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Wang Y, Wu Y, Wang J, Zhang H, Du L, Wang K, Duan H. Predictors of gastrointestinal bleeding in patients with acute coronary syndrome and the optimal duration of dual antiplatelet therapy. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2024; 29:15. [PMID: 38808215 PMCID: PMC11132419 DOI: 10.4103/jrms.jrms_452_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/05/2023] [Accepted: 11/13/2023] [Indexed: 05/30/2024]
Abstract
Background This study aims to estimate the risk factors of gastrointestinal (GI) bleeding in patients with acute coronary syndrome (ACS) and to evaluate the optimal duration of dual antiplatelet therapy (DAPT). Materials and Methods We enrolled 1266 patients with ACS in a telephone follow-up program to determine whether any of the patients were hospitalized for GI bleeding. We collected baseline data, laboratory tests, electrocardiograms, and echocardiography covering all ACS patients. Multivariable regression was performed to adjust for confounders and predictors of GI bleeding. At the same time, the optimal duration of DAPT for ACS patients was evaluated. Results A total of 1061 ACS patients were included in the study. After 13-68 months, 48 patients (4.5%) were hospitalized for GI bleeding. The risk of GI bleeding was significantly increased in patients treated with DAPT for more than 18 months (hazard ratio 12.792, 5.607-29.185, P < 0.01). Receiver Operating Characteristic curve showed that the duration of DAPT using a cutoff of 14.5 months resulted in a sensitivity of 66.7% and a specificity of 77%. Conclusion In patients with ACS, DAPT time are the main risk factors of GI bleeding. The optimal duration of DAPT is 14.5 months.
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Affiliation(s)
- Yanyu Wang
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yingle Wu
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Jingqiao Wang
- Henan Key Laboratory of Epigenetics, School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Hengliang Zhang
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Laijing Du
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Ke Wang
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Hongqiang Duan
- Department of Cardiology, The First Affiliated Hospital and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
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Teperikidis E, Boulmpou A, Potoupni V, Kundu S, Singh B, Papadopoulos C. Does the long-term administration of proton pump inhibitors increase the risk of adverse cardiovascular outcomes? A ChatGPT powered umbrella review. Acta Cardiol 2023; 78:980-988. [PMID: 37431972 DOI: 10.1080/00015385.2023.2231299] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/14/2023] [Accepted: 06/26/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are commonly prescribed for the treatment of acid-related disorders. In the context of coronary artery disease (CAD), PPIs are commonly prescribed along with antiplatelet medications. In fact, the potential interaction between these two classes of medications has been subject to much debate. This review aimed to summarise the findings from systematic reviews and meta-analyses on the casual relationship between PPI use (alone) and major adverse cardiovascular events (MACE). Furthermore, the recent release of ChatGPT has provided reviewers with a powerful natural language processing tool. We therefore aimed to assess the utility of ChatGPT in the systematic review process. METHODS A comprehensive search of PubMed was conducted to identify relevant systematic reviews and meta-analyses published up to March 2023. Two independent reviewers assessed the eligibility of the studies, extracted the data, and assessed the methodological quality using AMSTAR 2.0. The population of interest was adults that received the medications of interest (PPIs) for a minimum of three months, regardless of indication. Control groups were defined as placebo or active comparators. The outcomes of interest were described under the general term MACE, which include cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. There were no restrictions with regards to time, but we only included reports in English. A different group of independent reviewers simultaneously ran the same process using ChatGPT. The results were then compared with the human generated results. RESULTS Seven systematic reviews and meta-analyses were included, involving a total of 46 randomised controlled trials and 33 observational studies. The studies examined the association between PPI use and MACE, including stroke, myocardial infarction, and all-cause mortality. The results of the individual studies were conflicting, with some showing a positive association between PPI use and MACE, some showing no association, and others showing mixed results. However, the majority of the studies that included observational data reported a positive association between PPI use and MACE. Sensitivity analyses conducted in some studies did not significantly alter the primary results, suggesting that the findings were robust. Furthermore, ChatGPT was successfully prompted to execute most tasks involved in this review. We therefore present text that was generated by ChatGPT, including the abstract, introduction, results, and discussion sections. CONCLUSION The findings of this umbrella review suggest that a causal relationship between PPI use and an increased risk of MACE cannot be ruled out. Further research is needed to better understand this relationship, particularly the underlying mechanisms and potential confounding factors. Healthcare professionals should consider the long-term use of PPIs and carefully weigh the risks and benefits for each patient. Finally, ChatGPT was successfully prompted to execute most of the tasks involved in this review. We therefore feel that this tool will be of great assistance in the field of evidence synthesis in the near future.
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Affiliation(s)
- Eleftherios Teperikidis
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessa-loniki, Thessaloniki, Greece
- Clinical Research Unit, Special Unit for Biomedical Research and Education (SUBRE), School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aristi Boulmpou
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessa-loniki, Thessaloniki, Greece
| | - Victoria Potoupni
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessa-loniki, Thessaloniki, Greece
| | - Satyabrata Kundu
- Department of Pharmacology, ISF College of Pharmacy, Moga, India
| | - Balpreet Singh
- Department of Biochemistry, Punjab Agricultural University, Ludhiana, India
| | - Christodoulos Papadopoulos
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessa-loniki, Thessaloniki, Greece
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Zhao Y, Zhou P, Gao W, Zhong H, Chen Y, Chen W, Waresi M, Xie K, Shi H, Gong H, He G, Qiu Z, Luo X, Li J. Cilostazol combined with P2Y 12 receptor inhibitors: A substitute antiplatelet regimen for aspirin-intolerant patients undergoing percutaneous coronary stent implantation. Clin Cardiol 2022; 45:189-197. [PMID: 35120275 PMCID: PMC8860475 DOI: 10.1002/clc.23787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/28/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
Background Cilostazol combined with P2Y12 receptor inhibitor has been used as a substitute regimen for aspirin‐intolerant patients undergoing percutaneous coronary stent implantation on a small scale. Its exact impact on platelet functions and clinical benefits of aspirin‐intolerant patients is unknown. Hypothesis Cilostazol combined with P2Y12 receptor inhibitors could be used as a substitute antiplatelet regimen for aspirin‐intolerant patients undergoing percutaneous coronary stent implantation. Methods In this multicenter prospective cohort trial, patients undergoing elective percutaneous coronary stent implantation were assigned to the cilostazol group (cilostazol plus P2Y12 receptor inhibitors), based on aspirin intolerance criteria, or the aspirin group (aspirin plus P2Y12 receptor inhibitors). Platelet PAC‐1, CD62p, and vasodilator‐stimulated phosphoprotein phosphorylation (VASP‐P) were detected by flow cytometry. The primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE) including all‐cause death, acute myocardial infarction, emerging arrhythmia, nonfatal stroke, and heart failure. The secondary endpoints were the Bleeding Academic Research Consortium (BARC) bleeding events. Results One hundred and fifty‐four aspirin‐intolerant percutaneous coronary stent implantation patients and 154 matched aspirin‐tolerant patients from a total of 2059 percutaneous coronary stent implantation patients were enrolled. The relative activation level of PAC‐1, CD62p, and platelet reaction index reflected by the VASP‐P test were similar in the two groups (p > .05). After 12 months of follow‐up, the incidence of all‐cause death was 1.9% in the cilostazol group and 1.3% in the aspirin group (risk ratio [RR], 1.500; 95% confidence interval [CI], 0.254–8.852; p = 1.000); the incidence of acute myocardial infarction was 0.6% in the cilostazol group and 1.3% in the aspirin group (RR, 0.500; 95% CI, 0.046–5.457; p = 1.000). No significant difference was seen in other MACCE events, or in any types of BARC bleeding events. Conclusions Cilostazol combined with P2Y12 inhibitors was not inferior to aspirin‐based standard therapy and could be used as a reasonable substitute antiplatelet regimen for aspirin‐intolerant patients undergoing percutaneous coronary stent implantation, but again with limitations, which required a larger sample and longer follow‐up to confirm its efficacy.
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Affiliation(s)
- Yikai Zhao
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Peng Zhou
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Wen Gao
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Haoxuan Zhong
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Yufei Chen
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Wei Chen
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Maieryemu Waresi
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Kun Xie
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Haiming Shi
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Hui Gong
- Department of CardiologyJinshan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Guibin He
- Department of CardiologyLuodian HospitalShanghaiPeople's Republic of China
| | - Zhaohui Qiu
- Department of CardiologyTongren Hospital of Shanghai Jiao Tong UniversityShanghaiPeople's Republic of China
| | - Xinping Luo
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
| | - Jian Li
- Department of CardiologyHuashan Hospital of Fudan UniversityShanghaiPeople's Republic of China
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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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Jourdi G, Godier A, Lordkipanidzé M, Marquis-Gravel G, Gaussem P. Antiplatelet Therapy for Atherothrombotic Disease in 2022—From Population to Patient-Centered Approaches. Front Cardiovasc Med 2022; 9:805525. [PMID: 35155631 PMCID: PMC8832164 DOI: 10.3389/fcvm.2022.805525] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/06/2022] [Indexed: 12/20/2022] Open
Abstract
Antiplatelet agents, with aspirin and P2Y12 receptor antagonists as major key molecules, are currently the cornerstone of pharmacological treatment of atherothrombotic events including a variety of cardio- and cerebro-vascular as well as peripheral artery diseases. Over the last decades, significant changes have been made to antiplatelet therapeutic and prophylactic strategies. The shift from a population-based approach to patient-centered precision medicine requires greater awareness of individual risks and benefits associated with the different antiplatelet strategies, so that the right patient gets the right therapy at the right time. In this review, we present the currently available antiplatelet agents, outline different management strategies, particularly in case of bleeding or in perioperative setting, and develop the concept of high on-treatment platelet reactivity and the steps toward person-centered precision medicine aiming to optimize patient care.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- *Correspondence: Georges Jourdi
| | - Anne Godier
- Université de Paris, Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- Department of Anesthesiology and Critical Care, AP-HP, Université de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Marquis-Gravel
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Pascale Gaussem
- Université de Paris, Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- Service d'Hématologie Biologique, AP-HP, Université de Paris, Hôpital Européen Georges Pompidou, Paris, France
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ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2022; 117:27-56. [PMID: 34807007 PMCID: PMC8754510 DOI: 10.14309/ajg.0000000000001538] [Citation(s) in RCA: 265] [Impact Index Per Article: 132.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/30/2021] [Indexed: 01/30/2023]
Abstract
Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.
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Jia RJ, Wang XP, Zhang ZH, Cui HH, Qin R, Du DY, Liu Y. Effect of Rabeprazole and Rebamipide in the Treatment of Upper Gastrointestinal Hemorrhage Associated with Dual Antiplatelet Therapy in Elderly Patients with Coronary Heart Disease. Clin Appl Thromb Hemost 2022; 28:10760296221130746. [PMID: 36411982 PMCID: PMC9703470 DOI: 10.1177/10760296221130746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 08/27/2023] Open
Abstract
To investigate the therapeutic effect of rabeprazole and rebamipide on patient age over 60 with dual antiplatelet therapy (DAPT)-related upper gastrointestinal hemorrhage following percutaneous coronary intervention (PCI). A total of 360 patients age over 60 undergoing PCI were recruited for antiplatelet therapy involving a combined treatment of aspirin (100 mg/d) and clopidogrel (75 mg/d). The enrolled patients were divided into 4 groups: the control group, the rabeprazole group, the rebamipide group, and the rabeprazole + rebamipide group. The incidence and severity of any upper gastrointestinal hemorrhage and the incidence of major adverse cardiac events (MACEs) were observed 6 months after the operation. The incidence of upper gastrointestinal hemorrhage in the 4 groups was 11.1%, 3.3%, 8.9%, and 1.1%, respectively, and the differences were statistically significant (P < 0.05). On comparing the groups, the differences between the control group and the rabeprazole group, those between the control group and the rabeprazole + rebamipide group, and those between the rebamipide group and the rabeprazole + rebamipide group were found to be statistically significant (P < 0.05). The severity of the upper gastrointestinal hemorrhage in the rabeprazole group and the rabeprazole + rebamipide group was significantly lower than that in the control group. The 4 groups exhibited no significant differences in the incidence of MACEs (P > 0.05). For patients age over 60 receiving DAPT following PCI in our study population, treatment with rabeprazole or a combination of rabeprazole and rebamipide could reduce the risk of upper gastrointestinal hemorrhage, as well as reduce its severity.
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Affiliation(s)
- Rong-Jie Jia
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Xiao-Peng Wang
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Zhen-Hua Zhang
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Hai-Hong Cui
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Rui Qin
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Da-Yong Du
- Department of Cardiology, The 305 Hospital of Chinese PLA, Beijing,
China
| | - Yang Liu
- Department of Cardiology, The 305 Hospital of Chinese PLA, Beijing,
China
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Guo H, Ye Z, Huang R. Clinical Outcomes of Concomitant Use of Proton Pump Inhibitors and Dual Antiplatelet Therapy: A Systematic Review and Meta-Analysis. Front Pharmacol 2021; 12:694698. [PMID: 34408652 PMCID: PMC8366318 DOI: 10.3389/fphar.2021.694698] [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] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/23/2021] [Indexed: 11/27/2022] Open
Abstract
Background: The safety and efficacy associated with the use of proton pump inhibitors (PPIs) by patients with coronary artery disease receiving dual antiplatelet therapy (DAPT) remain unclear. Methods: The evaluated outcomes included combined major adverse cardiovascular events (MACEs), myocardial infarction (MI), all-cause mortality, and gastrointestinal (GI) bleeding. A random effects meta-analysis, stratified by study design, was performed and heterogeneity was assessed using the I2 statistic. Results: In total, 6 randomized controlled trials (RCTs) (6930 patients) and 16 observational studies (183,546 patients) were included. Analysis of RCTs showed that there were no significant differences in the incidences of MACEs (risk ratio [RR] = 0.89 [95% confidence interval (CI) = 0.75–1.05]), MI (RR = 0.93 [95% CI = 0.76–1.15]), and all-cause mortality (RR = 0.79 [95% CI = 0.50–1.23]) in the PPI groups vs. the non-PPI groups. Pooled data from observational studies revealed an inconsistent association between the use of each PPI subtype and the increased risks of MACEs during clopidogrel treatment. There was no increased risk of MACEs or all-cause mortality associated with the use of PPIs (as a class) and other P2Y12 inhibitors. Both the RCTs and observational studies revealed that the use of PPIs significantly reduced the risks of GI bleeding. Conclusion: The use of PPIs was associated with a reduced risk of GI bleeding in patients treated with DAPT after percutaneous coronary intervention or acute coronary syndrome. There was no clear evidence of an association between the use of PPIs and adverse cardiovascular events. Clinical Trial Registration: identifier [CRD42020190315]
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Affiliation(s)
- Hongzhou Guo
- Cardiac Center/Division of Cardiovascular Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhishuai Ye
- Cardiac Center/Division of Cardiovascular Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Rongchong Huang
- Cardiac Center/Division of Cardiovascular Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Trials of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention Lack Strategies to Ensure Appropriate Gastroprotection. Am J Gastroenterol 2021; 116:821-824. [PMID: 33982954 PMCID: PMC8119932 DOI: 10.14309/ajg.0000000000001134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Gastrointestinal bleeding is a morbid complication of dual antiplatelet therapy (DAPT). We evaluated the extent to which contemporary trials of DAPT included steps to ensure appropriate use of proton pump inhibitor (PPI) gastroprotection and reported rates of PPI use. METHODS A methodological review of randomized trials comparing varying durations of DAPT after percutaneous coronary intervention. RESULTS Among 21 trials, none incorporated protocol procedures or guidance for prescribing PPIs. Five reported rates of PPI use (range 25.6-69.1%). DISCUSSION PPI gastroprotection is overlooked in major trials of DAPT. Appropriate use of PPI gastroprotection represents an important opportunity to improve patient safety.
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Pioppo L, Bhurwal A, Reja D, Tawadros A, Mutneja H, Goel A, Patel A. Incidence of Non-variceal Upper Gastrointestinal Bleeding Worsens Outcomes with Acute Coronary Syndrome: Result of a National Cohort. Dig Dis Sci 2021; 66:999-1008. [PMID: 32328894 DOI: 10.1007/s10620-020-06266-7] [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: 12/06/2019] [Accepted: 04/10/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization. METHODS This was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay. RESULTS A total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03-1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63-2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001). DISCUSSION Our study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.
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Affiliation(s)
- Lauren Pioppo
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA.
| | - Abhishek Bhurwal
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
| | - Debashis Reja
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
| | - Augustine Tawadros
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
| | - Hemant Mutneja
- Department of Internal Medicine, John H Stroger, Hospital of Cook County, 1969 Ogden Ave, Chicago, IL, 60612, USA
| | - Akshay Goel
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA
| | - Anish Patel
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, 1 RWJ Place, New Brunswick, NJ, 09801, USA
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Mizokami Y, Yamamoto T, Atarashi H, Yamashita T, Akao M, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Kaburagi J, Takita A, Inoue H. Current status of proton pump inhibitor use in Japanese elderly patients with non-valvular atrial fibrillation: A subanalysis of the ANAFIE Registry. PLoS One 2020; 15:e0240859. [PMID: 33151969 PMCID: PMC7644054 DOI: 10.1371/journal.pone.0240859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/04/2020] [Indexed: 01/16/2023] Open
Abstract
The real-world status of proton pump inhibitor (PPI) use in patients with atrial fibrillation (AF) receiving antithrombotic treatment is largely unknown. The All Nippon AF In the Elderly (ANAFIE) Registry, a prospective, multicenter, observational study, aimed to determine treatment patterns, risk factors, and outcomes among elderly (aged ≥75 years) Japanese non-valvular AF (NVAF) patients in the real-world clinical setting. The present subanalysis of the ANAFIE Registry determined the PPI prescription status of 32,490 elderly Japanese NVAF patients. Patients were stratified by PPI use (PPI+) or no PPI use (PPI−). Risk scores for stroke (CHADS2, CHA2DS2-VASc) and bleeding (HAS-BLED), anticoagulant use, time in therapeutic range (TTR) for warfarin, and anticoagulant/antiplatelet combination use were evaluated. PPIs were used in 11,981 (36.9%) patients. Compared with the PPI− group, the PPI+ group included a greater proportion of female patients (45.2% vs 41.3%; P <0.0001) and had significantly higher CHADS2, CHA2DS2-VASc, and HAS-BLED scores (P <0.0001 for each) as well as higher prevalences of several comorbidities. In the PPI+ group, 54.6% of patients did not have gastrointestinal (GI) disorders and were likely prescribed a PPI to prevent GI bleeding events. Most of the patients with a GI disorder in the PPI+ group had reflux esophagitis. Compared with patients not receiving anticoagulants, a significantly higher proportion of patients receiving anticoagulants received PPIs. For patients receiving anticoagulants, antiplatelet drugs, and both drugs, rates of PPI use were 34.1%, 44.1%, and 53.5%, respectively (P <0.01). Although the rate of PPI use was the highest for NVAF patients receiving both antiplatelet and anticoagulants, no clear differences were observed in the anticoagulants used. These data suggest that PPIs were actively prescribed in high-risk cases and may have been used to prevent GI bleeding among elderly NVAF patients receiving antithrombotic drugs. Trial registration:UMIN000024006
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Affiliation(s)
- Yuji Mizokami
- Department of Gastroenterology, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Takatsugu Yamamoto
- Department of Medicine, Teikyo University, Itabashi City, Tokyo, Japan
- * E-mail:
| | | | | | - Masaharu Akao
- National Hospital Organization Kyoto Medical Center, Fushimi Ward, Kyoto, Japan
| | - Takanori Ikeda
- Toho University Omori Medical Center, Ota City, Tokyo, Japan
| | - Yukihiro Koretsune
- National Hospital Organization Osaka National Hospital, Chuo Ward, Osaka, Japan
| | - Ken Okumura
- Saiseikai Kumamoto Hospital, Minami Ward, Kumamoto, Japan
| | | | | | - Kazunori Toyoda
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | - Masahiro Yasaka
- National Hospital Organization Kyushu Medical Center, Chuo Ward, Fukuoka, Japan
| | | | - Satoshi Teramukai
- Kyoto Prefectural University of Medicine, Kamigyo Ward, Kyoto, Japan
| | - Tetsuya Kimura
- Medical Science Department, Daiichi Sankyo Co., Ltd., Chuo City, Tokyo, Japan
| | - Jumpei Kaburagi
- Medical Science Department, Daiichi Sankyo Co., Ltd., Chuo City, Tokyo, Japan
| | - Atsushi Takita
- Biostatistics and Data Management Department, Daiichi Sankyo Co., Ltd., Shinagawa-ku, Tokyo, Japan
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12
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Komarov AL, Shakhmatova OO, Korobkova VV. [The balance of benefit and risk in prescribing antithrombotic therapy for patients with coronary artery disease. How to deal with the gastrointestinal bleeding problem?]. ACTA ACUST UNITED AC 2020; 60:115-124. [PMID: 33155950 DOI: 10.18087/cardio.2020.7.n1159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 11/18/2022]
Abstract
The review focuses on upper gastrointestinal (GI) bleeding in patients with ischemic heart disease (IHD) receiving an antithrombotic therapy. Approaches to risk stratification for GI bleeding and correction of modifiable factors that determine the probability of such events are addressed in detail. Recommendations are provided for administration of stomach-protecting drugs. The interrelation of risk factors for thromboses and bleedings is stressed, and possible indications for a multicomponent antithrombotic therapy in patients with stable IHD are discussed.
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Affiliation(s)
- A L Komarov
- National Medical Research Center of Cardiology, Moscow, Russia
| | - O O Shakhmatova
- National Medical Research Center of Cardiology, Moscow, Russia
| | - V V Korobkova
- National Medical Research Center of Cardiology, Moscow, Russia
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13
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Biondi-Zoccai G, Antonazzo B, Giordano A, Versaci F, Frati G, Ronzoni S, Nudi A, Nudi F. Oral antiplatelet therapy in the elderly undergoing percutaneous coronary intervention: an umbrella review. J Thorac Dis 2020; 12:1656-1664. [PMID: 32395309 PMCID: PMC7212118 DOI: 10.21037/jtd.2019.12.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Percutaneous coronary intervention has become a mainstay in the management of coronary artery disease. While initially advanced age was considered a relative contraindication to invasive management of coronary artery disease, current cardiovascular practice stands solidly on an early invasive approach for elderly patients, typically based on radial access and drug-eluting stent implantation. Since the advent of coronary stents, oral antiplatelet therapy has proved crucial to maximize the benefits and minimize the risks of stenting, and this holds even truer in older patients rather than in younger ones. Indeed, the elderly is typically at higher risk of thrombotic events as well as bleeding complications, and thus careful decision making must be exercised to prescribe the most appropriate antiplatelet regimen. We thus conducted an umbrella review with scoping purposes on oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention, retrieving 8 pertinent systematic reviews. We found that, while several drugs are available, ranging from aspirin to cilostazol, clopidogrel, dipyridamole, prasugrel, ticagrelor, and ticlopidine, most commonly a dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor is recommended, with subtle adjustments for pretreatment, loading, dose, duration, escalation or de-escalation, with the potential adjunct in selected patients of novel oral anticoagulants. Indeed, a flexible and individualized approach to oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention is paramount, factoring patient features (exploiting thrombotic, bleeding and frailty scores), triage (including when appropriate non-invasive assessment of anatomic and functional significance of coronary artery disease), angiographic and other invasive imaging features, interventional technique, stent choice, rehabilitation, and secondary prevention.
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Affiliation(s)
- Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Napoli, Italy
| | | | - Arturo Giordano
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy
| | - Francesco Versaci
- Unità Operativa Complessa di UTIC, Emodinamica e Cardiologia, Ospedale Santa Maria Goretti, Latina, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,IRCCS NEUROMED, Pozzilli, Italy
| | | | - Alessandro Nudi
- Service of Hybrid Cariac Imaging, Madonna della Fiducia Clinic, Rome, Italy
| | - Francesco Nudi
- Service of Hybrid Cariac Imaging, Madonna della Fiducia Clinic, Rome, Italy
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14
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Manolis AA, Manolis TA, Melita H, Katsiki N, Manolis AS. Proton pump inhibitors and cardiovascular adverse effects: Real or surreal worries? Eur J Intern Med 2020; 72:15-26. [PMID: 31796246 DOI: 10.1016/j.ejim.2019.11.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/21/2019] [Accepted: 11/24/2019] [Indexed: 02/06/2023]
Abstract
Proton pump inhibitors (PPIs) are among the most widely prescribed agents, either for treatment or prophylaxis of gastrointestinal (GI) disease, that are often administered for prolonged or chronic use. Patients with cardiovascular (CV) disease frequently receive PPIs for prophylaxis against GI bleeding due to common use of antithrombotic drugs. Over the last several years there is a growing number of reports associating chronic PPI use with a variety of serious CV and non-CV adverse effects. In this context, PPI use has been independently associated with an increased risk of CV morbidity (myocardial infarction, stroke, other CV events) and mortality. However, the critique remains that these data do not largely derive from randomized controlled trials. On the other hand, in certain conditions, the benefits of PPIs may outweigh the risks of adverse CV effects. As the indications for prolonged, particularly lifelong, prophylactic use of PPIs are not compelling and in the light of evidence of serious CV and other adverse effects, clinicians have to reconsider such long-term use of these drugs. Importantly, histamine 2 blockers have not been found to be associated with increased CV risk and thus may be an alternative therapeutic option in certain patients. These issues are amply discussed together with the potential mechanisms of these pleiotropic and off-target effects of PPIs, which are also depicted in an illustrative schema; data are also presented on differential effects of specific agents involved, alternative modes of therapy available, and relevant current guidelines on this issue.
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Affiliation(s)
| | | | | | - Niki Katsiki
- First Department of Internal Medicine, Division of Endocrinology and Metabolism, Diabetes Center, Medical School, AHEPA University Hospital, Thessaloniki, Greece
| | - Antonis S Manolis
- Third and First Department of Cardiology, Athens University School of Medicine, Ippokrateio Hospital, Vas. Sofias 114, Athens 115 27, Greece.
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Swan D, Loughran N, Makris M, Thachil J. Management of bleeding and procedures in patients on antiplatelet therapy. Blood Rev 2020; 39:100619. [DOI: 10.1016/j.blre.2019.100619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/31/2019] [Accepted: 10/10/2019] [Indexed: 02/06/2023]
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Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, Leontiadis GI, Abraham NS, Calvet X, Chan FKL, Douketis J, Enns R, Gralnek IM, Jairath V, Jensen D, Lau J, Lip GYH, Loffroy R, Maluf-Filho F, Meltzer AC, Reddy N, Saltzman JR, Marshall JK, Bardou M. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med 2019; 171:805-822. [PMID: 31634917 PMCID: PMC7233308 DOI: 10.7326/m19-1795] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
DESCRIPTION This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. METHODS An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. RECOMMENDATIONS Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
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Affiliation(s)
- Alan N Barkun
- McGill University, Montreal, Quebec, Canada (A.N.B.)
| | - Majid Almadi
- McGill University, Montreal, Quebec, Canada, and King Saud University, Riyadh, Saudi Arabia (M.A.)
| | - Ernst J Kuipers
- Erasmus University Medical Center, Rotterdam, the Netherlands (E.J.K.)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, and VA Connecticut Healthcare System, West Haven, Connecticut (L.L.)
| | - Joseph Sung
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Frances Tse
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | | | | | - Xavier Calvet
- Hospital Parc Taulí de Sabadell, University of Barcelona, Sabadell, Spain, and CiberEHD (Instituto de Salud Carlos III), Madrid, Spain (X.C.)
| | - Francis K L Chan
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - James Douketis
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Robert Enns
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (R.E.)
| | - Ian M Gralnek
- Technion-Israel Institute of Technology, Emek Medical Center, Afula, Israel (I.M.G.)
| | | | - Dennis Jensen
- University of California, Los Angeles, Los Angeles, California (D.J.)
| | - James Lau
- Chinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)
| | - Gregory Y H Lip
- University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, and Aalborg University, Aalborg, Denmark (G.Y.L.)
| | - Romaric Loffroy
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
| | | | | | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India (N.R.)
| | - John R Saltzman
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.R.S.)
| | - John K Marshall
- McMaster University, Hamilton, Ontario, Canada (F.T., G.I.L., J.D., J.K.M.)
| | - Marc Bardou
- Dijon-Bourgogne University Hospital, Dijon, France (R.L., M.B.)
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