January 1, 2018MedicineOpen Access

Influence of proton pump inhibitors on clinical outcomes in coronary heart disease patients receiving aspirin and clopidogrel

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Why the study?

Does concomitant proton pump inhibitor use affect clinical outcomes in coronary heart disease patients receiving aspirin and clopidogrel?

Structured PICO

Does concomitant proton pump inhibitor use affect clinical outcomes in coronary heart disease patients receiving aspirin and clopidogrel?

Population

33,492 patients with coronary heart disease receiving dual antiplatelet therapy (aspirin and clopidogrel) pooled from 4 randomized controlled trials and 8 controlled observational studies

Intervention

Concomitant proton pump inhibitors (PPIs)

Comparator

No concomitant proton pump inhibitors (PPIs)

Outcome

Major adverse cardiovascular events and gastrointestinal bleedingcomposite

In patients on aspirin and clopidogrel, concomitant PPI use is associated with increased major adverse cardiovascular events, stent thrombosis, and revascularization, despite reducing gastrointestinal bleeding.

Implication

May warrant selective PPI use in high GI-risk patients on dual antiplatelet therapy; leaves open net benefit pending randomized trials.

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.