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Fischbach W, Bornschein J, Hoffmann JC, Koletzko S, Link A, Macke L, Malfertheiner P, Schütte K, Selgrad DM, Suerbaum S, Schulz C. Update S2k-Guideline Helicobacter pylori and gastroduodenal ulcer disease of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:261-321. [PMID: 38364851 DOI: 10.1055/a-2181-2225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
| | - Jan Bornschein
- Translational Gastroenterology Unit John, John Radcliffe Hospital Oxford University Hospitals, Oxford, United Kingdom
| | - Jörg C Hoffmann
- Medizinische Klinik I, St. Marien- und St. Annastiftskrankenhaus, Ludwigshafen, Deutschland
| | - Sibylle Koletzko
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU-Klinikum Munich, Munich, Deutschland
- Department of Paediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, 10-719 Olsztyn, Poland
| | - Alexander Link
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Lukas Macke
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Peter Malfertheiner
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
| | - Kerstin Schütte
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Niels-Stensen-Kliniken Marienhospital Osnabrück, Osnabrück, Deutschland
| | - Dieter-Michael Selgrad
- Medizinische Klinik Gastroenterologie und Onkologie, Klinikum Fürstenfeldbruck, Fürstenfeldbruck, Deutschland
- Klinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Sebastian Suerbaum
- Universität Munich, Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, Munich, Deutschland
- Nationales Referenzzentrum Helicobacter pylori, Pettenkoferstr. 9a, 80336 Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
| | - Christian Schulz
- Medizinische Klinik und Poliklinik II Campus Großhadern, Universitätsklinikum Munich, Munich, Deutschland
- Deutsches Zentrum für Infektionsforschung, Standort Munich, Munich, Deutschland
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Mekhail A, Young P, Mekhail AM, Tinawi G, Haran C, Clayton N, Galvin S. Stress Ulcer Prophylaxis in Cardiac Surgery: A Retrospective Cohort Study to Analyze the Effects of SUP Cessation. J Intensive Care Med 2023; 38:917-921. [PMID: 37093762 DOI: 10.1177/08850666231171327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is an important complication among critically ill adults, especially those having cardiac surgery as management is complicated by the requirement for antiplatelet/anticoagulant therapy. As a result, stress ulcer prophylaxis (SUP) has become routine practice in many centers, utilizing either proton pump inhibitors (PPIs) or histamine-2 receptor blockers (H2RBs). Recent evidence from the PEPTIC trial indicated an increase in mortality risk among cardiac surgery patients receiving PPIs compared to H2RBs. Considering these findings, alongside practical difficulties surrounding the transition to H2RBs as a prophylactic agent in New Zealand, Wellington Hospital intensive care unit elected to discontinue routine PPI use for SUP in cardiac surgery patients. A retrospective study was conducted to assess patient outcomes following the discontinuation of routine SUP. METHOD A retrospective cohort study was conducted of all adult patients who underwent cardiac surgery at Wellington Hospital between February/2018 and January/2022, and divided patients into cohorts before and after the discontinuation of routine use of SUP on the 31st of January 2020. The primary outcomes were the rate of UGIB, oesophagogastroduodenoscopy (OGD) and 180-day postoperative mortality. Secondary outcomes included rates of postoperative Clostridium difficile enteritis, pneumonia, deep sternal wound infection, and length of stay of the index admission. RESULTS The rate of UGIB statistically significantly increased since the cessation of routine SUP in January 2020 (2.4% vs 5.4%, P-value = .004). This finding was mirrored with the increased rates of OGD (1.9% vs 4.0%, P-value = .005). There were no significant changes in 180-day mortality, hospital length of stay, or any of the postoperative infective complications analyzed, pneumonia, deep sternal wound infection, or C difficile enteritis. CONCLUSION This study suggests an association between routine use of SUP and reduced rates of clinically significant UGIB and OGD requirements in cardiac surgery patients without increasing risk of infective complications or postoperative mortality.
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Affiliation(s)
- Andrew Mekhail
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
| | - Paul Young
- Department of Intensive Care Medicine, Wellington Hospital, Wellington, New Zealand
| | - Ann-Marie Mekhail
- Department of Intensive Care Medicine, Wellington Hospital, Wellington, New Zealand
| | - Georges Tinawi
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
| | - Cheyaanthan Haran
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
| | - Nicholas Clayton
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
| | - Sean Galvin
- Department of Cardiothoracic Surgery, Wellington Hospital, Wellington, New Zealand
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Aktualisierte S2k-Leitlinie Helicobacter
pylori und gastroduodenale Ulkuskrankheit der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – Juli 2022 – AWMF-Registernummer: 021–001. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:544-606. [PMID: 37146633 DOI: 10.1055/a-1975-0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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Zaman A, Prendergast B, Hildick-Smith D, Blackman D, Anderson R, Spence MS, Mylotte D, Smith D, Wilding B, Chapman C, Atkins K, Pollock KG, Qureshi AC, Banning A. An Update on Anti-thrombotic Therapy Following Transcatheter Aortic Valve Implantation: Expert Cardiologist Opinion from a UK and Ireland Delphi Group. Interv Cardiol 2023; 18:e13. [PMID: 37398870 PMCID: PMC10311398 DOI: 10.15420/icr.2022.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/11/2022] [Indexed: 07/04/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is an effective and established treatment for symptomatic aortic stenosis. However, there is a lack of consensus concerning the need for peri- and post-procedural anti-thrombotic medication. Contemporary guidelines recommend that anti-thrombotic therapy is balanced against a patient's bleeding risk following TAVI, but do not fully consider the evolving evidence base. The purpose of the Delphi panel recommendations presented here is to provide a consensus elicited from a panel of experts who regularly prescribe anti-thrombotic therapy post-TAVI. The goal was to address evidence gaps across four key topics: anti-thrombotic therapy (anti-platelet and/or anti-coagulant) in TAVI patients in sinus rhythm; anti-thrombotic therapy in TAVI patients with AF; direct oral anti-coagulants versus vitamin K antagonists; and the need for UK/Ireland specific guidance. This consensus statement aims to inform clinical decision-making by providing a concise, evidence-based summary of best practice for prescribing anti-thrombotic therapies following TAVI and highlights areas where further research is needed.
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Affiliation(s)
- Azfar Zaman
- Department of Cardiology, Freeman HospitalNewcastle upon Tyne, UK
- Newcastle UniversityNewcastle upon Tyne, UK
| | - Bernard Prendergast
- Department of Cardiology, St Thomas’ HospitalLondon, UK
- Cleveland ClinicLondon, UK
| | - David Hildick-Smith
- Sussex Cardiac Centre, Regional Specialist Unit, Brighton and Sussex University HospitalsBrighton, UK
| | - Daniel Blackman
- Department of Cardiology, Leeds Teaching Hospitals NHS TrustLeeds, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of WalesCardiff, UK
- Cardiff Metropolitan UniversityCardiff, UK
| | - Mark S Spence
- Department of Cardiology Mater Private HospitalDublin, Ireland
| | - Darren Mylotte
- Department of Cardiology, University Hospitals GalwayGalway, Ireland
- National University of GalwayGalway, Ireland
| | - David Smith
- Department of Cardiology, Morriston HospitalSwansea, UK
- University of SwanseaSwansea, UK
| | - Ben Wilding
- Health Economics and Outcomes ResearchCardiff, UK
| | - Chris Chapman
- Bristol Myers Squibb PharmaceuticalsUxbridge, Middlesex, UK
| | - Kirsty Atkins
- Bristol Myers Squibb PharmaceuticalsUxbridge, Middlesex, UK
| | | | | | - Adrian Banning
- Department of Cardiology, John Radcliffe HospitalOxford, UK
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Clerici B, Cattaneo M. Pharmacological Efficacy and Gastrointestinal Safety of Different Aspirin Formulations for Cardiovascular Prevention: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040137. [PMID: 37103016 PMCID: PMC10145431 DOI: 10.3390/jcdd10040137] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/18/2023] [Accepted: 03/20/2023] [Indexed: 04/28/2023] Open
Abstract
Aspirin inhibits platelet function by irreversibly inhibiting the synthesis of thromboxane A2 (TxA2). Aspirin, at low doses, is widely used for cardiovascular prevention. Gastrointestinal discomfort, mucosal erosions/ulcerations and bleeding are frequent complications of chronic treatment. To reduce these adverse effects, different formulations of aspirin have been developed, including enteric-coated (EC) aspirin, the most widely used aspirin formulation. However, EC aspirin is less effective than plain aspirin in inhibiting TxA2 production, especially in subjects with high body weight. The inadequate pharmacological efficacy of EC aspirin is mirrored by lower protection from cardiovascular events in subjects weighing >70 kg. Endoscopic studies showed that EC aspirin causes fewer erosions of the gastric mucosa compared to plain aspirin (which is absorbed in the stomach) but causes mucosal erosions in the small intestine, where it is absorbed. Several studies demonstrated that EC aspirin does not reduce the incidence of clinically relevant gastrointestinal ulceration and bleeding. Similar results were found for buffered aspirin. Although interesting, the results of experiments on the phospholipid-aspirin complex PL2200 are still preliminary. Considering its favorable pharmacological profile, plain aspirin should be the preferred formulation to be used for cardiovascular prevention.
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Affiliation(s)
- Bianca Clerici
- Divisione di Medicina Generale II, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Via Di Rudinì 8, 20142 Milano, Italy
| | - Marco Cattaneo
- Fondazione Arianna Anticoagulazione, Via Paolo Fabbri 1/3, 40138 Bologna, Italy
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Adalja D, Zala H, Victor V, Sheth A, Willyard C, Suzuki E, Patel HP, Majmundar M, Vallabhajosyula S, Doshi R. Incidence, Current Guidelines and Management of Gastrointestinal Bleeding after Transcatheter Aortic Valve Replacement: A Systematic Review. Curr Cardiol Rev 2023; 19:e230622206351. [PMID: 35747979 PMCID: PMC10201885 DOI: 10.2174/1573403x18666220623150830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND There is a significant increase in morbidity and mortality in patients complicated by major bleeding following transcatheter aortic valve replacement (TAVR). It has become more challenging to manage such complications when the patient needs to be on anticoagulation or antiplatelet agent post-procedure to prevent thrombotic/embolic complications. METHODS We systematically reviewed all available randomized controlled trials and observational studies to identify incidence rates of gastrointestinal bleeding post-procedure. After performing a systematic search, a total of 8731 patients from 15 studies (5 RCTs and 10 non-RCTs) were included in this review. RESULTS The average rate of gastrointestinal bleeding during follow-up was 3.0% in randomized controlled trials and 1.9% among observational studies. CONCLUSION Gastrointestinal bleeding has been noted to be higher in the RCTs as compared to observational studies. This review expands knowledge of current guidelines and possible management of patients undergoing TAVR.
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Affiliation(s)
- Devina Adalja
- Department of Internal Medicine, St Joseph's University Medical Center, Paterson, NJ, USA
| | - Harshvardhan Zala
- Department of Clinical Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varun Victor
- Department of Internal Medicine, Canton Medical Education Foundation, Canton, OH, USA
| | - Aakash Sheth
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Charles Willyard
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, NV, USA
| | - Emi Suzuki
- Department of Pediatrics, UCSF- Fresno, Fresno, CA, USA
| | - Harsh P. Patel
- Department of Internal Medicine, Louis A Weiss Memorial Hospital, Chicago, IL, USA
| | - Monil Majmundar
- Department of Cardiology, Maimonides Medical Center, Brooklyn, New York, USA
| | | | - Rajkumar Doshi
- Department of Cardiology, St Joseph's University Medical Center, Paterson, NJ, USA
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Tam CC, Tse HF. Antiplatelet Therapy Aims and Strategies in Asian Patients with Acute Coronary Syndrome or Stable Coronary Artery Disease. J Clin Med 2022; 11:jcm11247440. [PMID: 36556067 PMCID: PMC9784545 DOI: 10.3390/jcm11247440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) has been the mainstay treatment to reduce ischemic events, such as myocardial infarction or stroke, in patients with coronary artery disease (CAD). The development of potent P2Y12 inhibitors (ticagrelor and prasugrel) has helped to further reduce ischemic events, particularly among high-risk patients. Meanwhile, the evolution of newer generations of drug-eluting stents are also improving outcomes of percutaneous coronary intervention. Research studies on antiplatelet therapy in recent years have focused on balancing ischemic and bleeding risks through different strategies, which include P2Y12 inhibitor monotherapy, escalation and de-escalation, and extended DAPT. Because results from the large number of clinical studies may sometimes appear conflicting, this review aims to summarize recent advances, and demonstrate that they are aligned by a general principle, namely, strategies may be adopted based on treatment aims for specific patients at several time points. Another aim of this review is to outline the important considerations for using antiplatelet therapy in Asian patients, in whom there is a greater prevalence of CYP2C19 loss-of-function mutations, and a common increased risk of bleeding, despite high platelet reactivity (the so-called "East Asian Paradox").
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Affiliation(s)
- Chor-Cheung Tam
- Division of Cardiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
- Correspondence:
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Zhang Y, Liu H, Liu X. Salvage treatment for severe upper gastrointestinal bleeding caused by Mallory-Weiss syndrome and myocardial depression after acute myocardial infarction. Heliyon 2022; 8:e11638. [DOI: 10.1016/j.heliyon.2022.e11638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/28/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
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He M, Qiu J, Bai Y, Wang Y, Chen G. Massive pleural effusion following high-power and short-duration radiofrequency ablation for treatment of atrial fibrillation: A case report and review of the literature. Front Cardiovasc Med 2022; 9:996481. [PMID: 36324739 PMCID: PMC9620720 DOI: 10.3389/fcvm.2022.996481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
Postpericardial injury syndrome (PPIS) is defined as pericarditis or pericardial effusion that results from recent myocardial infarction or intracardiac interventions. These symptoms typically include fever, leukocytosis, a high erythrocyte sedimentation rate, and elevated C-reactive protein levels. Additionally, pericardial effusion and pleural effusion may be present. It is considered to be a common complication in cardio-surgery with an occurrence of 3-30%. In the past 20 years, a high number of patients with atrial fibrillation have suffered from PPIS following radiofrequency catheter ablation. However, previous reports focused on identifying cardiac tamponade and pericardial effusion as their main clinical manifestations. Solitary pulmonary involvement following PPIS with the radiofrequency catheter ablation may occur. We report a case of PPIS that presented pleural effusion as the dominant feature soon after the operation and systematic review to illustrate the clinical characteristics of PPIS.
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The Safety of Long-Term Proton Pump Inhibitor Use on Cardiovascular Health: A Meta-Analysis. J Clin Med 2022; 11:jcm11144096. [PMID: 35887860 PMCID: PMC9322047 DOI: 10.3390/jcm11144096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 07/11/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction: Proton pump inhibitors (PPIs) are one of the most prescribed classes of drugs worldwide as a first-line treatment of acid-related disorders. Although adverse effects are rare and rapidly reversible after a short exposure, concerns have been recently raised about a greater toxicity on cardiovascular health after a longer exposure, especially when combined with clopidogrel. We aimed to evaluate the safety of long-term PPI use on cardiovascular health in patients with known atheromatous cardiovascular disease. Methods: A literature search was conducted in the PubMed, Embase, and Cochrane Library databases and grey literature in April 2022. Articles published between 2014 and 2022 were considered relevant if they were designed as randomized controlled trials (RCTs) that included post hoc analyses or prospective observational studies and if they investigated clinical cardiovascular outcomes associated with PPI use for 6 months or more in patients suffering from cardiovascular disease requiring antiplatelet agent therapy and/or coronary angioplasty. Statistical analyses were performed using RevMan 5.4 software (Computer program, the Cochrane Collaboration, 2020, London, UK). The risk of bias was assessed using the Cochrane risk-of-bias tool for the RCTs and the Newcastle−Ottawa scale for the observational studies. Results: A total of 10 full-text articles involving 53,302 patients were included. Substantial heterogeneity was found among the 10 included studies. The primary analysis showed no significant differences between the PPI group and the control group for the risks of major adverse cardiovascular events (MACEs), all-cause death (ACD), or target vessel revascularization (TVR) using a random-effects model (OR 1.15, 95% CI 0.98−1.35, p = 0.08, I2 = 73%; OR 1.24, 95% CI 0.94−1.65, p = 0.13, I2 = 63%; and OR 1.19, 95% CI 0.76−1.87, p = 0.45, I2 = 61%, respectively). The primary analysis yielded similar results for the risks of myocardial infarction (MI), stroke, and cardiovascular death (CVD) using a fixed-effects model (OR 0.98, 95% CI 0.88−1.09, p = 0.66, I2 = 0%; OR 1.02, 95% CI 0.90−1.17, p = 0.73, I2 = 0%; and OR 1.04, 95% CI 0.94−1.16, p = 0.44, I2 = 35%, respectively). Likewise, a subgroup analysis based on eight randomized controlled trials failed to identify any association between PPI use and the risks of MACEs, MI, stroke, TVR, ACD, or CVD using a fixed-effects model (overall pooled OR 1.01, 95% CI 0.96−1.06; p = 0.66; I2 = 0%). The pulled data from the two included observational studies (OS) demonstrated a significantly increased risk of MACEs in the PPI group (OR 1.42, 95% CI [1.29−1.57], p <0.001; I2 = 0%). In another subgroup analysis, no evidence of an increased risk of adverse cardiovascular events in the co-therapy PPI/clopidogrel versus clopidogrel alone groups was found with the exception of the risk of ACD (OR 1.50, 95% CI 1.23−1.82, p = 0.001, I2 = 0%). Nevertheless, after performing a sensitivity analysis reaching heterogeneity I2 = 0%, the co-prescription of PPIs and clopidogrel was at increased risk of MACEs (p < 0.001), CVD (p = 0.008), and TVR (p < 0.001) but remained statistically non-significant for the risk of MI (p = 0.11). Conclusions: The overall results of this meta-analysis showed that long-term PPI use was not associated with an increased risk of adverse cardiovascular events. However, inconsistent results were found for combined PPI/clopidogrel therapy. These results should be considered with caution in light of the significant heterogeneity, the limited number of included studies, and the lack of adjustment for potential confounders.
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Saven H, Zhong L, McFarlane IM. Co-prescription of Dual-Antiplatelet Therapy and Proton Pump Inhibitors: Current Guidelines. Cureus 2022; 14:e21885. [PMID: 35273851 PMCID: PMC8901154 DOI: 10.7759/cureus.21885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/13/2022] Open
Abstract
Dual-antiplatelet therapy (DAPT) prevents thrombotic complications associated with coronary artery disease, acute coronary syndrome, and stent thrombosis following the percutaneous coronary intervention or coronary artery bypass grafting. When initiating DAPT, the risk of thrombosis must be balanced with the increased risk of upper gastrointestinal bleed (UGIB). Proton-pump inhibitors (PPIs) are concurrently prescribed with DAPT to reduce bleeding risk. In this review, we discuss the benefits and potential complications of DAPT/PPI co-prescription. The only large international randomized control trial (RCT), Clopidogrel and the Optimization of Gastrointestinal Events Trial (COGENT), shows robust evidence that PPIs are a safe and effective method to reduce the risk of bleeding in patients on DAPT. However, more large-scale RCTs are needed to study potential long-term effects and draw a stronger conclusion on this topic.
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Affiliation(s)
- Hannah Saven
- Internal Medicine, State University of New York (SUNY) Downstate College of Medicine, New York, USA
| | - Lynna Zhong
- Internal Medicine, State University of New York (SUNY) Downstate College of Medicine, New York, USA
| | - Isabel M McFarlane
- Internal Medicine, State University of New York (SUNY) Downstate Medical Center, New York, USA
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12
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Chen C, Liu H, Duan R, Wang F, Duan L. The efficacy and safety of acid suppressants for gastrointestinal bleeding prophylaxis in cardiac care unit patients. J Gastroenterol Hepatol 2021; 36:2131-2140. [PMID: 33586808 PMCID: PMC8451749 DOI: 10.1111/jgh.15432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/17/2020] [Accepted: 01/31/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Concerns regarding adverse events associated with proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) for gastrointestinal bleeding (GIB) prophylaxis in the intensive care unit have increased in recent years. Few studies have focused on acid suppressant use in the cardiac care unit (CCU) setting exclusively. We performed a cohort study to determine the efficacy and safety of acid suppressants for GIB prophylaxis in CCU patients. METHODS This retrospective cohort study included adults who were admitted directly to the CCU for more than 2 days from January 1, 2014, to April 30, 2019. The Crusade score was calculated to evaluate the risk of GIB. The primary outcomes were clinically important gastrointestinal bleeding (CIGIB), hospital-acquired pneumonia (HAP), and in-hospital mortality. RESULTS Of the 3318 patients enrolled, 2284 (68.8%) patients received PPIs, 515 (15.5%) received H2RAs, and 519 (15.7%) received no acid suppressants. After adjusting for potential confounders, utilization of PPIs (2.69, 95% confidence interval [0.62-11.73]) and H2RAs (1.41, 95% confidence interval [0.19-10.36]) were not associated with a lower risk of CIGIB than the control. Sensitivity analyses revealed that PPI use was an independent risk factor for in-hospital mortality in patients over 75 years old, with an adjusted odds ratio of 4.08 (1.14-14.63). PPIs increased the risk of HAP in patients over 75 years old and in those with heart failure, with adjusted odds ratios of 2.38 (1.06-5.34) and 2.88 (1.34-7.28), respectively. CONCLUSIONS Proton pump inhibitors and H2RAs for GIB prophylaxis in CCU patients were not associated with a lower risk of CIGIB than the controls. PPI therapy is associated with increased risks of HAP and in-hospital mortality in patients over 75 years old. PPIs may increase the risk of HAP in patients with heart failure.
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Affiliation(s)
- Chen Chen
- Department of GastroenterologyPeking University Third HospitalBeijingChina
| | - Hui Liu
- Department of Medical Informatics CenterPeking UniversityBeijingChina
| | - Ruqiao Duan
- Department of GastroenterologyPeking University Third HospitalBeijingChina
| | - Fangfang Wang
- Department of Cardiology and Institute of Vascular MedicinePeking University Third Hospital, NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Peptides, Beijing Key Laboratory of Cardiovascular Receptors ResearchBeijingChina
| | - Liping Duan
- Department of GastroenterologyPeking University Third HospitalBeijingChina
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Sarnaik MK, Modi S, Pisipati Y, Vaidya S, Syed Gaggatur N, Sange AH, Srinivas N, Sange I. Proton Pump Inhibitors: Exploring Cardiovascular Complications and Prescription Protocol. Cureus 2021; 13:e16744. [PMID: 34354892 PMCID: PMC8328806 DOI: 10.7759/cureus.16744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2021] [Indexed: 11/05/2022] Open
Abstract
Proton pump inhibitors (PPIs) are among the most extensively prescribed medications internationally for gastroesophageal reflux disease treatment and the prevention of gastrointestinal bleeding. Their efficiency, ease of availability, and low side effect profile offer several advantages over other treatment modalities. Long-term use and inappropriate prescribing habits have increased the presence of this class of drugs, prompting several studies to reassess their adverse effects. This article explored the possibility of a relationship between PPIs and cardiovascular adverse effects while highlighting the current prescription guidelines for PPIs. We further examined the need for more research into the etiology of PPI-related cardiovascular adverse effects and strategies to alleviate these risks.
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Affiliation(s)
| | - Srimy Modi
- Internal Medicine, K. J. Somaiya Medical College, Mumbai, IND
| | | | - Sarayoo Vaidya
- Internal Medicine, M S Ramaiah Medical College, Bangalore, IND
| | | | - Aliya H Sange
- Internal Medicine, Dubai Medical College, Dubai, ARE
| | - Natasha Srinivas
- Internal Medicine, BGS Global Institute of Medical Sciences, Bangalore, IND
| | - Ibrahim Sange
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Medicine, K. J. Somaiya Medical College, Mumbai, IND
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Bhatt DL, Pollack CV. The Future of Aspirin Therapy in Cardiovascular Disease. Am J Cardiol 2021; 144 Suppl 1:S40-S47. [PMID: 33706989 DOI: 10.1016/j.amjcard.2020.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Much has been written about the demise of aspirin (ASA) but reports of its death are premature. The drug remains one of the most widely prescribed by physicians worldwide. It is cheap, familiar, and effective for a variety of uses, including in patients with acute or prior myocardial infarction, ischemic stroke, peripheral artery disease, and percutaneous or surgical revascularization procedures, as well as for use for pain and fever relief. Beyond physician prescription or recommendation, over the counter use of ASA is common, including for primary cardiovascular prevention, though this decision really should involve a discussion of risks and benefits with a physician. ASA is an essential member of the duo that makes up dual antiplatelet therapy (a P2Y12 inhibitor plus ASA) and also dual pathway inhibition (vascular dose rivaroxaban plus ASA), and data for both approaches are growing. Furthermore, research is ongoing as to the optimal dosing frequency (once vs twice daily), potentially safer gastrointestinal delivery, and possibly more effective formulations in terms of platelet inhibition. One goal of ASA research is to try to reduce bleeding complications that are a risk with all anti-thrombotic therapies. Although its exact roles will continue to evolve, the future for ASA remains bright.
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15
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Abrignani MG, Gatta L, Gabrielli D, Milazzo G, De Francesco V, De Luca L, Francese M, Imazio M, Riccio E, Rossini R, Scotto di Uccio F, Soncini M, Zullo A, Colivicchi F, Di Lenarda A, Gulizia MM, Monica F. Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO). Eur J Intern Med 2021; 85:1-13. [PMID: 33279389 DOI: 10.1016/j.ejim.2020.11.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/03/2020] [Accepted: 11/16/2020] [Indexed: 02/05/2023]
Abstract
Aspirin and P2Y12 receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through hepatic CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The FDA and the EMA sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y12 receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. Like vitamin K antagonists (VKAs), DOACs can determine gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GI bleeding as compared with apixaban and warfarin. In patients taking oral anticoagulant with GI risk factor, PPI could be recommended, even if usefulness of PPIs in these patients deserves further data. Helicobacter pylori should always be searched, and treated, in patients with history of peptic ulcer disease (with or without complication). Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.
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Affiliation(s)
| | - Luigi Gatta
- Gastroenterogy Unit, Versilia Hospital, Lido di Camaiore, Italy
| | | | - Giuseppe Milazzo
- Department of Medicine, Ospedale Vittorio Emanuele III, Salemi, Italy
| | | | - Leonardo De Luca
- Dept. Of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - Maura Francese
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy
| | - Massimo Imazio
- Cardiology, AOU Città della Salute e della Scienza, Turin, Italy
| | - Elisabetta Riccio
- Department of Transplantation, UOSC of Gastroenterology and Endoscopy, AORN 'A. Cardarelli', Napoli, Italy
| | | | | | | | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL ROMA 1, Rome, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, University Hospital and Health Services of Trieste, Italy
| | - Michele Massimo Gulizia
- Division of Cardiology, Garibaldi-Nesima Hospital, Catania, Italy; President, Heart Care Foundation, Italy
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste, Italy
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16
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Dillinger JG, Laine M, Bouajila S, Paganelli F, Henry P, Bonello L. Antithrombotic strategies in elderly patients with acute coronary syndrome. Arch Cardiovasc Dis 2021; 114:232-245. [PMID: 33632631 DOI: 10.1016/j.acvd.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 12/22/2022]
Abstract
Elderly patients represent a growing proportion of the acute coronary syndrome population in Western countries. However, their frequent atypical symptoms at presentation often lead to delays in management and to misdiagnosis. Furthermore, their prognosis is poorer than that of younger patients because of physiological changes in platelet function, haemostasis and fibrinolysis, but also a higher proportion of comorbidities and frailty, both of which increase the risk of recurrent thrombotic and bleeding events. This complex situation, with ischaemic and haemorrhagic risk factors often being intertwined, may lead to confusion about the required treatment strategy, sometimes resulting in inadequate management or even to therapeutic nihilism. It is therefore critical to provide a comprehensive overview of our understanding of the pathophysiological processes underlying acute coronary syndrome in elderly patients, and to summarise the results from the latest clinical trials to help decision making for these high-risk patients.
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Affiliation(s)
- Jean-Guillaume Dillinger
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France.
| | - Marc Laine
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France; Mediterranean Association for research and studies in cardiology (MARS cardio), 13015 Marseille, France
| | - Sara Bouajila
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Franck Paganelli
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France
| | - Patrick Henry
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Laurent Bonello
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France; Mediterranean Association for research and studies in cardiology (MARS cardio), 13015 Marseille, France
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17
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Aspirin in Primary Prevention: What Changed? A Critical Appraisal of Current Evidence. Am J Cardiol 2021; 141:38-48. [PMID: 33221264 DOI: 10.1016/j.amjcard.2020.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
Aspirin has been the mainstay of both secondary and primary prevention of cardiovascular disease for half a century. In 2018, 3 trials showed a modest reduction in cardiovascular outcomes that appeared counterbalanced by the risk of clinically significant bleeding. The latest ACC/AHA primary prevention guidelines downgraded their recommendation for aspirin use in primary prevention to that of physician preference. Despite the consistent and robust evidence previously supporting the use of aspirin in cardiovascular disease prevention, little discussion has been given to mechanisms or analytic explanations for this revision of recommendations. In this review, we explore 3 possible mechanisms that may have contributed to the alteration of our perception of aspirin's role in primary prevention. These include changes in the population potentially using aspirin in primary prevention, changes in cardiovascular disease and its presentation, and changes in aspirin itself. Here we present a translational look at knowledge gaps that should be addressed to better guide contemporary aspirin use in primary prevention. In conclusion, based on these considerations, the current recommendations might be improved by recalibration of the cardiovascular risk threshold above which aspirin should be recommended for primary prevention, including the incorporation of newer risk assessment modalities such as calcium scoring. A second enhancement would be developing a bleeding risk calculator to support clinicians' assessment of risk vs benefit. The use of enteric-coated aspirin vs noncoated aspirin should also be reassessed.
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18
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Nicolau JC, Bhatt DL, Hohnloser SH, Kimura T, Lip GYH, Miede C, Nordaby M, Oldgren J, Steg PG, Ten Berg JM, Godoy LC, Cannon CP. Dabigatran Dual Therapy vs Warfarin Triple Therapy Post-Percutaneous Coronary Intervention in Patients with Atrial Fibrillation With/Without a Proton Pump Inhibitor: A Pre-Specified Analysis of the RE-DUAL PCI Trial. Drugs 2021; 80:995-1005. [PMID: 32562206 PMCID: PMC7320045 DOI: 10.1007/s40265-020-01323-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background and Objective In patients with atrial fibrillation following percutaneous coronary intervention, if a proton pump inhibitor is used, could that allow the use of warfarin triple therapy, or is there additional reduction in bleeding while using it with dual therapy? Methods The RE-DUAL PCI trial randomized 2725 patients with atrial fibrillation post-percutaneous coronary intervention to dabigatran dual therapy (110 or 150 mg twice daily, with clopidogrel or ticagrelor) or warfarin triple therapy (with clopidogrel or ticagrelor, and aspirin for 1–3 months). This prespecified subgroup analysis evaluated risks of a first major bleeding event or clinically relevant non-major bleeding event, all gastrointestinal bleeding, and a composite efficacy endpoint of all-cause mortality/thromboembolic event or unplanned revascularization according to baseline use of a proton pump inhibitor. Results Of 2678 analyzed patients, 1641 (61.3%) were receiving a proton pump inhibitor at baseline. Dabigatran 110 and 150 mg dual therapy reduced the risk of major bleeding events or clinically relevant non-major bleeding events vs warfarin triple therapy regardless of proton pump inhibitor use, with comparable risk of the composite efficacy endpoint (all interaction p values > 0.05). For gastrointestinal bleeding, no interaction was observed between study treatment and proton pump inhibitor use (interaction p values 0.84 and 0.62 for dabigatran 110 and 150 mg dual therapy, respectively, vs warfarin triple therapy). Conclusions Dabigatran 110 and 150 mg dual therapy reduced the risk of major bleeding events or clinically relevant non-major bleeding events vs warfarin triple therapy, regardless of proton pump inhibitor use at baseline, in patients with atrial fibrillation who underwent percutaneous coronary intervention. Risk of the composite efficacy endpoint appeared to be similar for dabigatran dual therapy vs warfarin triple therapy in patients receiving/not receiving a proton pump inhibitor. ClinicalTrials.gov unique identifier NCT02164864. Video abstract
Electronic supplementary material The online version of this article (10.1007/s40265-020-01323-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Enéas Carvalho Aguiar, 44, Sao Paulo, SP, 05403-000, Brazil.
| | - Deepak L Bhatt
- Brigham and Women's Hospital and Heart and Vascular Center, and Harvard Medical School, Boston, MA, USA
| | | | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center, and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Philippe Gabriel Steg
- Université de Paris, FACT, INSERM U_1148, Paris, France.,Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Lucas C Godoy
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Enéas Carvalho Aguiar, 44, Sao Paulo, SP, 05403-000, Brazil.,Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Christopher P Cannon
- Brigham and Women's Hospital and Heart and Vascular Center, and Harvard Medical School, Boston, MA, USA
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19
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He W, Shu X, Zhu E, Deng B, Lin Y, Wu X, Zhou Z, Wang J, Nie R. Intermittent concurrent use of clopidogrel and proton pump inhibitors did not increase risk of adverse clinical outcomes in Chinese patients with coronary artery disease. BMC Cardiovasc Disord 2021; 21:75. [PMID: 33546595 PMCID: PMC7863361 DOI: 10.1186/s12872-021-01884-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are frequently prescribed to patients with coronary heart disease (CHD) under antiplatelet therapy to prevent gastrointestinal (GI) bleeding. However, its clinical impact is still under debate, especially in Asian population. This study was undertaken to explore the effects of concurrent use of clopidogrel and PPIs on the clinical outcomes in Chinese patients with CHD in secondary prevention. METHODS A single-center retrospective study was conducted in 638 patients with CHD on consecutive clopidogrel therapy for at least 1 year. After 18-month follow-up, adverse clinical events were collected. Cox regression was used to calculate hazard ratios (HR) and 95% confidence interval (CI) for the effect of PPI use on the outcomes. A total of 638 patients were recruited from 2014 to 2015 in this study, among whom 201 were sustained PPI users, 188 were intermittent PPI users and the remaining 249 were non-PPI users. RESULTS Compared with sustained PPI users, intermittent use of PPIs was associated with a lower risk of stroke, major adverse cardiac events (MACE) and net adverse clinical event (NACE) (stroke: adjusted HR: 0.109, 95% CI 0.014-0.878, p = 0.037; MACE: adjusted HR: 0.293, 95% CI 0.119-0.722; p = 0.008; NACE: adjusted HR: 0.357, 95% CI 0.162-0.786, p = 0.011). Subgroup analysis further revealed the benefit of intermittent PPI use was significant in male CHD patients over 60 years old, with hypertension or chronic kidney disease, and undergoing percutaneous coronary intervention during hospitalization. CONCLUSION The current findings suggest that the intermittent concurrent use of PPIs and clopidogrel is not associated with an increased risk of 18-month adverse clinical outcomes, and intermittent use of PPIs is associated with a lower rate of MACE and NACE.
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Affiliation(s)
- Wanbing He
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, 107 Yanjiang West Rd., Guangzhou, 510120, Guangdong Province, China
| | - Xiaorong Shu
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, 107 Yanjiang West Rd., Guangzhou, 510120, Guangdong Province, China
| | - Enyi Zhu
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, 107 Yanjiang West Rd., Guangzhou, 510120, Guangdong Province, China
| | - Bingqing Deng
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, 107 Yanjiang West Rd., Guangzhou, 510120, Guangdong Province, China
| | - Yongqing Lin
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, 107 Yanjiang West Rd., Guangzhou, 510120, Guangdong Province, China
| | - Xiaoying Wu
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, 107 Yanjiang West Rd., Guangzhou, 510120, Guangdong Province, China
| | - Zenan Zhou
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, 107 Yanjiang West Rd., Guangzhou, 510120, Guangdong Province, China
| | - Jingfeng Wang
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, 107 Yanjiang West Rd., Guangzhou, 510120, Guangdong Province, China
| | - Ruqiong Nie
- Department of Cardiology, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, 107 Yanjiang West Rd., Guangzhou, 510120, Guangdong Province, China.
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20
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Lin SF, Lin PC, Chang CC, Chang WL, Chu FY. Investigation of the interaction between proton pump inhibitors and clopidogrel using VerifyNow P2Y12 assay. Medicine (Baltimore) 2020; 99:e23695. [PMID: 33327360 PMCID: PMC7738015 DOI: 10.1097/md.0000000000023695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/11/2020] [Accepted: 11/13/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Randomized trials and observation studies have revealed conflicting results regarding the interaction between clopidogrel and proton pump inhibitors (PPIs). The aim of our study was to provide laboratory evidence regarding whether PPIs blunt the antiplatelet reactivity of clopidogrel. METHODS We included records of Asian patients who received clopidogrel treatment for cardiovascular or cerebrovascular events and the VerifyNow P2Y12 assay for platelet reactivity monitoring. The responsiveness of antiplatelet effect to clopidogrel was analyzed according to 3 criteria:Results: Patients treated without PPIs did not differ significantly from those concomitantly treated with PPIs in terms of levels of PI (25.7% ± 24.3% vs 23.0 ± 25.3%, P = .4315), PRU (187.3 ± 74.0 vs 197.4 ± 77.3, P = .3373), or responsiveness to antiplatelet (adjusted absolute risk, 3.5%; 95% confidence interval, - 10.7 to 17.7%; P = .6297). Patients treated with lansoprazole, esomeprazole, pantoprazole, and rabeprazole exhibited no significant differences in PRU or PI levels compared with those treated without PPIs. By contrast, patients treated with dexlansoprazole exhibited a significantly decreased level of PI (25.7% ± 24.3% vs 14.0% ± 21.6%, P = .0297) and responsiveness to clopidogrel under the criterion PI > 20% (adjusted absolute risk: 10.5%; 95% confidence interval: 2.6% to 43.6%; P = .0274). CONCLUSION No robust interaction between clopidogrel and PPIs was found, but caution should be exercised in the concomitant use of dexlansoprazole and clopidogrel in Asians.
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Affiliation(s)
- Sheng-Feng Lin
- School of Public Health, College of Public Health, Taipei Medical University, Taipei
- Department of Clinical Pathology, Far Eastern Memorial Hospital
- Department of Neurology, Far Eastern Memorial Hospital
- Division of Hospitalist, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei
| | - Pei-Chin Lin
- Department of Clinical Pathology, Far Eastern Memorial Hospital
| | - Chih-Chun Chang
- Department of Clinical Pathology, Far Eastern Memorial Hospital
- Department of Nursing, Cardinal Tien Junior College of Healthcare and Management, Yilan
| | - Wei-Lun Chang
- Department of Pharmacy, Far Eastern Memorial Hospital, New Taipei
| | - Fang-Yeh Chu
- Department of Clinical Pathology, Far Eastern Memorial Hospital
- Graduate School of Biotechnology and Bioengineering, Yuan Ze University, Taoyuan City
- Department of Medical Laboratory Science and Biotechnology, Yuanpei University of Medical Technology, Hsinchu City
- School of Medical Laboratory Science and Biotechnology, Taipei Medical University, Taipei City, Taiwan
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21
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Li Y, Wang X, Bao D, Liao Z, Li J, Han X, Wang H, Xu K, Li Z, Stone GW, Han Y. Optimal antiplatelet therapy for prevention of gastrointestinal injury evaluated by ANKON magnetically controlled capsule endoscopy: Rationale and design of the OPT-PEACE trial. Am Heart J 2020; 228:8-16. [PMID: 32745734 PMCID: PMC7294257 DOI: 10.1016/j.ahj.2020.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/07/2020] [Indexed: 12/15/2022]
Abstract
Background Gastrointestinal injury is a common complication in patients treated with antiplatelet agents after percutaneous coronary intervention (PCI). However, the effects of different antiplatelet regimens on the incidence and severity of gastrointestinal injury have not been well studied, principally due to the lack of a low-risk sensitive and accurate detection system. Trial design OPT-PEACE is a multicenter, randomized, double-blind, placebo-controlled trial. Gastrointestinal injury will be evaluated with the ANKON magnetically controlled capsule endoscopy system (AMCE), a minimally invasive approach for detecting mucosal lesions in the stomach, duodenum and small intestine. Patients without AMCE-detected gastrointestinal erosions, ulceration or bleeding after drug-eluting stent implantation are enrolled and treated with open-label aspirin (100 mg/d) plus clopidogrel (75 mg/d) for 6 months. Thereafter, 480 event-free patients will undergo repeat AMCE and are randomly assigned in a 1:1:1 ratio to receive aspirin plus clopidogrel, aspirin plus placebo or clopidogrel plus placebo for an additional 6 months. A final AMCE is performed at 12 months. The primary endpoint is the incidence of gastric or intestinal mucosal lesions (erosions, ulceration, or bleeding) within 12 months after enrollment. Conclusions OPT-PEACE is the first study to investigate the incidence and severity of gastrointestinal injury in patients receiving different antiplatelet therapy regimens after stent implantation. This trial will inform clinical decision-making for personalized antiplatelet therapy post-PCI.
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Affiliation(s)
- Yi Li
- Department of Cardiology, General hospital of Northern Theater Command, Shenyang, China
| | - Xiaozeng Wang
- Department of Cardiology, General hospital of Northern Theater Command, Shenyang, China
| | - Dan Bao
- Department of Cardiology, General hospital of Northern Theater Command, Shenyang, China
| | - Zhuan Liao
- Digestive Endoscopy Center, Department of Gastroenterology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jing Li
- Department of Cardiology, General hospital of Northern Theater Command, Shenyang, China
| | - Xiao Han
- Department of Endoscopy, General hospital of Northern Theater Command, Shenyang, China
| | - Heyang Wang
- Department of Cardiology, General hospital of Northern Theater Command, Shenyang, China
| | - Kai Xu
- Department of Cardiology, General hospital of Northern Theater Command, Shenyang, China
| | - Zhaoshen Li
- Digestive Endoscopy Center, Department of Gastroenterology, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart and the Cardiovascular Research Foundation, New York
| | - Yaling Han
- Department of Cardiology, General hospital of Northern Theater Command, Shenyang, China.
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22
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Verma BR, Montane B, Chetrit M, Khayata M, Furqan MM, Ayoub C, Klein AL. Pericarditis and Post-cardiac Injury Syndrome as a Sequelae of Acute Myocardial Infarction. Curr Cardiol Rep 2020; 22:127. [PMID: 32856192 DOI: 10.1007/s11886-020-01371-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Pericarditis secondary to acute myocardial infarction (AMI) is known to develop either immediately or after a latent period of few months. Due to varied presentation and timing, its diagnosis and treatment can be challenging. This article reviews underlying mechanisms and the role of cardiac imaging in investigating and managing this condition. RECENT FINDINGS Timely diagnosis of pericarditis after AMI is important to prevent potential progression to complicated pericarditis. Clinical suspicion warrants initial investigation with serum inflammatory levels, electrocardiogram, and echocardiography. When findings are inconclusive, cardiac magnetic resonance imaging and computerized tomography can provide additional diagnostic information. Pericarditis after AMI is a treatable condition. Clinicians should maintain a high suspicion in this era of revascularization and develop a strategic plan for timely diagnosis and management.
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Affiliation(s)
- Beni R Verma
- Department of Cardiovascular Medicine and Department of Thoracic and Cardiovascular Surgery Cleveland Clinic, Center for Diagnosis and Treatment of Pericardial Disease, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, USA
| | - Bryce Montane
- Department of Cardiovascular Medicine and Department of Thoracic and Cardiovascular Surgery Cleveland Clinic, Center for Diagnosis and Treatment of Pericardial Disease, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, USA
| | - Michael Chetrit
- Department of Cardiovascular Medicine and Department of Thoracic and Cardiovascular Surgery Cleveland Clinic, Center for Diagnosis and Treatment of Pericardial Disease, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, USA
| | - Mohamed Khayata
- Department of Cardiovascular Medicine and Department of Thoracic and Cardiovascular Surgery Cleveland Clinic, Center for Diagnosis and Treatment of Pericardial Disease, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, USA
| | - Muhammad M Furqan
- Department of Cardiovascular Medicine and Department of Thoracic and Cardiovascular Surgery Cleveland Clinic, Center for Diagnosis and Treatment of Pericardial Disease, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine and Department of Thoracic and Cardiovascular Surgery Cleveland Clinic, Center for Diagnosis and Treatment of Pericardial Disease, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, USA
| | - Allan L Klein
- Department of Cardiovascular Medicine and Department of Thoracic and Cardiovascular Surgery Cleveland Clinic, Center for Diagnosis and Treatment of Pericardial Disease, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, USA.
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23
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Abstract
Abstract
Direct oral anticoagulants (
DOAC
s) have quickly become attractive alternatives to the long‐standing standard of care in anticoagulation, vitamin K antagonist.
DOAC
s are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010,
DOAC
s have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of
DOAC
s, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of
DOAC
s and act as a practical reference for clinicians to optimize
DOAC
use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
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Affiliation(s)
| | - Eric Stecker
- Electrophysiology Section Knight Cardiovascular Institute Oregon Health & Science University Portland OR
| | - Bruce A. Warden
- Center for Preventive Cardiology Knight Cardiovascular Institute Oregon Health & Science University Portland OR
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24
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Abstract
Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long-standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOACs, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOACs and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
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Affiliation(s)
| | - Eric Stecker
- Electrophysiology SectionKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
| | - Bruce A. Warden
- Center for Preventive CardiologyKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
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25
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Cainzos-Achirica M, Miedema MD, McEvoy JW, Al Rifai M, Greenland P, Dardari Z, Budoff M, Blumenthal RS, Yeboah J, Duprez DA, Mortensen MB, Dzaye O, Hong J, Nasir K, Blaha MJ. Coronary Artery Calcium for Personalized Allocation of Aspirin in Primary Prevention of Cardiovascular Disease in 2019: The MESA Study (Multi-Ethnic Study of Atherosclerosis). Circulation 2020; 141:1541-1553. [PMID: 32233663 DOI: 10.1161/circulationaha.119.045010] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recent American College of Cardiology/American Heart Association Primary Prevention Guidelines recommended considering low-dose aspirin therapy only among adults 40 to 70 years of age who are at higher atherosclerotic cardiovascular disease (ASCVD) risk but not at high risk of bleeding. However, it remains unclear how these patients are best identified. The present study aimed to assess the value of coronary artery calcium (CAC) for guiding aspirin allocation for primary prevention by using 2019 aspirin meta-analysis data on cardiovascular disease relative risk reduction and bleeding risk. METHODS The study included 6470 participants from the MESA Study (Multi-Ethnic Study of Atherosclerosis). ASCVD risk was estimated using the pooled cohort equations, and 3 strata were defined: <5%, 5% to 20%, and >20%. All participants underwent CAC scoring at baseline, and CAC scores were stratified as =0, 1 to 99, ≥100, and ≥400. A 12% relative risk reduction in cardiovascular disease events was used for the 5-year number needed to treat (NNT5) calculations, and a 42% relative risk increase in major bleeding events was used for the 5-year number needed to harm (NNH5) estimations. RESULTS Only 5% of MESA participants would qualify for aspirin consideration for primary prevention according to the American College of Cardiology/American Heart Association guidelines and using >20% estimated ASCVD risk to define higher risk. Benefit/harm calculations were restricted to aspirin-naive participants <70 years of age not at high risk of bleeding (n=3540). The overall NNT5 with aspirin to prevent 1 cardiovascular disease event was 476 and the NNH5 was 355. The NNT5 was also greater than or similar to the NNH5 among estimated ASCVD risk strata. Conversely, CAC≥100 and CAC≥400 identified subgroups in which NNT5 was lower than NNH5. This was true both overall (for CAC≥100, NNT5=140 versus NNH5=518) and within ASCVD risk strata. Also, CAC=0 identified subgroups in which the NNT5 was much higher than the NNH5 (overall, NNT5=1190 versus NNH5=567). CONCLUSIONS CAC may be superior to the pooled cohort equations to inform the allocation of aspirin in primary prevention. Implementation of current 2019 American College of Cardiology/American Heart Association guideline recommendations together with the use of CAC for further risk assessment may result in a more personalized, safer allocation of aspirin in primary prevention. Confirmation of these findings in experimental settings is needed.
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Affiliation(s)
- Miguel Cainzos-Achirica
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (M.C.-A., J.W.M., Z.D., R.S.B., O.D., K.N., M.J.B.)
| | | | - John W McEvoy
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (M.C.-A., J.W.M., Z.D., R.S.B., O.D., K.N., M.J.B.)
- National Institute for Prevention and Cardiovascular Health, Galway, Ireland (J.W.M.)
- National University of Ireland, Galway (J.W.M.)
- Saolta University Healthcare Group, University College Hospital Galway, Ireland (J.W.M.)
| | | | - Philip Greenland
- Feinberg School of Medicine, Northwestern University, Chicago, IL (P.G.)
| | - Zeina Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (M.C.-A., J.W.M., Z.D., R.S.B., O.D., K.N., M.J.B.)
| | - Matthew Budoff
- Harbor-University of California Medical Center, Los Angeles (M.B.)
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (M.C.-A., J.W.M., Z.D., R.S.B., O.D., K.N., M.J.B.)
| | - Joseph Yeboah
- Wake Forest Baptist Health, Winston-Salem, NC (J.Y.)
| | - Daniel A Duprez
- Cardiovascular Division, University of Minnesota, Minneapolis (D.A.D.)
| | | | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (M.C.-A., J.W.M., Z.D., R.S.B., O.D., K.N., M.J.B.)
| | | | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (M.C.-A., J.W.M., Z.D., R.S.B., O.D., K.N., M.J.B.)
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, The Johns Hopkins University, Baltimore, MD (M.C.-A., J.W.M., Z.D., R.S.B., O.D., K.N., M.J.B.)
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26
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Wang J, Zhang Y, Liu YM, Yang XC, Chen YY, Wu GJ, He XH, Duan L, Dong Y, Ma RF. Uncovering the protective mechanism of Huoxue Anxin Recipe against coronary heart disease by network analysis and experimental validation. Biomed Pharmacother 2019; 121:109655. [PMID: 31734577 DOI: 10.1016/j.biopha.2019.109655] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/21/2019] [Accepted: 11/06/2019] [Indexed: 12/12/2022] Open
Abstract
Coronary heart disease (CHD) is a leading cause of death and disability worldwide. Huoxue Anxin Recipe (HAR) is a novel Chinese Herbal Medicine formula of that has been used to treat CHD for several decades. Our previous study found that HAR had anti-oxidative effects, and could promote myocardial angiogenesis and improve cardiac function following myocardial infarction (MI) in rats. However, the active compounds, potential targets, and biological processes related to HAR have not been systematically investigated. Here, network pharmacology and experimental validation were used to study the protective mechanisms of HAR against CHD. We identified 124 active components, 124 verified targets, and 111 predictive targets. A total of 1192 genes related to CHD were identified by cDNA microarray and database analysis. A total of 47 putative targets of HAR against CHD were identified, including 32 verified targets and 15 predictive targets. ClueGo enrichment analysis identified 49 biological processes involved in the anti-CHD effects of HAR. Among them, the negative regulation of blood coagulation and regulation of collagen biosynthetic process were experimentally validated. After constructing a protein-protein interaction network and clustering with MECODE and ClusterONE, 162 key proteins (from ClueGo and clustering) were used to construct an internal interaction network. Complement C3 (C3), Fibrinogen alpha (FGA), Fibrinogen gamma (FGG), interleukin-6 (IL6), and Apolipoprotein A1 (APOA1) were the top 5 hub proteins identified by cytoHubber analysis. HAR limited the concentrations of C3, FGA, FGG, and IL6 and increased APOA1 levels. The results indicated that HAR could down-regulate blood coagulation, regulate collagen biosynthesis, inhibit peroxidation and inflammation injury, and promote cholesterol efflux. HAR could be a potential source of novel and effective drugs for CHD.
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Affiliation(s)
- Jie Wang
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Yun Zhang
- Immunology Research Department, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Yong-Mei Liu
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Xiao-Chen Yang
- Department of Cardiology & Health Care, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Yin-Ying Chen
- Department of Research Office, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Guang-Jun Wu
- Immunology Research Department, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Xuan-Hui He
- Immunology Research Department, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Lian Duan
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Yan Dong
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Ru-Feng Ma
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
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27
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Ostroumova OD, Kochetkov AI, Pereverzev AP, Kravchenko EV, Kazjulin AN, Andreev DN, Pavleeva EE. [The relationship between the combined use of various proton pump inhibitors with antiplatelet drugs and the risk of cardiovascular complications]. TERAPEVT ARKH 2019; 91:118-126. [PMID: 32598763 DOI: 10.26442/00403660.2019.08.000355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
In the article the problem of the combined use of clopidogrel and various proton pump inhibitors (PPIs) in terms of cardiovascular complications risk and stent thrombosis is considered. The results of meta - analyses and a systematic reviews affecting this issue are represented in detail. The inter - drug interactions mechanisms of various PPIs with clopidogrel based on the characteristics of the metabolism in the liver cytochromes system are discussed. The authors conducted a search, systematization and analysis of studies regarding the association between cardiovascular risk and combined use of individual medications from PPI class with clopidogrel, and these results are presented in the review. Currently available data do not allow to answer the question about the differences between individual PPIs in their impact on the risk of adverse cardiovascular events due to the small number of such studies, design heterogeneity, differences in the inclusion criteria and end points as well as in the rate of administration of individual PPIs.
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Affiliation(s)
- O D Ostroumova
- Pirogov Russian National Research Medical University - Russian Clinical and Research Center of Gerontology.,Sechenov First Moscow State Medical University (Sechenov University)
| | - A I Kochetkov
- Pirogov Russian National Research Medical University - Russian Clinical and Research Center of Gerontology
| | - A P Pereverzev
- Pirogov Russian National Research Medical University - Russian Clinical and Research Center of Gerontology
| | - E V Kravchenko
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - A N Kazjulin
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - D N Andreev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - E E Pavleeva
- Yevdokimov Moscow State University of Medicine and Dentistry
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28
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Prophylactic Use of Mucosal Protective Agents and Proton Pump Inhibitors in Patients Undergoing Percutaneous Coronary Intervention. J Cardiovasc Pharmacol 2019; 74:137-142. [DOI: 10.1097/fjc.0000000000000684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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29
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Proton Pump Inhibition in Patients Treated With Novel Antithrombotic Drugs: Should We Worry About Thrombosis? J Cardiovasc Pharmacol 2019; 72:71-76. [PMID: 29738377 DOI: 10.1097/fjc.0000000000000593] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Proton pump inhibition (PPI) administered together with antiplatelet and anticoagulant agents reduces the risk of gastrointestinal hemorrhage. Several novel antithrombotic agents have been recently introduced for patients with acute coronary syndrome (prasugrel and ticagrelor) or for patients requiring long-term anticoagulation (dabigatran, rivaroxaban, apixaban, edoxaban, and betrixaban). In fact, these agents might offer even stronger inhibition of platelets or coagulation compared with older agents; therefore, the need for gastroprotection might be even stronger when these new agents are used for long-term antithrombotic therapy. On the contrary, there are several reports regarding an adverse interaction between PPI and antithrombotic agents connected with a reduction in antithrombotic therapy on-treatment levels, implicating a higher risk of thrombosis. This interaction was demonstrated in clopidogrel-treated patients and more recently also in dabigatran-treated patients. This article discusses a possible novel antithrombotic therapy/PPI interaction leading to higher risk of thrombosis.
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30
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Hariri E, Lessard D, Gore J, Rade J, Goldberg R. Are We Optimizing the Use of Dual Antiplatelet Therapy in Patients Hospitalized with Acute Myocardial Infarction? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:182-188. [PMID: 31129036 DOI: 10.1016/j.carrev.2019.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/12/2019] [Accepted: 04/18/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is a mainstay treatment for hospital survivors of an acute myocardial infarction (AMI). However, there are limited data on the prescribing patterns of DAPT among patients hospitalized with AMI during recent years. OBJECTIVE To examine decade-long trends (2001-2011) in the use of DAPT versus antiplatelet monotherapy and patient characteristics associated with DAPT use. METHODS The study population consisted of 2389 adults hospitalized with an initial AMI at all 11 central Massachusetts medical centers on a biennial basis between 2001 and 2011. DAPT was defined as the discharge use of aspirin plus either clopidogrel or prasugrel. Logistic regression analysis was used to identify patient characteristics associated with DAPT use. RESULTS The average age of the study population was 65 years, and 69% of patients were discharged on DAPT. The use of DAPT at the time of hospital discharge increased from 49% in 2001 to 74% in 2011; this increasing trend was seen across all age groups, both sexes, types of AMI, and in those who underwent a PCI. After multivariable adjustment, patients 65-74 years old (adjusted odds ratio (aOR) = 0.53, 95% CI: 0.36-0.80) and those who underwent coronary artery bypass surgery (aOR = 0.11, 95% CI: 0.07-0.18) were less likely to have received DAPT, while men (aOR = 14.60, 95% CI: 10.66-19.98) and those who underwent cardiac catheterization and stenting (aOR = 14.60, 95% CI: 10.66-19.98) were significantly more likely to have received DAPT at discharge than respective comparison groups. CONCLUSIONS Between 2001 and 2011, the use of DAPT increased markedly among patients hospitalized with AMI. However, a significant proportion of patients were not discharged on this therapy. Greater awareness is needed to incorporate DAPT into the management of patients hospitalized with AMI.
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Affiliation(s)
- Essa Hariri
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Darleen Lessard
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Joel Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Jeffrey Rade
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Robert Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States of America.
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31
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Raber I, McCarthy CP, Vaduganathan M, Bhatt DL, Wood DA, Cleland JGF, Blumenthal RS, McEvoy JW. The rise and fall of aspirin in the primary prevention of cardiovascular disease. Lancet 2019; 393:2155-2167. [PMID: 31226053 DOI: 10.1016/s0140-6736(19)30541-0] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 12/21/2022]
Abstract
Aspirin is one of the most frequently used drugs worldwide and is generally considered effective for the secondary prevention of cardiovascular disease. By contrast, the role of aspirin in primary prevention of cardiovascular disease is controversial. Early trials evaluating aspirin for primary prevention, done before the turn of the millennium, suggested reductions in myocardial infarction and stroke (although not mortality), and an increased risk of bleeding. In an effort to balance the risks and benefits of aspirin, international guidelines on primary prevention of cardiovascular disease have typically recommended aspirin only when a substantial 10-year risk of cardiovascular events exists. However, in 2018, three large randomised clinical trials of aspirin for the primary prevention of cardiovascular disease showed little or no benefit and have even suggested net harm. In this narrative Review, we reappraise the role of aspirin in primary prevention of cardiovascular disease, contextualising data from historical and contemporary trials.
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Affiliation(s)
- Inbar Raber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Cian P McCarthy
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - David A Wood
- National Institute for Prevention and Cardiovascular Health, National University of Ireland, Galway, Ireland; National Heart and Lung Institute, Imperial College, London, UK
| | - John G F Cleland
- National Heart and Lung Institute, Imperial College, London, UK; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John W McEvoy
- National Institute for Prevention and Cardiovascular Health, National University of Ireland, Galway, Ireland; Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of Cardiology, Department of Medicine, Saolta University Healthcare Group, University College Hospital Galway, Galway, Ireland.
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32
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Wang L, Pei D, Ouyang YQ, Nie X. Meta-analysis of risk and protective factors for gastrointestinal bleeding after percutaneous coronary intervention. Int J Nurs Pract 2018; 25:e12707. [PMID: 30456863 DOI: 10.1111/ijn.12707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 09/30/2018] [Accepted: 10/05/2018] [Indexed: 01/22/2023]
Abstract
AIM To quantitatively analyse factors related to gastrointestinal bleeding after percutaneous coronary intervention and provide evidence for the prevention of gastrointestinal bleeding. DATA SOURCES AND REVIEW METHODS Cochrane Library, Pubmed, Embase, and Ovid databases were searched from inception to 31 May 2018; case-control and cohort studies published in English were included. The methodological quality of each study was assessed by two independent reviewers using the Newcastle-Ottawa Scale. Meta-analysis was performed using Revman version 5.3. RESULTS A total of 16 publications yielded data about risk factors. It was found that age older than 70 years, age (per 10-year increase), female sex, baseline anaemia, history of smoking, history of using alcohol, history of peptic ulcer disease, chronic renal failure, previous bleeding, shock, congestive heart failure, acute myocardial infarction, prior use of inotropic medications, and prior use of antithrombotic medications were positively associated with gastrointestinal bleeding. Four articles yielded data about protective factors. It was found that proton-pump inhibitor and bivalirudin therapy were negatively associated with gastrointestinal bleeding after percutaneous coronary intervention. CONCLUSION This research found risk and protective factors which can assist in effective management of this potentially fatal complication.
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Affiliation(s)
- Lan Wang
- School of Health Sciences of Wuhan University, Wuhan, China.,Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dajun Pei
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | - Xiaofei Nie
- School of Health Sciences of Wuhan University, Wuhan, China
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The Impacts of Peptic Ulcer on Functional Outcomes of Ischemic Stroke. J Stroke Cerebrovasc Dis 2018; 28:311-316. [PMID: 30391329 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/19/2018] [Accepted: 09/30/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND PURPOSE Studies have shown that peptic ulcer increased the risk of ischemic stroke and stroke recurrence. This study aimed to evaluate the impacts of peptic ulcer on functional outcomes of ischemic stroke. METHODS Patients with first-ever ischemic stroke were grouped as with and without history of peptic ulcer. Functional outcomes were evaluated with modified Rankin scale at 90 days after the index stroke. Favorable functional outcomes were defined as with a modified Rankin scale score of 0-2. Logistic regression was used to identify predictors for favorable functional outcomes at 90 days. RESULTS Among the 2577 enrolled patients with ischemic stroke, 129 (5.0%) had a history of peptic ulcer. The proportion of favorable outcome was higher in patients without peptic ulcer than those with (59.3% versus 42.6%, P < .001). Multivariate logistic analysis detected that history of peptic ulcer (odds ratio [OR] = 2.89, 95% confidence interval [CI], 1.03-8.10, P = .043), National Institute of Health Stroke Scale score (OR = 2.11, 95% CI, 1.79-2.48, P < .001), and large-artery atherosclerosis stroke subtype (OR = 4.08, 95% CI, 1.11-15.03, P = .035) decreased the likelihood of favorable outcomes. CONCLUSIONS Ischemic stroke patients with peptic ulcer may have an increased risk of less favorable neurological outcome at 90 days after the index stroke.
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Ogunbayo GO, Messerli AW, Ha LD, Elbadawi A, Olorunfemi O, Darrat Y, Guglin M, Okwechime R, Akanya D, Abdel-Latif A, Smyth SS, Elayi CS. Trends in the Incidence and In-Hospital Outcomes of Patients With Atrial Fibrillation Complicated by Non-ST-Segment Elevation Myocardial Infarction. Angiology 2018; 70:317-324. [PMID: 30231624 DOI: 10.1177/0003319718801087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) can present with non-ST-segment elevation myocardial infarction (NSTEMI). The incidence, characteristics, outcomes, and treatment of this subgroup of patients with AF remains poorly studied. Using data from the National Inpatient Sample database, we (1) compared baseline characteristics of patients with AF with/without NSTEMI, (2) evaluated their outcomes and associated trends over the study period (2004-2013), and (3) evaluated revascularization (by percutaneous coronary intervention or coronary artery bypass graft [CABG]) and the impact on patient outcomes. Of the 3 923 436 patients admitted with a primary diagnosis of AF, 47 785 (1.2%) had a secondary diagnosis of NSTEMI. In this subgroup with AF and NSTEMI, there was a significant trend toward a decrease in mortality ( P = .002), stroke ( P < .001), and gastrointestinal bleeding ( P < .001) during the study period. Compared to unrevascularized patients, revascularized patients were more likely to be younger (72.2 ± 10.2 vs 77.0 ± 11.8 years old, P < .001), male (57.8 vs 42.7%, P < .001), and had a much higher incidence of coronary risk factors. Revascularization was associated with increased survival in multivariable analysis (odds ratio: 0.562, 95% confidence interval: 0.334-0.946, P = .03). In conclusion, among patients admitted with AF, 1.2% were diagnosed with NSTEMI. A minority of patients with AF and NSTEMI underwent revascularization and had better in-hospital outcomes.
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Affiliation(s)
- Gbolahan O Ogunbayo
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Adrian W Messerli
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Le Dung Ha
- 2 Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Ayman Elbadawi
- 2 Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Odunayo Olorunfemi
- 2 Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Yousef Darrat
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Maya Guglin
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Remi Okwechime
- 3 Department of Internal Medicine, Wychoff Heights Medical Center, NY, USA
| | - Deborah Akanya
- 4 Department of Internal Medicine, St Vincents Medical Center, Bridgeport, CT, USA
| | - Ahmed Abdel-Latif
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Susan S Smyth
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Claude S Elayi
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
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Only full adherence to proton pump inhibitors protects against drug-induced upper gastrointestinal bleeding. Eur J Clin Pharmacol 2018; 74:1503-1511. [PMID: 30043109 DOI: 10.1007/s00228-018-2523-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/10/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE The use of gastroprotective agents has allowed significant progress in the prevention of upper gastrointestinal bleeding (UGIB) associated with non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet agents. Nevertheless, some concerns remain regarding the gastroprotective dosage and treatment duration. Our aim was to study the effect of gastroprotective agents in UGIB induced by NSAIDs and single- or dual-antiplatelet therapy. METHODS A multicenter case-control study was conducted including 577 cases diagnosed with UGIB and 1343 sex-, age-, and hospital-matched controls. To estimate exposure to NSAIDs and gastroprotective agents, consumption was calculated for the 4 weeks prior to hospital admission in terms of defined daily doses (DDDs). Risk groups for UGIB induced by NSAIDs and single- or dual-antiplatelet therapy were defined as a function of each drug dose, use of gastrointestine-damaging drugs, and risk factors for UGIB. Odds ratios (ORs) with 95% confidence intervals (CIs) were adjusted for single- (model 1) and dual- (model 2) antiplatelet therapy. RESULTS Full adherence (> 0.80DDD) to proton pump inhibitors (PPIs) was the only gastroprotective therapy that significantly reduced the risk of UGIB, considering NSAID risk (OR: 0.53; 95% CI: 0.30-0.95) and dose (OR: 0.48; 95% CI: 0.27-0.87) with ORs adjusted for single-antiplatelet therapy (model 1) and NSAID risk (OR: 0.55; 95% CI: 0.31-0.98) and dose (OR: 0.49; 95% CI: 0.28-0.89) with ORs adjusted for dual-antiplatelet therapy (model 2). CONCLUSIONS These results reinforce the recommendation of adding a PPI at effective doses (full adherence) to prevent UGIB induced by NSAIDs, or single- or dual-antiplatelet therapy.
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36
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Toews I, George AT, Peter JV, Kirubakaran R, Fontes LES, Ezekiel JPB, Meerpohl JJ. Interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units. Cochrane Database Syst Rev 2018; 6:CD008687. [PMID: 29862492 PMCID: PMC6513395 DOI: 10.1002/14651858.cd008687.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Upper gastrointestinal (GI) bleeding due to stress ulcers contributes to increased morbidity and mortality in people admitted to intensive care units (ICUs). Stress ulceration refers to GI mucosal injury related to the stress of being critically ill. ICU patients with major bleeding as a result of stress ulceration might have mortality rates approaching 48.5% to 65%. However, the incidence of stress-induced GI bleeding in ICUs has decreased, and not all critically ill patients need prophylaxis. Stress ulcer prophylaxis can result in adverse events such as ventilator-associated pneumonia; therefore, it is necessary to evaluate strategies that safely decrease the incidence of GI bleeding. OBJECTIVES To assess the effect and risk-benefit profile of interventions for preventing upper GI bleeding in people admitted to ICUs. SEARCH METHODS We searched the following databases up to 23 August 2017, using relevant search terms: MEDLINE; Embase; the Cochrane Central Register of Controlled Trials; Latin American Caribbean Health Sciences Literature; and the Cochrane Upper Gastrointestinal and Pancreatic Disease Group Specialised Register, as published in the Cochrane Library (2017, Issue 8). We searched the reference lists of all included studies and those from relevant systematic reviews and meta-analyses to identify additional studies. We also searched the World Health Organization International Clinical Trials Registry Platform search portal and contacted individual researchers working in this field, as well as organisations and pharmaceutical companies, to identify unpublished and ongoing studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs with participants of any age and gender admitted to ICUs for longer than 48 hours. We excluded studies in which participants were admitted to ICUs primarily for the management of GI bleeding and studies that compared different doses, routes, and regimens of one drug in the same class because we were not interested in intraclass effects of drugs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by Cochrane. MAIN RESULTS We identified 2292 unique records.We included 129 records reporting on 121 studies, including 12 ongoing studies and two studies awaiting classification.We judged the overall risk of bias of two studies as low. Selection bias was the most relevant risk of bias domain across the included studies, with 78 studies not clearly reporting the method used for random sequence generation. Reporting bias was the domain with least risk of bias, with 12 studies not reporting all outcomes that researchers intended to investigate.Any intervention versus placebo or no prophylaxisIn comparison with placebo, any intervention seems to have a beneficial effect on the occurrence of upper GI bleeding (risk ratio (RR) 0.47, 95% confidence interval (CI) 0.39 to 0.57; moderate certainty of evidence). The use of any intervention reduced the risk of upper GI bleeding by 10% (95% CI -12.0% to -7%). The effect estimate of any intervention versus placebo or no prophylaxis with respect to the occurrence of nosocomial pneumonia, all-cause mortality in the ICU, duration of ICU stay, duration of intubation (all with low certainty of evidence), the number of participants requiring blood transfusions (moderate certainty of evidence), and the units of blood transfused was consistent with benefits and harms. None of the included studies explicitly reported on serious adverse events.Individual interventions versus placebo or no prophylaxisIn comparison with placebo or no prophylaxis, antacids, H2 receptor antagonists, and sucralfate were effective in preventing upper GI bleeding in ICU patients. Researchers found that with H2 receptor antagonists compared with placebo or no prophylaxis, 11% less developed upper GI bleeding (95% CI -0.16 to -0.06; RR 0.50, 95% CI 0.36 to 0.70; 24 studies; 2149 participants; moderate certainty of evidence). Of ICU patients taking antacids versus placebo or no prophylaxis, 9% less developed upper GI bleeding (95% CI -0.17 to -0.00; RR 0.49, 95% CI 0.25 to 0.99; eight studies; 774 participants; low certainty of evidence). Among ICU patients taking sucralfate versus placebo or no prophylaxis, 5% less had upper GI bleeding (95% CI -0.10 to -0.01; RR 0.53, 95% CI 0.32 to 0.88; seven studies; 598 participants; moderate certainty of evidence). The remaining interventions including proton pump inhibitors did not show a significant effect in preventing upper GI bleeding in ICU patients when compared with placebo or no prophylaxis.Regarding the occurrence of nosocomial pneumonia, the effects of H2 receptor antagonists (RR 1.12, 95% CI 0.85 to 1.48; eight studies; 945 participants; low certainty of evidence) and of sucralfate (RR 1.33, 95% CI 0.86 to 2.04; four studies; 450 participants; low certainty of evidence) were consistent with benefits and harms when compared with placebo or no prophylaxis. None of the studies comparing antacids versus placebo or no prophylaxis provided data regarding nosocomial pneumonia.H2 receptor antagonists versus proton pump inhibitorsH2 receptor antagonists and proton pump inhibitors are most commonly used in practice to prevent upper GI bleeding in ICU patients. Proton pump inhibitors significantly more often prevented upper GI bleeding in ICU patients compared with H2 receptor antagonists (RR 2.90, 95% CI 1.83 to 4.58; 18 studies; 1636 participants; low certainty of evidence). When taking H2 receptor antagonists, 4.8% more patients might experience upper GI bleeding (95% CI 2.1% to 9%). Nosocomial pneumonia occurred in similar proportions of participants taking H2 receptor antagonists and participants taking proton pump inhibitors (RR 1.02, 95% CI 0.77 to 1.35; 10 studies; 1256 participants; low certainty of evidence). AUTHORS' CONCLUSIONS This review shows that antacids, sucralfate, and H2 receptor antagonists might be more effective in preventing upper GI bleeding in ICU patients compared with placebo or no prophylaxis. The effect estimates of any treatment versus no prophylaxis on nosocomial pneumonia were consistent with benefits and harms. Evidence of low certainty suggests that proton pump inhibitors might be more effective than H2 receptor antagonists. Therefore, patient-relevant benefits and especially harms of H2 receptor antagonists compared with proton pump inhibitors need to be assessed by larger, high-quality RCTs to confirm the results of previously conducted, smaller, and older studies.
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Affiliation(s)
- Ingrid Toews
- Medical Center, Faculty of Medicine, University of FreiburgEvidence in Medicine / Cochrane GermanyBreisacher Straße 153FreiburgBaden‐WürttembergGermany79110
| | - Aneesh Thomas George
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - John V Peter
- Christian Medical College & HospitalMedical Intensive Care UnitIda Scudder RoadVelloreTamil NaduIndia632004
| | - Richard Kirubakaran
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Luís Eduardo S Fontes
- Petrópolis Medical SchoolDepartment of Evidence‐Based Medicine, Intensive Care, GastroenterologyAv Barao do Rio Branco, 1003PetrópolisRJBrazil25680‐120
| | - Jabez Paul Barnabas Ezekiel
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
| | - Joerg J Meerpohl
- Medical Center, Faculty of Medicine, University of FreiburgEvidence in Medicine / Cochrane GermanyBreisacher Straße 153FreiburgBaden‐WürttembergGermany79110
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Xu Z, Wang L, Lin Y, Wang Z, Zhang Y, Li J, Li S, Ye Z, Yuan K, Shan W, Liu X, Fan X, Xu G. The Impacts of Peptic Ulcer on Stroke Recurrence. J Stroke Cerebrovasc Dis 2018; 27:2106-2111. [PMID: 29653802 DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/28/2018] [Accepted: 03/12/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Peptic ulcer has been associated with an increased risk of stroke. This study aimed to evaluate the impacts of peptic ulcer on stroke recurrence and mortality. SUBJECTS AND METHODS Patients with first-ever ischemic stroke were retrospectively confirmed with or without a history of peptic ulcer. The primary end point was defined as fatal and nonfatal stroke recurrence. Risks of 1-year fatal and nonfatal stroke recurrence were analyzed with the Kaplan-Meier method. Predictors of fatal and nonfatal stroke recurrence were evaluated with the Cox proportional hazards model. RESULTS Among the 2577 enrolled patients with ischemic stroke, 129 (5.0%) had a history of peptic ulcer. The fatal and nonfatal stroke recurrence within 1 year of the index stroke was higher in patients with peptic ulcer than in patients without peptic ulcer (12.4% versus 7.2%, P = .030). Cox proportional hazards model detected that age (hazard ratio [HR] = 1.018, 95% confidence interval [CI] 1.005-1.031, P = .008), hypertension (HR = 1.397, 95% CI 1.017-1.918, P = .039), and history of peptic ulcer (HR = 1.853, 95% CI 1.111-3.091, P = .018) were associated with stroke recurrence. CONCLUSIONS Ischemic stroke patients with peptic ulcer may have an increased risk of stroke recurrence. The results emphasize the importance of appropriate prevention and management of peptic ulcer for secondary stroke prevention.
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Affiliation(s)
- Zongliang Xu
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu 210002, China; Department of Neurology, Jiangning Hospital Affiliated of Nanjing Medical University, Nanjing, Jiangsu 211100, China
| | - Ling Wang
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Ying Lin
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu 210002, China; Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Zhaojun Wang
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu 210002, China; Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Yun Zhang
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu 210002, China
| | - Junrong Li
- Department of Neurology, Jiangning Hospital Affiliated of Nanjing Medical University, Nanjing, Jiangsu 211100, China
| | - Shenghua Li
- Department of Neurology, Jiangning Hospital Affiliated of Nanjing Medical University, Nanjing, Jiangsu 211100, China
| | - Zusen Ye
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu 210002, China
| | - Kunxiong Yuan
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu 210002, China
| | - Wanying Shan
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu 210002, China; Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China
| | - Xinying Fan
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu 210002, China; Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China.
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu 210002, China; Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, China.
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Sehested TSG, Gerds TA, Fosbøl EL, Hansen PW, Charlot MG, Carlson N, Hlatky MA, Torp-Pedersen C, Gislason GH. Long-term use of proton pump inhibitors, dose-response relationship and associated risk of ischemic stroke and myocardial infarction. J Intern Med 2018; 283:268-281. [PMID: 29024109 DOI: 10.1111/joim.12698] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Use of proton pump inhibitors (PPIs) has been associated with cardiovascular disease amongst patients not on antiplatelet therapy. The associations of PPI use, duration and dose, with risk of first-time ischemic stroke and myocardial infarction (MI) are poorly understood. METHODS All Danish individuals with no prior history of MI or stroke, who had an elective upper gastrointestinal endoscopy performed between 1997 and 2012, were identified from nationwide registries. We used multiple Poisson regression to test associations with current PPI use and its dose and used multiple cause-specific Cox regression and g-formula methods to analyze long-term use. RESULTS Amongst 214 998 individuals, during a median follow-up of 5.8 years, there were 7916 ischemic strokes and 5608 MIs. Current PPI exposure was associated with significantly higher rates of both ischemic stroke (Hazard ratio (HR) 1.13; 95% confidence interval (CI) 1.08-1.19) and MI (HR 1.31, CI 1.23-1.39) after adjusting for age, sex, comorbidities and concomitant medication. High-dose PPI was associated with increased rates of ischemic stroke (HR 1.31, CI 1.21-1.42) and MI (HR 1.43, CI 1.30-1.57). Histamine H2 receptor antagonists (H2RAs) use was not significantly associated with ischemic stroke (HR 1.02, CI 0.84-1.24) or MI (HR 1.15, CI 0.92-1.43). Long-term users of PPIs, compared with nonusers, had a 29% (CI 5%-59%) greater absolute risk of ischemic stroke and a 36% (CI 7%-73%) greater risk of MI within a 6-month period. CONCLUSION Use of PPIs was associated with increased risks of first-time ischemic stroke and MI, particularly amongst long-term users and at high doses.
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Affiliation(s)
- T S G Sehested
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen K, Denmark
| | - T A Gerds
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen K, Denmark
- Department of Biostatistics, Copenhagen University, Copenhagen, Denmark
| | - E L Fosbøl
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - P W Hansen
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen K, Denmark
- Department of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - M G Charlot
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark
| | - N Carlson
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen K, Denmark
- Department of Internal Medicine, Gastroenterology section, Holbaek Hospital, Holbaek, Denmark
| | - M A Hlatky
- Department of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - C Torp-Pedersen
- Department of Health, Science and Technology, Department of Cardiology and Epidemiology/Biostatistics, Aalborg University, Aalborg University Hospital, Hellerup, Denmark
| | - G H Gislason
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen K, Denmark
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Scally B, Emberson JR, Spata E, Reith C, Davies K, Halls H, Holland L, Wilson K, Bhala N, Hawkey C, Hochberg M, Hunt R, Laine L, Lanas A, Patrono C, Baigent C. Effects of gastroprotectant drugs for the prevention and treatment of peptic ulcer disease and its complications: a meta-analysis of randomised trials. Lancet Gastroenterol Hepatol 2018; 3:231-241. [PMID: 29475806 PMCID: PMC5842491 DOI: 10.1016/s2468-1253(18)30037-2] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 12/13/2022]
Abstract
Background Gastroprotectant drugs are used for the prevention and treatment of peptic ulcer disease and might reduce its associated complications, but reliable estimates of the effects of gastroprotectants in different clinical settings are scarce. We aimed to examine the effects of proton-pump inhibitors (PPIs), prostaglandin analogues, and histamine-2 receptor antagonists (H2RAs) in different clinical circumstances by doing meta-analyses of tabular data from all relevant unconfounded randomised trials of gastroprotectant drugs. Methods We searched MEDLINE and Embase from Jan 1, 1950, to Dec 31, 2015, to identify unconfounded, randomised trials of a gastroprotectant drug (defined as a PPI, prostaglandin analogue, or H2RA) versus control, or versus another gastroprotectant. Two independent researchers reviewed the search results and extracted the prespecified outcomes and key characteristics for each trial. We did meta-analyses of the effects of gastroprotectant drugs on ulcer development, bleeding, and mortality overall, according to the class of gastroprotectant, and according to the individual drug within a gastroprotectant class. Findings We identified comparisons of gastroprotectant versus control in 849 trials (142 485 participants): 580 prevention trials (110 626 participants), 233 healing trials (24 033 participants), and 36 trials for the treatment of acute upper gastrointestinal bleeding (7826 participants). Comparisons of one gastroprotectant drug versus another were available in 345 trials (64 905 participants), comprising 160 prevention trials (32 959 participants), 167 healing trials (28 306 participants), and 18 trials for treatment of acute upper gastrointestinal bleeding (3640 participants). The median number of patients in each trial was 78 (IQR 44·0–210·5) and the median duration was 1·4 months (0·9–2·8). In prevention trials, gastroprotectant drugs reduced development of endoscopic ulcers (odds ratio [OR] 0·27, 95% CI 0·25–0·29; p<0·0001), symptomatic ulcers (0·25, 0·22–0·29; p<0·0001), and upper gastrointestinal bleeding (0·40, 0·32–0·50; p<0·0001), but did not significantly reduce mortality (0·85, 0·69–1·04; p=0·11). Larger proportional reductions in upper gastrointestinal bleeding were observed for PPIs than for other gastroprotectant drugs (PPIs 0·21, 99% CI 0·12–0·36; prostaglandin analogues 0·63, 0·35–1·12; H2RAs 0·49, 0·30–0·80; phet=0·0005). Gastroprotectant drugs were effective in preventing bleeding irrespective of the use of non-steroidal anti-inflammatory drugs (phet=0·56). In healing trials, gastroprotectants increased endoscopic ulcer healing (3·49, 95% CI 3·28–3·72; p<0·0001), with PPIs more effective (5·22, 99% CI 4·00–6·80) than prostaglandin analogues (2·27, 1·91–2·70) and H2RAs (3·80, 3·44–4·20; phet<0·0001). In trials among patients with acute bleeding, gastroprotectants reduced further bleeding (OR 0·68, 95% CI 0·60–0·78; p<0·0001), blood transfusion (0·75, 0·65–0·88; p=0·0003), further endoscopic intervention (0·56, 0·45–0·70; p<0·0001), and surgery (0·72, 0·61–0·84; p<0·0001), but did not significantly reduce mortality (OR 0·90, 0·72–1·11; p=0·31). PPIs had larger protective effects than did H2RAs for further bleeding (phet=0·0107) and blood transfusion (phet=0·0130). Interpretation Gastroprotectants, in particular PPIs, reduce the risk of peptic ulcer disease and its complications and promote healing of peptic ulcers in a wide range of clinical circumstances. However, this meta-analysis might have overestimated the benefits owing to small study bias. Funding UK Medical Research Council and the British Heart Foundation.
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Affiliation(s)
- Benjamin Scally
- Emergency Department, Glasgow Royal Infirmary, Glasgow, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Jonathan R Emberson
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK
| | - Enti Spata
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK
| | - Christina Reith
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Kelly Davies
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Heather Halls
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Lisa Holland
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Kate Wilson
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Neeraj Bhala
- Gastroenterology and Liver Unit, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, UK; Institute of Applied Health Research, University of Birmingham, Edgbaston, UK
| | - Christopher Hawkey
- Nottingham Digestive Diseases Centre, Queen's Medical Centre, Nottingham, UK
| | - Marc Hochberg
- Department of Medicine and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Richard Hunt
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University Health Science Centre, Hamilton, ON, Canada
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Angel Lanas
- Service of Digestive Diseases, University Clinic Hospital, University of Zaragoza, IIS Aragón, CIBERehd, Zaragoza, Spain
| | - Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Colin Baigent
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK.
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Weighing the Anti-Ischemic Benefits and Bleeding Risks from Aspirin Therapy: a Rational Approach. Curr Atheroscler Rep 2018; 20:15. [DOI: 10.1007/s11883-018-0717-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Hu W, Tong J, Kuang X, Chen W, Liu Z. Influence of proton pump inhibitors on clinical outcomes in coronary heart disease patients receiving aspirin and clopidogrel: A meta-analysis. Medicine (Baltimore) 2018; 97:e9638. [PMID: 29504996 PMCID: PMC5779765 DOI: 10.1097/md.0000000000009638] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are usually prescribed to protect against gastrointestinal bleeding in patients on dual antiplatelet therapy. This meta-analysis reviewed clinical outcomes in patients taking aspirin and clopidogrel, with and without concomitant PPIs to address concerns of adverse reactions. METHODS We searched PubMed, Embase, and the Cochrane Library for articles published between January 1, 2010 and April 11, 2017. The primary end points were major adverse cardiovascular events and gastrointestinal bleeding. Secondary end points were myocardial infarction, stent thrombosis, revascularization, cardiogenic death, and all-cause mortality. RESULTS The meta-analysis included 33,492 patients in 4 randomized controlled trials and 8 controlled observational studies. Overall, patients taking PPIs had statistical differences in major adverse cardiovascular events [odds ratio (OR) 1.17 (95% confidence interval [CI] 1.07-1.28); P = .001; I = 28.3%], gastrointestinal bleeding [OR 0.58 (95% CI 0.36-0.92); P = .022; I = 80.6%], stent thrombosis [OR 1.30 (95% CI 1.01-1.68); P = .041; I = 0%], and revascularization [OR 1.20 (95% CI 1.04-1.38); P = .011; I = 5.1%], compared those not taking PPIs. There were no significant differences in myocardial infarction [OR 1.03 (95% CI 0.87-1.22); P = .742; I = 0%], cardiogenic death [OR 1.09 (95% CI 0.83-1.43); P = .526; I = 0%], or all-cause mortality [OR 1.08 (95% CI 0.93-1.25); P = .329; I = 0%). CONCLUSIONS Among the patients taking aspirin and clopidogrel, the results indicated that the combined use of PPIs increased the rates of major adverse cardiovascular events, stent thrombosis, and revascularization.
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Affiliation(s)
| | - Jin Tong
- Department of Respirology, The Second Affiliated Hospital/The Second Clinical Institute, Chongqing Medical University, Chongqing, China
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Fujita M, Manabe N, Murao T, Osawa M, Hirai S, Fukushima S, Shogen Y, Nakato R, Ishii M, Matsumoto H, Hata J, Shiotani A. Differences in the clinical course of 516 Japanese patients with upper gastrointestinal bleeding between weekday and weekend admissions. Scand J Gastroenterol 2017; 52:1365-1370. [PMID: 28925290 DOI: 10.1080/00365521.2017.1377762] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Patients suspected of having upper gastrointestinal bleeding (UGIB) admitted during the weekend tend to have a poor outcome in western countries. However, no Japanese studies have been reported on this matter. We aimed to evaluate differences in the clinical course of patients with UGIB between weekday and weekend admissions in Japan. METHODS Medical records of patients who had undergone emergency endoscopy for UGIB were retrospectively reviewed. The severity of UGIB was evaluated using the Glasgow-Blatchford (GB) and AIMS65 score. Patients in whom UGIB was stopped and showed improved iron deficiency anemia after admission were considered as having a good clinical course. RESULTS We reviewed 516 consecutive patients and divided them into two groups: Group A (daytime admission on a weekday: 234 patients) and Group B (nighttime or weekend admission: 282 patients). There was no significant difference in GB and AIM65 scores between the Groups. The proportions of patients with good clinical course were not significantly different between groups (A, 67.5% and B, 67.0%; p = .90). However, patients in Group B underwent hemostatic treatments more frequently compared with those in Group A (58.5% vs 47.4%, p = .012). Multivariate analysis showed that taking acid suppressants, no need for blood transfusions, use of hemostatic treatments, and GB score <12 were associated with a good clinical course. CONCLUSIONS There were no significant differences in the clinical outcomes of patients with UGIB admitted during daytime on weekdays and those admitted at nighttime or weekends partly owing to the sufficient performance of endoscopic hemostatic treatments.
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Affiliation(s)
- Minoru Fujita
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Noriaki Manabe
- b Department of Clinical Pathology and Laboratory Medicine, Division of Endoscopy and Ultrasonography , Kawasaki Medical School , Kurashiki , Japan
| | - Takahisa Murao
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Motoyasu Osawa
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Shinsuke Hirai
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Shinya Fukushima
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Yo Shogen
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Rui Nakato
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Manabu Ishii
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Hiroshi Matsumoto
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
| | - Jiro Hata
- b Department of Clinical Pathology and Laboratory Medicine, Division of Endoscopy and Ultrasonography , Kawasaki Medical School , Kurashiki , Japan
| | - Akiko Shiotani
- a Department of Internal Medicine, Division of Gastroenterology , Kawasaki Medical School , Kurashiki , Japan
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Abstract
PURPOSE OF REVIEW The present review summarizes the past year's literature, both clinical and basic science, regarding physiologic and pharmacologic regulation of gastric acid secretion in health and disease. RECENT FINDINGS Gastric acid kills microorganisms, assists digestion, and facilitates absorption of iron, calcium, and vitamin B12. The main stimulants of acid secretion are the hormone gastrin, released from antral G cells; paracrine agent histamine, released from oxyntic enterochromaffin-like cells; and neuropeptide acetylcholine, released from antral and oxyntic intramural neurons. Gastrin is also a trophic hormone that participates in carcinogenesis. Helicobacter pylori may increase or decrease acid secretion depending upon the acuity and predominant anatomic focus of infection; most patients manifest hypochlorhydria. Despite the fact that proton pump inhibitors (PPIs) are amongst the most widely prescribed drugs, they are underutilized in patients at high risk for UGI bleeding. Although generally considered well tolerated, concerns have been raised regarding associations between PPI use and dementia, kidney disease, myocardial infarction, pneumonia, osteoporosis, dysbiosis, small bowel injury, micronutrient deficiency, and fundic gland polyps. SUMMARY Our understanding of the physiologic, pathophysiologic, and pharmacologic regulation of gastric secretion continues to advance. Such knowledge is crucial for improved and safe management of acid-peptic disorders.
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Spitzer E, Frei M, Zaugg S, Hadorn S, Kelbaek H, Ostojic M, Baumbach A, Tüller D, Roffi M, Engstrom T, Pedrazzini G, Vukcevic V, Magro M, Kornowski R, Lüscher TF, von Birgelen C, Heg D, Windecker S, Räber L. Rehospitalizations Following Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction: Results From a Multi-Center Randomized Trial. J Am Heart Assoc 2017; 6:JAHA.117.005926. [PMID: 28780509 PMCID: PMC5586438 DOI: 10.1161/jaha.117.005926] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Rehospitalizations (RHs) after ST‐elevation myocardial infarction carry a high economic burden and may deteriorate quality of life. Characterizing patients at higher risk may allow the design of preventive measures. We studied the frequency, reasons, and predictors for unplanned cardiac and noncardiac RHs in ST‐elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. Methods and Results In this post‐hoc analysis of the COMFORTABLE AMI (Comparison of Biolimus Eluted From an Erodible Stent Coating With Bare Metal Stents in Acute ST‐Elevation Myocardial Infarction; NCT00962416) trial including 1137 patients, unplanned cardiac and noncardiac RHs occurred in 133 (11.7%) and in 79 patients (6.9%), respectively, at 1 year. The most frequent reasons for unplanned cardiac RHs were recurrent chest pain without evidence of ischemia (20.4%), recurrent chest pain with ischemia and coronary intervention (16.9%), and ischemic events (16.9%). Unplanned noncardiac RHs occurred most frequently attributed to bleeding (24.5%), infections (14.3%), and cancer (9.1%). On multivariate analysis, left ventricular ejection fraction (22% increase in the rate of RHs per 10% decrease; P=0.03) and angiographic myocardial infarction Syntax score (34% increase per 10‐point increase; P=0.01) were independent predictors of unplanned cardiac RHs. Age emerged as the only independent predictor of unplanned noncardiac RHs. Regional differences for unplanned cardiac RHs were observed. Conclusions Among ST‐elevation myocardial infarction patients undergoing primary percutaneous coronary intervention in the setting of a randomized, clinical trial, unplanned cardiac RHs occurred in 12% with recurrent chest pain being the foremost reason. Unplanned noncardiac RHs occurred in 7% with bleeding as the leading cause. Left ventricular ejection fraction and Syntax score were independent predictors of unplanned cardiac RHs and identified patient subgroups in need for improved secondary prevention. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00962416.
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Affiliation(s)
- Ernest Spitzer
- Department of Cardiology, Bern University Hospital, Bern, Switzerland.,Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Martina Frei
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Serge Zaugg
- Clinical Trials Unit, University of Bern, Switzerland.,Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Susanne Hadorn
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Henning Kelbaek
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Miodrag Ostojic
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Andreas Baumbach
- William Harvey Research Institute, Queen Mary University and Barts Heart Centre, London, United Kingdom
| | - David Tüller
- Cardiology Department, Triemlispital, Zurich, Switzerland
| | | | - Thomas Engstrom
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Vladan Vukcevic
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Michael Magro
- Department of Cardiology, TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Ran Kornowski
- Rabin Medical Center, Petach Tikva, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Thomas F Lüscher
- Cardiology Department, University Hospital Zurich, Zurich, Switzerland
| | | | - Dik Heg
- Clinical Trials Unit, University of Bern, Switzerland.,Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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Fuster V. Editor-in-Chief's Top Picks From 2016: Part One. J Am Coll Cardiol 2017; 69:981-1009. [PMID: 28231952 DOI: 10.1016/j.jacc.2017.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Each week, I record audio summaries for every article in JACC, as well as an issue summary. While this process has been incredibly time-consuming, I have become quite familiar with every paper that we publish. Thus, I personally select papers (both original investigations and review articles) from 15 distinct specialties each year for your review. In addition to my personal choices, I have included manuscripts that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these manuscripts in this issue of JACC. Part One includes the sections: Basic & Translational Research, Cardiac Failure, Cardiomyopathies/Myocardial & Pericardial Diseases, Congenital Heart Disease, Coronary Disease & Interventions, and CVD Prevention & Health Promotion (1-74). Part Two will include the sections: CV Medicine & Society, Hypertension, Imaging, Metabolic & Lipid Disorders, Rhythm Disorders, Valvular Heart Disease, and Vascular Medicine.
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Gray A, McQuillan C, Menown IBA. Advances in Clinical Cardiology 2016: A Summary of the Key Clinical Trials. Adv Ther 2017; 34:1503-1527. [PMID: 28537000 PMCID: PMC5504210 DOI: 10.1007/s12325-017-0560-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The findings of many new cardiology clinical trials over the last year have been published or presented at major international meetings. This paper aims to describe and place in context a summary of the key clinical trials in cardiology presented between January and December 2016. METHODS The authors reviewed clinical trials presented at major cardiology conferences during 2016 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), European Association for the Study of Diabetes (EASD), Transcatheter Cardiovascular Therapeutics (TCT), and the American Heart Association (AHA). Selection criteria were trials with a broad relevance to the cardiology community and those with potential to change current practice. RESULTS A total of 57 key cardiology clinical trials were identified for inclusion. Here we describe and place in clinical context the key findings of new data relating to interventional and structural cardiology including delayed stenting following primary angioplasty, contrast-induced nephropathy, management of jailed wires, optimal duration of dual antiplatelet therapy (DAPT), stenting vs bypass for left main disease, new generation stents (BioFreedom, Orsiro, Absorb), transcatheter aortic valve implantation (Edwards Sapien XT, transcatheter embolic protection), and closure devices (Watchman, Amplatzer). New preventative cardiology data include trials of bariatric surgery, empagliflozin, liraglutide, semaglutide, PCSK9 inhibitors (evolocumab and alirocumab), and inclisiran. Antiplatelet therapy trials include platelet function monitoring and ticagrelor vs clopidogrel for peripheral vascular disease. New data are also presented in fields of heart failure (sacubitril/valsartan, aliskiren, spironolactone), atrial fibrillation (rivaroxaban in patients undergoing coronary intervention, edoxaban in DC cardioversion), cardiac devices (implantable cardioverter defibrillator in non-ischemic cardiomyopathy), and electrophysiology (cryoballoon vs radiofrequency ablation). CONCLUSION This paper presents a summary of key clinical cardiology trials during the past year and should be of practical value to both clinicians and cardiology researchers.
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Affiliation(s)
- Alastair Gray
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, UK
| | - Conor McQuillan
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, UK
| | - Ian B A Menown
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, UK.
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New scoring model (DARSYM score) to predict post-discharge bleeding after successful second-generation drug-eluting stent implantation. Heart Vessels 2017; 32:1285-1295. [PMID: 28560486 DOI: 10.1007/s00380-017-1000-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 05/26/2017] [Indexed: 10/19/2022]
Abstract
We aimed to create a scoring model to predict post-discharge bleeding (PDB) after drug-eluting stent (DES) implantation in Japanese subjects. We enrolled 1912 consecutive patients undergoing DES implantation (age 70 ± 10 years; 72% male). PDB was defined as a composite of type 5, 3, and 2 bleeding using the Bleeding Academic Research Consortium criteria. A Cox proportional hazard model assessed predictors, and we then derived a clinical model stratifying risk of PDB after DES implantation. Ninety-eight patients (6.7%) experienced PDB; gastrointestinal bleeding (GIB) was most common (n = 66, 67%), followed by intracranial bleeding (n = 24, 25%). PDB was independently associated with age >80 years [risk ratio (RR): 1.89, p < 0.001], hypertension (RR: 1.68, p = 0.03), severe renal dysfunction (RR: 1.56, p = 0.04), anemia on admission (RR: 1.75, p = 0.02), prior history of GIB (RR: 3.49, p < 0.001), NSAIDs use (RR: 2.33, p = 0.03), and introduction of triple antithrombotic therapy (RR: 2.94, p < 0.001). A clinical prediction rule for risk of bleeding events including seven baseline factors was derived. A better predictive ability for PDB was found using this new scoring system than the HAS-BLED score [c statistics, 0.85 (95% CI 0.83-0.87) and c statistics, 0.71 (95% CI 0.69-0.73), respectively; p < 0.001]. This new scoring system including patient characteristics and laboratory variables can identify patients at high risk of PDB after DES implantation.
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Shamliyan TA, Middleton M, Borst C. Patient-centered Outcomes with Concomitant Use of Proton Pump Inhibitors and Other Drugs. Clin Ther 2017; 39:404-427.e36. [PMID: 28189362 DOI: 10.1016/j.clinthera.2017.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE We performed a systematic review of patient-centered outcomes after the concomitant use of proton pump inhibitors (PPIs) and other drugs. METHODS We searched 4 databases in July 2016 to find studies that reported mortality and morbidity after the concomitant use of PPIs and other drugs. We conducted direct meta-analyses using a random-effects model and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group approach. FINDINGS We included data from 17 systematic reviews and meta-analyses, 16 randomized controlled trials, and 16 observational studies that examined the concomitant use of PPIs with medications from 10 drug classes. Low-quality evidence suggests that the use of PPIs is associated with greater morbidity when administered with antiplatelet drugs, bisphosphonates, antibiotics, anticoagulants, metformin, mycophenolate mofetil, or nelfinavir. Concomitant PPIs reduce drug-induced gastrointestinal bleeding and are associated with greater docetaxel and cisplatin response rates in patients with metastatic breast cancer. For demonstrated statistically significant relative risks and benefits from concomitant PPIs, the magnitudes of the effects are small, with <100 attributable events per 1000 patients treated, and the effects are inconsistent among specific drugs. Among individual PPIs, the concomitant use of pantoprazole or esomeprazole, but not omeprazole or lansoprazole, is associated with an increased risk for all-cause mortality, nonfatal myocardial infarction, or stroke. Clopidogrel is associated with a greater risk for myocardial infarction compared with prasugrel. Conflicting results between randomized controlled trials and observational studies and high risk for bias in the body of evidence lessened our confidence in the results. IMPLICATIONS Available evidence suggests a greater risk for adverse patient outcomes after the concomitant use of PPIs and medications from 9 drug classes and warns against inappropriate drug combinations.
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Affiliation(s)
- Tatyana A Shamliyan
- Evidence-Based Medicine Center, Quality Assurance, Elsevier, Philadelphia, Pennsylvania.
| | - Maria Middleton
- Evidence-Based Medicine Center, Elsevier, Philadelphia, Pennsylvania
| | - Clarissa Borst
- Clinical Drug Information, Elsevier, Philadelphia, Pennsylvania
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Upper Gastrointestinal Toxicity Associated With Long-Term Aspirin Therapy: Consequences and Prevention. Curr Probl Cardiol 2017; 42:146-164. [PMID: 28363584 DOI: 10.1016/j.cpcardiol.2017.01.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Antiplatelet therapy represents a fundamental part of preventive management for patients who are at risk of a secondary cardiovascular disease (CVD) event. In most cases, the antiplatelet regimen is based on low-dose aspirin, a drug that is highly effective in reducing the incidence of CVD events, but is associated with a substantial risk of gastrointestinal (GI) toxicity. The dyspeptic symptoms, which can result from aspirin administration, and which may occur with or without associated ulceration and bleeding, may lead patients to discontinue therapy, thus increasing their CVD risk. For patients in whom aspirin is indicated and who are deemed to be at increased risk of upper GI events, concomitant therapy with a proton pump inhibitor (PPI) is currently recommended. These agents are highly effective in reducing the upper GI lesions associated with aspirin therapy and have been associated with increased aspirin adherence. However, widespread under-prescribing of PPIs and potential noncompliance with their use means that substantial numbers of patients are at unnecessary risk of upper GI toxicity and-if aspirin therapy is discontinued-CVD events. Provision of aspirin and an immediate-release PPI as a coordinated-delivery combination tablet has been shown to both reduce the risk of gastric ulcer formation and improve patient compliance. This strategy, which may ultimately reduce the incidence of CVD outcomes because of the associated reduction in GI symptoms and the potential for greater patient adherence to aspirin, warrants further investigation under both randomized controlled conditions (explanatory trials), and in real-life settings (pragmatic trials).
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