Analysis of Gastrointestinal Prophylaxis in Patients Receiving Dual Antiplatelet Therapy with Aspirin and Clopidogrel

BACKGROUND: Dual antiplatelet therapy (DAPT) has been found to reduce the risk of cardiac death, myocardial infarction, stroke, and stent thrombosis following acute coronary syndrome and percutaneous coronary intervention. However, this therapy has also been shown to increase the risk of gastrointestinal (GI) bleeding as high as 2-fold, especially in patients with multiple risk factors. Proton pump inhibitor (PPI) therapy decreases this risk. The current consensus document on reducing GI risks associated with antiplatelet agents no longer recommends PPI therapy for all patients receiving aspirin (ASA) and clopidogrel. The consensus recommendation reserves PPI therapy for patients receiving DAPT with a history of upper GI bleeding or prespecified risk factors for GI bleeding. OBJECTIVES: To (a) describe the use of GI prophylaxis in patients on DAPT with ASA and clopidogrel and (b) assess the incidence of adverse outcomes that occurred during readmissions within 6 months of the index hospitalization. METHODS: A retrospective chart review of patients receiving DAPT between February 1, 2011, and October 15, 2011, was performed to assess the appropriateness of GI prophylaxis based on the current consensus document. Therapy was defined as appropriate if an indication for prophylaxis was present and PPI therapy was prescribed, or if no indication was present and no GI prophylaxis was given. Inappropriate prophylaxis was defined as no indication for GI prophylaxis yet therapy received, or prophylaxis indicated but incorrect prophylaxis prescribed. Incorrect prophylaxis included no prophylaxis, histamine H2 blocker therapy, antacid, or combination therapy. During subsequent hospitalizations in the 6-month period following discharge from the index admission, patients were assessed for the development of vascular-, GI-, and PPI-related adverse events. RESULTS: 250 patients receiving DAPT during the study period were evaluated. Gastrointestinal prophylaxis was appropriate in 48% (119/250) of patients. Of the remaining patients, 56.4% (74/131) met guideline criteria for GI prophylaxis but did not receive a PPI at discharge, whereas 43.5% (57/131) of patients received GI prophylaxis when not indicated. Thirty-three adverse events were identified during readmissions, with the most common type being vascular followed by GI and PPI adverse events, respectively. CONCLUSIONS: More than half of the patients did not receive GI prophylaxis appropriately. The most common reason for nonadherence to the consensus document was no prophylaxis when indicated. Vascular events could not be directly attributed to PPI use, and GI events occurred despite prophylaxis. Overall, there was a low incidence of adverse events related to the use of PPI therapy.