Proton pump inhibitors and myocardial infarction: an application of active comparators in a self-controlled case series

BACKGROUND: Previous studies investigating potential cardiovascular adverse events of acid-suppressing drugs are susceptible to protopathic bias and confounding. We aimed to investigate the association between short-term risk of myocardial infarction (MI) and proton pump inhibitors (PPIs) using a self-controlled case series (SCCS) with an active comparator. METHODS: We conducted a SCCS using a population-wide database from Hong Kong from 2003–2014. Adult with ≥1 outpatient oral PPI prescription or H(2) receptor antagonist (H(2)RA) and MI during the observation period were included. We used both simple ratio and effect modifier approaches to SCCS with active comparators to obtain comparator adjusted estimates. RESULTS: A total of 2802 and 1889 people with MI who had exposure to PPIs and H(2)RA were included respectively. We observed a higher risk of MI during days 1–14 following the start of PPI prescription (Incidence rate ratio (IRR): 2.30, 95% confidence interval (CI): 1.76–3.00) versus baseline. Similarly, we observed a higher risk of MI during days 1–14 following the start of H(2)RA prescription (IRR: 2.46, 95%CI: 1.92–3.16) versus baseline. In the novel SCCS analyses, comparator adjusted estimates were 0.93 (95%CI: 0.57–1.30) and 0.83 (95%CI: 0.58–1.20) during days 1–14 in simple ratio and effect modifier approach, respectively. CONCLUSIONS: We observed no difference in risk of MI associated with PPIs compared with baseline using H(2)RA as the active comparator. The elevated risk of MI associated with PPIs is likely due to protopathic bias. More studies are required to explore the feasibility of using active comparators in SCCS to address protopathic bias in addition to confounding.