Introduction Death after upper gastrointestinal (GI) bleeding is commonly due to cardiovascular disease and early re-initiation of anti-platelet therapy after haemostasis is associated with a reduction in all-cause and cardiovascular mortality. 2012 NICE upper GI bleeding guidelines advocate early re-initiation of antiplatelet agents for primary or secondary prevention of cardiovascular disease.
Methods The Health Improvement Network (THIN) is a UK primary care database containing data from over 15 million subjects. Subjects were identified with an existing diagnosis of ischaemic heart disease (IHD) or stroke, who were taking antiplatelet agents (aspirin, clopidogrel, ticagrelor, prasugrel or dipyridamole) and had an upper GI bleed between 2000 and 2017. Re-initiation of antiplatelet agents (defined as a record of at least one prescription after the upper GI bleeding event) within 28, 56 and 90 days was examined. Interrupted time series analysis (ITS) was performed to investigate changes in prescribing practices before and after the 2012 NICE guidelines, with prescription of statins over the same time period used as a negative control.
Results 6,372 subjects prescribed antiplatelet agents and 9,615 prescribed statins with a clinical code for upper GI bleeding and IHD or stroke were identified. Between 2000 and 2017, the proportion of subjects who had their antiplatelet agents re-initiated post-upper GI bleed increased from 33.9 to 55.6% (p<0.001), 41.2 to 71.3% (p<0.001) and 45.8 to 75.0% (p<0.001) at 28, 56 and 90 days respectively. There was no significant change in re-initiation of statins within 90 days (77.8 to 81.6%, p=0.60). The ITS revealed that the 2012 NICE guidelines had no significant effect on re-initiation of antiplatelet agents at 90 days (incidence rate ratio for post-trend change 1.001 (95% CI 0.999–1.003), p=0.55).
Conclusions There has been a progressive and statistically significant increase in early re-initiation of antiplatelet agents after upper GI bleeding in the UK between 2000 and 2017. However, the 2012 NICE upper GI bleeding guidelines appeared to have no significant effect on prescribing practices.
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