Use of proton pump inhibitors (PPI) in patients with acute coronary syndrome (ACS) receiving dual-antiplatelet therapy (DAPT)

Cardiovascular diseases (CVD) accounted for an alarming 17.9 million deaths globally in 2019. Acute coronary syndrome (ACS) is often the most common initial presentation of CVD. ACS encompasses of ST-elevation Myocardial Infarction (STEMI), Non-ST elevation Myocardial Infarction (NSTEMI) and unstable angina. It accounts for over 100,000 admissions to hospitals annually1 and has a mortality rate of around 15% pre-hospitalisation and 10% during a hospital admission.2 European Society of Cardiology (ESC) guidelines recommend use of Dual Antiplatelet Therapy (DAPT) which comprises of aspirin and a P2Y12 as treatment for ACS. DAPT is estimated to increase the risk of GI bleed by 1.2–2.4%. To reduce this risk of bleeding, ESC guideline until recently recommended Proton Pump Inhibitor (PPI) in all patients receiving DAPT.3 The aim of this quality improvement project was to assess current compliance rates and recommend effective measures to improve compliance rates to 100%. Data on all patients who presented to our cardiac centre with either a STEMI or NSTEMI over a 6-month period was collected. We excluded patients transferred from nearby district general hospitals for Percutaneous Coronary Intervention (PCI). We analysed electronic records, prescription charts and discharge summaries to assess the compliance rates on the use of PPI in patients receiving DAPT and incidence rates of GI bleed in this cohort of patients. There were 543 patients who attended our hospital with either a STEMI or NSTEMI over the 6-months. STEMI was the cause of ACS in 44.4% of our patients. Clinicians initiated DAPT in 486 patients. 98.1% of all patients had PPI prescribed alongside DAPT. Lansoprazole was the most common PPI prescribed in 92% of patient's, 5% omeprazole, 2% famotidine and 1% esomeprazole. There were three patients on DAPT who had UGI bleed and two deaths as a result of this. All patients who had an incidence of UGI bleed had not received PPI therapy. There was no clear documentation of the risk of bleeding using scores such as CRUSADE or ACUITY in patients who did not receive PPI therapy. There was a change in ESC guideline in 2023 that now recommends PPI use only in patients with a high risk of bleeding.4 The incidence of UGI bleed was higher in patients who were not on PPI therapy in comparison to those who were. There was poor documentation on bleeding risk in patients not started on PPI therapy. To improve this, we led a teaching session to doctors and pharmacists to raise awareness of the current ACS protocol on our prescribing system and importance of using risk stratification tools and documentation of scores in patient notes to ensure we are prescribing in line with the latest ESC guidelines. British Heart Foundation. Our Vision Is a World Free from the Fear of Heart and Circulatory diseases. UK Factsheet [Internet]. British Heart Foundation. 2023. Available from: https://www.bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-uk-factsheet.pdf Asaria P, Bennett JE, Elliott P, Rashid T, Iyathooray Daby H, Douglass M, et al. Contributions of event rates, pre-hospital deaths, and deaths following hospitalisation to variations in myocardial infarction mortality in 326 districts in England: a spatial analysis of linked hospitalisation and mortality data. The Lancet Public Health. 2022 Jul;7(10). Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. European Heart Journal. 2017 Aug 26;39(3):213–60. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal. 2023 Aug 25;44(38).