use, or two or more of the following risk factors: age ≥65 years, dyspepsia, gastroesophageal reflux disease, and chronic alcohol use. Patients on oral anticoagulants were excluded. Regression modeling was used to compute average risk of UGI bleeding in relation to PPI use at 1 year.

Results:

From 2003-2014, 46,301 patients met entry criteria for analysis. Of these, 10,074 patients were at high risk of UGI bleeding. UGI bleeding occurred in 1% (95% confidence interval [CI], 0.9–1.1%) of all patients and 1.7% (95% CI, 1.5–2.0%) of all high-risk patients. Use of PPIs was associated with a 38% relative risk reduction (RR) of 0.62 (95% CI, 0.48–0.77), but only minor absolute RR (ARR) in all patients (ARR, 0.44%; 95% CI, 0.39–0.48%) and among those deemed at high risk for UGI (ARR, 0.47%; 95% CI, 0.43–0.51%).

Conclusions:

Although UGI bleeding occurred infrequently, PPI use was associated with a lower risk of UGI bleeding in both low- and high-risk patients.

Perspective:

Barring the limitations of a retrospective analysis, this study highlights the following: 1) Overall rates of UGI bleeding are low among AMI patients on DAPT, 2) PPI use is associated with lower rates of UGI bleeding regardless of risk, and 3) the current high-risk prediction tool was not able to identify patients who would most benefit from PPI use. There remains no role for routine use of PPI among patients on DAPT.

Clinical Topics: Acute Coronary Syndromes, Dyslipidemia, Prevention, Lipid Metabolism

Keywords: Acute Coronary Syndrome, Dyspepsia, Gastroesophageal Reflux, Gastrointestinal Hemorrhage, Hemorrhage, Myocardial Infarction, Platelet Aggregation Inhibitors, Proton Pump Inhibitors, Proton Pumps, Risk Factors, Secondary Prevention


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