NEW YORK (Reuters Health) – The incidence of upper gastrointestinal (GI) bleeding is “remarkably high” in patients with acute myocardial infarction (AMI) who undergo primary percutaneous coronary intervention (PCI) and receive routine dual antiplatelet therapy, a study from Taiwan suggests.
“Prophylaxis against upper GI bleeding with a proton pump inhibitor (PPI) is indicated for patients hospitalized for AMI, particularly those of advanced Killip classes,” Dr. Hon-Kan Yip, from Kaohsiung Chang Gung Memorial Hospital, Taiwan, noted in an email to Reuters Health.
“Since a PPI is known to interact with the antiplatelet agent clopidogrel resulting in an elevated risk of intra-coronary thrombosis, an interval of at least four hours is suggested between the administrations of these agents,” Dr. Yip added.
“Surprisingly,” the short-term incidence and long-term prevalence of major adverse upper GI events have “seldom been reported” in patients with ST-segment elevation (STEMI) undergoing primary PCI, the study team notes in the September 19 online issue of the American Journal of Cardiology.
To investigate, they studied 1,368 patients with STEMI who underwent primary PCI and received aspirin and clopidogrel at their institution between May 2002 and September 2010.
While in the hospital, 122 patients (8.9%) developed upper GI bleeding and 135 (9.9%) developed the composite outcome of major adverse upper GI events, defined as gastric ulcer, duodenal ulcer, gastroduodenal ulcer, or upper GI bleeding.
Confirming prior studies, older age, increased serum creatinine level, advanced Killip score of 3 or greater and respiratory failure support were independent predictors of in-hospital upper GI events.
About one quarter of patients who developed major adverse upper GI events in the hospital (35 of 135; 25.9%) died of cardiac or non-cardiac causes before discharge. This compares with 10.4% of patients who had no major upper GI events while in the hospital or during clinical follow-up (116 of 1,117 patients).
The investigators also report that 16% of the patients who suffered major upper GI events in the hospital developed recurrent major upper GI events during an average follow-up of about 3.3 years. The vast majority of these patients (97%) received long-term clopidogrel.
“More important,” write the authors, roughly 10% of “uneventfully discharged” patients suffered a major adverse upper GI event during follow-up, most commonly gastric ulcers (52%).
The incidence of in-stent thrombosis after the withdrawal of aspirin because of peptic ulcer or upper GI bleeding on long-term follow-up was less than 1%.
These findings, Dr. Yip and colleagues conclude, suggest that “precautions against peptic ulcer disease, such as the use of prophylactic PPIs, in patients with STEMI after primary PCI” are needed.
In an email to Reuters Health, Dr. Hiroshi Yasuda, from St. Marianna University School of Medicine, Kawasaki, Japan, who was not involved in the study, noted that “several reports have indicated that incidence of upper GI bleeding is higher within one month of PCI.”
This includes a retrospective study he and his colleagues published in 2009 in Internal Medicine. The study involved 243 patients who underwent drug-eluting stent implantation and received dual anti-platelet therapy after surgery. It showed that concomitant use of an anti-secretory agent was associated with a reduced risk of upper GI bleeding.
“Many cardiologists in Japan have been using an anti-secretory drug in the prevention of upper GI bleeding,” Dr. Yasuda told Reuters Health.
After the FDA advisory on possible interaction between PPI and clopidogrel, he added, H2 receptor antagonists “seems preferentially to be used. I agree that prophylactic use of an anti-secretory drug is important especially in advanced Killip patients,” Dr. Yasuda said.
Am J Cardiol 2011.
