Reduced risk of gastrointestinal bleeding associated with proton pump inhibitor therapy in patients treated with dual antiplatelet therapy after myocardial infarction

Abstract

Aims Guidelines differ in their recommendations on therapy to prevent gastrointestinal bleeding for patients treated with dual antiplatelet treatment (DAPT). We sought to investigate the effectiveness of proton pump inhibitors (PPIs) to prevent upper gastrointestinal (UGI) bleeding in patients using DAPT following myocardial infarction (MI) in relation to current European Society of Cardiology guidelines recommendations. Methods and results We linked Danish nationwide registries to identify patients taking DAPT 7 days following hospital discharge for an acute MI, and excluded individuals on anticoagulation therapy. We used multiple Cox regression modelling, to compute average risk of UGI bleeding in relation to PPI use. The associated treatment efficacy was compared based on guideline risk assessment. We studied 46 301 patients on DAPT after MI. Only 35% of patients at higher risk of UGI bleeding received recommended treatment with a PPI based on the guideline criteria. The 1--year risk of UGI bleeding was 1.0% [95% confidence interval (CI) 0.9–1.1%] and 1.7% (CI 1.5–2.0%) for high-risk patients. Overall PPI compared with no therapy, was associated with a risk ratio for UGI bleeding of 0.62 (CI 0.48–0.77) corresponding to an absolute risk difference of 0.44% (CI 0.39–0.48%). Proton pump inhibitor therapy was associated with a similar absolute risk difference [0.47% (CI 0.43–0.51%)] for high-risk patients. Conclusion Proton pump inhibitor therapy is used less than suggested by guidelines in patients treated with DAPT following MI and was generally associated with reduced risk of UGI bleeding. Considering the overall low risk of bleeding, more focus should be on identifying patients benefiting the most from PPI therapy.

No Differences in Gastrointestinal Bleeding Risk among Clopidogrel-, Ticagrelor-, or Prasugrel-Based Dual Antiplatelet Therapy

“…After the event, more patients in the new antiplatelets group restarted DAPT when compared with clopidogrel-based DAPT. Finally, in contrast to other studies [35], our results indicate good adherence to the guidelines [36], which recommend PPI-concomitant treatment in patients on DAPT. On the other hand, after DAPT withdrawal, most patients continued PPI therapy even though many of them likely no longer showed any indication for the need for continued treatment.…”

Upper gastrointestinal mucosal injury associated with ticagrelor plus aspirin, ticagrelor alone, or aspirin alone at 1‐year after coronary artery bypass grafting

“…Recently, a study investigated the PPI effectiveness on DAPT in 46 301 patients with MI history from Danish nationwide registries. 22 The results demonstrated that only 35% of patients at higher risk of upper GI bleeding received PPI treatment, which was lower than suggested by guidelines in patients treated with DAPT following MI. These data may contribute to the adjustment of subsequent antiplatelet regimens and concomitant use of PPIs to reduce the risk of upper GI bleeding in the second year post-CABG.…”

Gastrointestinal Bleeding in Patients Admitted to Cardiology: risk factors and a new risk score

“…Similarly, previous studies had reported that PPI could not decrease the incidence of GIB in patients after anticoagulant therapy with dabigatran [15]. It was noteworthy that a study that 46,301 patients with dual antiplatelet therapy after myocardial infarction were recruited, reported PPI could reduce the risk of GIB, However, long-term outcomes needed to be further observed [16]. Ray et al [17]demonstrated that oral PPI could decrease the incidence of upper GIB in hospitalized patients treated with oral anticoagulants.…”