Post-PCI Cardiac Risk Up With Clopidogrel + PPI
SAN DIEGO — Prophylactic use of a proton pump inhibitor plus clopidogrel after percutaneous coronary revascularization was associated with significantly greater risk for cardiovascular events, compared with clopidogrel alone, a small retrospective study found.
After percutaneous coronary intervention (PCI), 40 (56%) of 72 patients who were discharged on concomitant clopidogrel and proton pump inhibitor (PPI) therapy developed major adverse coronary events over a mean follow-up of 50 months, compared with 92 (38%) of 243 patients discharged on clopidogrel alone, Dr. Ekta Gupta and her associates reported at the annual meeting of the American College of Gastroenterology.
After adjustment for baseline characteristics including the type of stent, patients in the combination-therapy group had a 95% excess risk for major adverse coronary events, said Dr. Gupta of the University of Arkansas, Little Rock.
“Our study suggests that 'routine' use of prophylactic PPIs to prevent gastrointestinal bleeding should be avoided” until results of prospective, randomized, controlled studies become available, she said.
The adverse coronary events studied included cardiac or noncardiac death, MI, and target vessel failure (defined as a composite of cardiac death, MI, or target vessel revascularization).
Most patients who got a PPI used rabeprazole, with a minority getting omeprazole or lansoprazole. The study excluded patients who received pantoprazole or esomeprazole because previous studies found no association between these two drugs and an impaired response to clopidogrel seen with the other PPIs, suggesting that the adverse PPI-clopidogrel interaction may not apply to the whole class of drugs, she said.
If a PPI is needed after PCI, it may be preferable to use esomeprazole or pantoprazole, Dr. Gupta said. Alternatively, clinicians may want to consider separating the dosing of clopidogrel and the PPI to avoid any potential drug-drug interaction, she said.
Dr. Gupta had no conflicts of interest related to this study.
