Background: The purpose of this study was to determine the readmission rate for acute myocardial infarction (AMI) in patients discharged on clopidogrel and a proton-pump inhibitor (PPI) versus patients discharged on clopidogrel alone after experiencing an AMI and undergoing stent placement. Clopidogrel is a prodrug that requires metabolism in the liver by the cytochrome P450 system (CYP450), in particular cytochrome P450 2C19 (CYP2C19).1 Recent studies have suggested that medications metabolized by CYP450, such as PPIs, influence the effect of clopidogrel on platelet function 2,3 with an increased risk of cardiovascular events. 4,5 PPIs are often administered with clopidogrel due to the increased bleeding risk of dual antiplatelet therapy, a strategy endorsed by existing consensus guidelines.6Hypothesis: Treatment with a PPI in combination with clopidogrel would increase the risk of readmission for an AMI after stent placement for AMI. Methods: We collected data on all patients discharged on clopidogrel after stent placement for an AMI between January 2003 and January 2008. Patients were followed for 1 year after their index hospitalization for readmission for an AMI. Rates of readmission were determined for those discharged on clopidogrel alone versus those discharged on clopidogrel and a PPI.Results: Patients discharged on clopidogrel and a PPI had higher rates of readmission for AMI within 1 year of stent implantation for AMI. Conclusions: Patients discharged on clopidogrel and a PPI, including esomeprazole and pantoprazole, seem to be at an increased risk of recurrent AMI within 1 year after stent placement for an AMI. IntroductionClopidogrel is a prodrug that is metabolized to its active metabolite by the cytochrome P450 enzyme system. Protom pump inhibitors (PPIs) are frequently prescribed in combination with clopidogrel to help reduce the risk of gastrointestinal bleeding. Several recent studies have suggested that many PPIs, especially those that undergo extensive metabolism by the cytochrome P450 2C19 system such as omeprazole, may diminish the antiplatelet effects and clinical effectiveness of clopidogrel. In contrast, other reports have not found any association between the use of PPIs in combination with clopidogrel and an increased risk of adverse cardiovascular outcomes. Therefore, we sought to assess the association between PPI and clopidogrel combination therapy after stent placement for an AMI and recurrent AMI.

This study sought to evaluate dobutamine stress cardiac magnetic resonance imaging (DCMRI) in women with abnormal stress nuclear testing results. Women with findings on stress nuclear exams, including electrocardiography and/or perfusion, thought to require further evaluation with invasive coronary angiography were prospectively enrolled. Multiplane cine imaging was obtained at rest and at each stage of inotropic stress with atropine as needed to achieve target heart rate. DCMRI results were compared with stress nuclear and invasive cardiac catheterization results. Of 23 patients enrolled successfully, 22 completed DCMRI examination without complications. In all cases, DCMRI imaging demonstrated appropriate stress response with no ischemia despite abnormalities on stress nuclear testing. In the 18 patients who also underwent invasive coronary angiography, no significant obstructive disease was identified. DCMRI may be a useful alternative to stress nuclear examination in women; larger studies are warranted to determine its potential to more accurately predict obstructive coronary artery disease. prev cardiol. 2008;11:135-140. ©2008 Le Jacq C ardiovascular disease is the leading cause of mortality in women in the United States. Coronary heart disease, which includes coronary atherosclerotic disease, myocardial infarction, acute coronary syndromes, and angina, is the largest subset of this mortality, with >240,000 women dying annually from the disease.1 However, women often present with atypical signs and symptoms of heart disease. 2,3 As such, noninvasive diagnostic and prognostic testing offers the potential to stratify women at increased coronary artery disease (CAD) risk from those at low risk for obstructive epicardial CAD. However, much of the evidence supporting contemporary recommendations for noninvasive diagnostic studies in women is extrapolated from studies conducted predominantly in cohorts of middle-aged men. Thus, a better understanding of the impact of sex differences in heart disease and on noninvasive cardiac testing in women would greatly improve clinical decision making.Nuclear imaging in women with typical angina in the absence of epicardial coronary stenoses has shown abnormal perfusion scans in some of these patients that may be indistinguishable from those seen due to focal coronary artery lesions. 4 Diastolic dysfunction may be another potential etiology of angina that is also more prevalent in women, 5-9 especially elderly women with hypertension. Exercise stress nuclear imaging is widely used to identify myocardial ischemia in both men and women. An estimated 7.8 million patients underwent nuclear perfusion imaging in 2002, approximately 40% of whom were women.10 While the technique is well established, electrocardiography and attenuation artifact can lead to false-positive diagnoses in women that may prompt subsequent invasive coronary angiography. 11,12Dobutamine stress cardiac magnetic resonance imaging (DCMRI) provides rapid assessment of ischemia without attenuation artifact, 13,14 ...