Gastroprotective Medication and Bleeding Risk Following ACS
Gastroprotective Medication and Bleeding Risk Following ACS
Background. Gastrointestinal (GI) bleeding following percutaneous coronary intervention (PCI) is associated with increased mortality. ACCF/AHA/SCAI guidelines recommend prophylaxis to prevent GI bleeding in patients, with the highest GI bleeding risks taking dual-antiplatelet therapy (DAPT). The REPLACE risk score identifies factors predictive of peri-PCI bleeding from vascular access and non-access sites. We determined whether high bleeding risk acute coronary syndrome (ACS) patients taking DAPT were appropriately provided with GI prophylaxis and investigated the association between age and clinical presentation on the likelihood of receiving prophylactic therapy.
Methods. This is a retrospective analysis of all non-elective PCI patients at a single center between May and December 2008 stratified by age (<65, 65–74, and ≥75 years). REPLACE scores were calculated and discharge medication was obtained from case records.
Results. Complete discharge medication data were available for 800 patients (median age, 63 years; 45.1% with ST-elevation myocardial infarction [STEMI]). A total of 370 patients (46.3%) were high bleeding risk (REPLACE scores ≥10), including all patients ≥75 years (n = 173), 83.5% of patients 65–74 years (n = 177), and 4.8% of patients <65 years (n = 20). In total, 97.6% were discharged on DAPT. Within the high bleeding risk group, 45.1% received GI prophylaxis. Patients 65–74 years were least likely to receive prophylaxis (<65 years, 60%; 65–74 years, 38.4%; ≥75 years, 50.3%; P<.03). Presentation with STEMI was independently associated with a reduced likelihood of GI prophylaxis provision (odds ratio, 0.63; 95% confidence interval, 0.40–0.99; P=.045).
Conclusions. Less than half of ACS patients at high bleeding risk taking DAPT are provided with GI prophylaxis. Increased use of objective bleeding risk scores may help guide risk/benefit decisions in patients taking clopidogrel and proton pump inhibitors.
Percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) is increasingly undertaken in elderly patients with multiple comorbidities and high bleeding risk. Peri-PCI bleeding is a major predictor of adverse outcome and is associated with increased mortality even after adjustment for confounding factors. Gastrointestinal (GI) bleeding following PCI occurs in 1.0%-2.7% of patients and is associated with significantly higher in-hospital, 30-day, and 1-year mortality. Increasing age is a strong predictor of peri-PCI GI bleeding with an incidence 2.79 times greater in patients >70 years. Patients taking dual-antiplatelet therapy (DAPT) are at higher risk of GI bleeding, although registry, case control, and randomized trial data suggest that this risk is significantly reduced by proton pump inhibitors (PPIs). ACCF/ACG/AHA guidelines from October 2008 initially recommended that all patients on DAPT or with risk factors for GI bleeding should receive GI prophylaxis with PPIs, though randomized trial data to support this approach were lacking. Subsequent focused updates of ACCF/AHA/SCAI guidelines in 2011 continue to recommend PPIs for patients taking DAPT who have a prior history of GI bleeding (class I, level of evidence C) and are appropriate for patients who have an increased risk of GI bleeding (including those of advanced age, or taking steroids, warfarin or non-steroidal anti-inflammatories; class IIa, level of evidence C). PPIs are not recommended for routine use in patients at low risk of GI bleeding.
Using a validated peri-PCI bleeding risk score, we determined whether invasively managed ACS patients with the highest bleeding risk who were taking DAPT were appropriately prescribed GI prophylaxis to minimize their risk of GI bleeding. We also determined the relationship between age and mode of ACS presentation on the prescription of GI prophylaxis by physicians following PCI.
Abstract and Introduction
Abstract
Background. Gastrointestinal (GI) bleeding following percutaneous coronary intervention (PCI) is associated with increased mortality. ACCF/AHA/SCAI guidelines recommend prophylaxis to prevent GI bleeding in patients, with the highest GI bleeding risks taking dual-antiplatelet therapy (DAPT). The REPLACE risk score identifies factors predictive of peri-PCI bleeding from vascular access and non-access sites. We determined whether high bleeding risk acute coronary syndrome (ACS) patients taking DAPT were appropriately provided with GI prophylaxis and investigated the association between age and clinical presentation on the likelihood of receiving prophylactic therapy.
Methods. This is a retrospective analysis of all non-elective PCI patients at a single center between May and December 2008 stratified by age (<65, 65–74, and ≥75 years). REPLACE scores were calculated and discharge medication was obtained from case records.
Results. Complete discharge medication data were available for 800 patients (median age, 63 years; 45.1% with ST-elevation myocardial infarction [STEMI]). A total of 370 patients (46.3%) were high bleeding risk (REPLACE scores ≥10), including all patients ≥75 years (n = 173), 83.5% of patients 65–74 years (n = 177), and 4.8% of patients <65 years (n = 20). In total, 97.6% were discharged on DAPT. Within the high bleeding risk group, 45.1% received GI prophylaxis. Patients 65–74 years were least likely to receive prophylaxis (<65 years, 60%; 65–74 years, 38.4%; ≥75 years, 50.3%; P<.03). Presentation with STEMI was independently associated with a reduced likelihood of GI prophylaxis provision (odds ratio, 0.63; 95% confidence interval, 0.40–0.99; P=.045).
Conclusions. Less than half of ACS patients at high bleeding risk taking DAPT are provided with GI prophylaxis. Increased use of objective bleeding risk scores may help guide risk/benefit decisions in patients taking clopidogrel and proton pump inhibitors.
Introduction
Percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) is increasingly undertaken in elderly patients with multiple comorbidities and high bleeding risk. Peri-PCI bleeding is a major predictor of adverse outcome and is associated with increased mortality even after adjustment for confounding factors. Gastrointestinal (GI) bleeding following PCI occurs in 1.0%-2.7% of patients and is associated with significantly higher in-hospital, 30-day, and 1-year mortality. Increasing age is a strong predictor of peri-PCI GI bleeding with an incidence 2.79 times greater in patients >70 years. Patients taking dual-antiplatelet therapy (DAPT) are at higher risk of GI bleeding, although registry, case control, and randomized trial data suggest that this risk is significantly reduced by proton pump inhibitors (PPIs). ACCF/ACG/AHA guidelines from October 2008 initially recommended that all patients on DAPT or with risk factors for GI bleeding should receive GI prophylaxis with PPIs, though randomized trial data to support this approach were lacking. Subsequent focused updates of ACCF/AHA/SCAI guidelines in 2011 continue to recommend PPIs for patients taking DAPT who have a prior history of GI bleeding (class I, level of evidence C) and are appropriate for patients who have an increased risk of GI bleeding (including those of advanced age, or taking steroids, warfarin or non-steroidal anti-inflammatories; class IIa, level of evidence C). PPIs are not recommended for routine use in patients at low risk of GI bleeding.
Using a validated peri-PCI bleeding risk score, we determined whether invasively managed ACS patients with the highest bleeding risk who were taking DAPT were appropriately prescribed GI prophylaxis to minimize their risk of GI bleeding. We also determined the relationship between age and mode of ACS presentation on the prescription of GI prophylaxis by physicians following PCI.
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