Impact of proton pump inhibitors on clinical outcomes in patients after acute myocardial infarction: a propensity score analysis from China Acute Myocardial Infarction (CAMI) registry

Risk of stroke associated with proton pump inhibitor use among individuals with and without pre-existing cardiovascular diseases: a systematic review and meta-analysis

BACKGROUND

Proton pump inhibitors (PPIs) are commonly used for managing gastroesophageal disorders but concerns about their potential association with increased stroke risk have emerged, especially among patients with pre-existing cardiovascular conditions such as acute coronary syndrome (ACS). This systematic review and meta-analysis aim to assess the risk of stroke associated with PPI use, stratified by the presence or absence of pre-existing CVD.

METHODS

This review was conducted following the PRISMA guidelines and included studies up to March 2024 from PubMed, Embase, and Web of Science. Eligible studies were longitudinal, including prospective cohorts, nested case-controls, and post-hoc analyses of RCTs that reported stroke outcomes in relation to PPI use. Data were synthesized using random-effects meta-analysis models in R software version 4.3.

RESULTS

Our search yielded 41 studies encompassing over 800,000 participants globally. Meta-analysis of 14 observational studies revealed a slight but non-significant increased stroke risk among patients with prior CVD (pooled HR = 1.222, 95% CI: 0.963 to 1.481, I² = 78%). In contrast, analysis of 15 studies without prior CVD showed a modestly increased risk (pooled HR = 1.15, 95% CI: 1.023 to 1.288, I² = 98%). Five RCTs involving patients with CVD reported a pooled RR of 1.158 (95% CI: 0.914 to 1.466), indicating no significant risk increase.

CONCLUSION

The association between PPI use and stroke risk appears modest and is influenced by the presence of cardiovascular conditions. Clinical decision-making should consider individual patient risk profiles, and further high-quality studies are needed to guide safer PPI prescribing practices.

Adverse events in patients with cardiovascular disease taking proton pump inhibitors

INTRODUCTION

Proton pump inhibitors (PPIs) rank among the most frequently prescribed medications to treat acid-related diseases. Mounting concerns surround the potential for serious adverse events, including cardiovascular events, associated with their prolonged use/misuse.

AREAS COVERED

This comprehensive review explores cardiovascular adverse events linked to PPI use among high-risk cardiovascular patients. A structured search was conducted on PubMed.

EXPERT OPINION

Many patients with cardiovascular disease who require antiplatelet treatment will require long-term PPI treatment. Interpreting the published data is not straightforward. First, because there is no plausible mechanistic explanation for PPIs to induce cardiovascular events apart from the potential interaction with the metabolism of thienopyridines. Although several observational studies have shown an increased cardiovascular risk and mortality in patients taking long-term PPIs, most available clinical trials and meta-analyses of available studies do not. However, the absence of firm evidence of this link does not necessarily imply that this association does not exist, and other hypothesis must be explored. Anemia is a common event in patients who take antiplatelet therapy and PPIs, and it is a factor associated with cardiovascular events and death. Anemia in these patients is often attributed to erosive lesions of the small intestine, where PPI may play a key role by modifying the microbiota.

The Efficacy and Safety of Proton Pump Inhibitors Combining Dual Antiplatelet Therapy in Patients with Coronary Intervention: A Systematic Review, Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials

Background

Proton pump inhibitors (PPIs) are used to prevent gastrointestinal hemorrhage in patients with coronary treatment undergoing dual antiplatelet therapy (DAPT).

Methods

A systematic review was performed to compare the outcomes between DAPT and DAPT + PPI in acute coronary syndrome (ACS) patients or patients who took percutaneous coronary intervention (PCI) with coronary stent implantation (PCI patients), and to estimate, for the first time, the sample size needed for reliable results via trial sequential analysis (TSA). The PubMed, EMBASE, the Cochrane Library and Web of Science databases were searched for articles authored from the onset until November 1, 2022, for randomized controlled trials (RCTs) comparing outcomes in ACS or PCI patients who undertook DAPT or DAPT + PPI. The primary outcomes were the incidence rate of gastrointestinal events and major adverse cardiovascular events (MACEs).

Results

The initial web search retrieved 786 literature references. Eventually, eight articles published between 2009 and 2020 were incorporated into the systematic review and meta-analysis. The combined results established a non-significant variation in MACEs incidences between the DAPT group and DAPT + PPI group [risk ratio (RR) = 0.93, 95% confidence interval (CI) = 0.81-1.06, p = 0.27, I 2 = 0%]; conversely, the incidence of gastrointestinal events was significantly decreased in the DAPT + PPI group in comparison with the DAPT group (RR = 0.33, 95% CI = 0.24-0.45, p < 0.00001, I 2 = 0%). TSA of MACEs and gastrointestinal events revealed that meta-analysis included adequate trials (required sample size = 6874) in the pool to achieve 80% study power.

Conclusions

Based on our results, DAPT + PPI can significantly reduce gastrointestinal outcomes without affecting cardiovascular outcomes in PCI and ACS patients compared to DAPT.

Co-prescription of Dual-Antiplatelet Therapy and Proton Pump Inhibitors: Current Guidelines

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.