From the Guidelines
A proton pump inhibitor (PPI) is recommended for patients with acute coronary syndrome (ACS) who are at high risk of gastrointestinal bleeding, particularly those receiving dual antiplatelet therapy (DAPT) with aspirin and an oral P2Y12 inhibitor. The primary reason for PPI use in ACS patients is to reduce the risk of gastrointestinal bleeding associated with antiplatelet therapy, especially when aspirin is combined with a P2Y12 inhibitor like clopidogrel, ticagrelor, or prasugrel 1. High-risk patients who would benefit most from PPI therapy include those with a history of peptic ulcer disease, gastrointestinal bleeding, advanced age (>65 years), concurrent use of anticoagulants, steroids, or NSAIDs, and H. pylori infection.
Some key points to consider when prescribing PPIs for ACS patients include:
- The PPI should be continued for the duration of DAPT, which typically ranges from 6-12 months after ACS 1
- Common PPIs used include omeprazole (20-40 mg daily), pantoprazole (40 mg daily), esomeprazole (20-40 mg daily), and lansoprazole (30 mg daily)
- The protective mechanism works by reducing gastric acid production, allowing the gastric mucosa to maintain its integrity despite the antiplatelet effects that impair clotting and mucosal healing
- While there were historical concerns about potential interactions between PPIs (particularly omeprazole) and clopidogrel, current clinical evidence suggests that any theoretical reduction in clopidogrel efficacy is outweighed by the reduction in bleeding risk in high-risk patients 1.
It is essential to note that not all ACS patients require PPI therapy, and the decision to prescribe a PPI should be based on the individual patient's risk factors for gastrointestinal bleeding 1.
From the Research
Requirement of PPI for Patients with ACS
The requirement of a Proton Pump Inhibitor (PPI) for patients with Acute Coronary Syndrome (ACS) is a topic of discussion among medical professionals.
- The European Society of Cardiology guidelines recommend that patients on Dual Antiplatelet Therapy (DAPT) should also be prescribed a PPI to reduce the risk of gastrointestinal (GI) bleeding 2.
- A study published in the BMJ open quality journal found that only 56% of patients on DAPT were coprescribed a PPI at baseline, and introduced interventions to improve concomitant prescription of PPI, resulting in 100% of patients on DAPT being coprescribed PPI within fourteen weeks 2.
- Another study published in Critical pathways in cardiology found that the use of PPI in patients with ACS was modest, although it did increase with an increasing number of previously identified GI risk factors 3.
Risk Factors for GI Bleeding
Certain risk factors increase the likelihood of GI bleeding in patients with ACS, including:
- Prior GI event 3
- Use of anticoagulants 3
- Age 65 years or older 4
- Low body weight (BMI <18.5) 4
- Diabetes 4
- Prior bleeding 4
Association between PPI Use and GI Bleeding
A study published in the Mayo Clinic proceedings found that patients using PPIs had a higher rate of GI bleeding compared with those not using PPIs, with a 58% higher risk of GI bleeding associated with early PPI use 5.
- However, the study also noted that randomized trials on early use of PPIs in patients with ACS receiving DAPT are warranted to fully understand the association between PPI use and GI bleeding 5.
Guidelines and Recommendations
The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend aspirin plus a P2Y12 inhibitor for at least 12 months for patients with ACS, with recommendations varying according to the risk of bleeding 4.
- The guidelines also suggest that clinicians should avoid prescribing certain antiplatelet agents to patients with a history of stroke or transient ischemic attack, or to patients older than 75 years or who weigh less than 60 kg 4.