Introduction NICE recommends dual anti-platelet therapy (DAPT) for 12 months following an acute coronary syndrome (ACS).1DAPT carries a risk of gastrointestinal (GI) bleeding. The incidence and outcome of patients who have a GI bleed whilst taking DAPT are not well known and despite recommendations, the protective effects of proton pump inhibitors (PPIs) in this group are debated.2We studied readmission rates with UGI bleeding and subsequent outcomes in ACS patients for one year following their event. We analysed data to ascertain whether there was any benefit to co-prescription of PPI with DAPT.
Method Data were collected using the Northumbria Myocardial Infarction National Audit Project (MINAP) database, for the calander year 2012. We analysed 12 month readmission rates with GI bleeding and subsequent outcomes; including endoscopic findings, the use of PPI, mortality data and age demographics.
Results 585 patients suffered an ACS in our study population. 12 patients (2%) were readmitted with GI bleeding within the first year. Nine patients were male, with a median age of 82 years, and three were female: median age 90 years. Lansoprazole (a PPI) 30mg daily was prescribed for 8/12 (66%) patients. Seven patients (58%) died; two directly as a consequence of GI bleeding and five due to subsequent complications.
In those taking a PPI the mortality rate was 50% (4/8). In the non-PPI group the mortality rate was higher at 75% (3/4). Regarding UGI endoscopy; four patients did not undergo intervention on clinical grounds. In those who underwent upper GI endoscopy, diagnoses included: oesophagitis, gastritis, duodenal ulceration, gastric ulceration, oesophageal ulceration and possible bleeding Dieulafoy lesion. In two patients, no cause for bleeding was found.
Considering those aged 80 or older; 227 patients suffered an ACS. Nine of these were readmitted with GI bleeding (4%) with only two patients surviving that admission (mortality rate 78%). In the 358 patients under the age of 80, the risk of re-admission with GI bleed was 0.8% and the mortality rate was zero.
Conclusion The risk of readmission with GI bleeding in the first year following ACS whilst on DAPT is low (2%). The protective effects of PPIs in GI bleeding in patients taking DAPT have not been demonstrated by this study. However, we note a higher mortality rate in the non-PPI group.
Patients over 80 years old have a poor outcome and higher mortality rate despite prescription of PPI. Treatment decisions for this specific group should be carefully considered.
Disclosure of interest None Declared.
NICE. Antiplatelet treatment:secondary prevention of CVD http://cks.nice.org.uk/antiplatelet-treatment
Moukarbel GV, et al. Gastrointestinal bleeding in high risk survivors of myocardial infarction. Eur Heart J. 2009;30:2226–2232
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