Use of proton pump inhibitors in patients with acute coronary syndrome treated with dual antiplatelet therapy: a tertiary care observation
Main Article Content
Keywords
acute coronary syndrome, proton pump inhibitor, gastrointestinal bleeding, antiplatelet agents, retrospective study
Abstract
Background: Dual antiplatelet therapy (DAPT) reduces the incidence of ischemic events and increases the risk of gastrointestinal bleeding (GIB). Proton pump inhibitors (PPIs) can be utilized to mitigate and prevent this risk; however, they are commonly underutilized. Objectives: This study evaluated PPI prescription practices and identified the factors influencing PPI use in patients with acute coronary syndrome (ACS) treated with DAPT in a regional tertiary care setting. Methods: We conducted a retrospective chart review of 310 patients with ACS treated with DAPT between 2017 and 2020. Data regarding PPI use, GIB events, and patient demographics were collected. Logistic regression was used to identify the factors associated with PPI prescriptions. Results: Among the 310 patients who met inclusion criteria, 83.3% of high-risk GIB patients received PPIs optimally, whereas 16.7% were overprescribed PPIs. In the non-PPI group, 72.7% of the high-risk patients did not receive PPIs. Significant factors influencing PPI prescribing included prior PPI use (OR 3.10, 95% CI 1.16–8.24), age ≥65 years (OR 2.55, 95% CI 1.49–4.38), and alcohol consumption (OR 2.24, 95% CI 1.04–4.81). Conclusion: The proportion of patients with ACS-DAPT with GIB risk who should receive PPI was high in Thailand. However, the optimal prescription rate was also high. A practice gap exists among patients with ACS DAPT without GIB risk because PPI are frequently overused. Age of at least 65 years, alcohol consumption, and current use of PPI significantly influenced optimal PPI prescription. Physicians should carefully consider these factors in all patients with ACS-DAPT to mitigate bleeding events.
References
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17. Hartman J, Nauka PC, Priyanka S, Chao J, Whitson MJ. Proton Pump Inhibitors Are Underprescribed in Patients Discharged on Dual Antiplatelet Therapy After Acute Coronary Syndrome. Gastroenterology. 2018;155(1):E37.
18. Chatrattanakulchai B, Hirunrassamee S, Kanchanaphibool I. Antisecretory drug use for prophylaxis of upper gastrointestinal bleeding in patients receiving aspirin together with clopidogrel. Veridian E-Journal, Science and Technology Silpakorn University. 2018;5(2):65-76.
19. Morneau KM, Reaves AB, Martin JB, Oliphant CS. Analysis of gastrointestinal prophylaxis in patients receiving dual antiplatelet therapy with aspirin and clopidogrel. J Manag Care Pharm. 2014;20(2):187-93. doi: 10.18553/jmcp.2014.20.2.187.
20. Baik M, Jeon J, Kim J, Yoo J. Proton Pump Inhibitor for Gastrointestinal Bleeding in Patients with Myocardial Infarction on Dual-Antiplatelet Therapy: A Nationwide Cohort Study. J Epidemiol Glob Health. 2024. Epub 20240624. doi: 10.1007/s44197-024-00267-9.
21. Shi W, Ni L, Yang J, Fan X, Yu M, Yang H, Yu M, Yang Y, China Acute Myocardial Infarction Registry study g. Appropriateness of gastrointestinal prophylaxis use during hospitalization in patients with acute myocardial infarction: Analysis from the China Acute Myocardial Infarction Registry. Clin Cardiol. 2021;44(1):43-50. Epub 20201119. doi: 10.1002/clc.23449.
22. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Juni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B, Group ESCSD. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-826. doi: 10.1093/eurheartj/ehad191.
23. Thai Heart Association CIAoT. Thai Atherosclerosis society. Thai acute coronary syndromes guideline. Bangkok: Nextstep D-sign; 2020.
24. Jinadu T, Radhakrishnan A, Fan L. Improving use of proton pump inhibitors with dual antiplatelet therapy in patients admitted with acute coronary syndrome. BMJ Open Qual. 2022;11(4). doi: 10.1136/bmjoq-2022-001956.
25. Marx N, Federici M, Schutt K, Muller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N, Group ESCSD. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J. 2023;44(39):4043-140. doi: 10.1093/eurheartj/ehad192.
26. Moukarbel GV, Signorovitch JE, Pfeffer MA, McMurray JJ, White HD, Maggioni AP, Velazquez EJ, Califf RM, Scheiman JM, Solomon SD. Gastrointestinal bleeding in high risk survivors of myocardial infarction: the VALIANT Trial. Eur Heart J. 2009;30(18):2226-32. Epub 20090625. doi: 10.1093/eurheartj/ehp256.
27. Yusof F, Sanguanhong S, Soorapan S, Pongwecharak J. Trends in prescribing volumes and costs of proton pump inhibitors in three outpatient specialties: a three-year retrospective study in a tertiary hospital in Thailand. Int J Pharm Pract. 2023;31(1):80-5. doi: 10.1093/ijpp/riac104.
28. Jensen BES, Hansen JM, Larsen KS, Junker AB, Lassen JF, Jensen SE, Schaffalitzky de Muckadell OB. Randomized clinical trial: the impact of gastrointestinal risk factor screening and prophylactic proton pump inhibitor therapy in patients receiving dual antiplatelet therapy. Eur J Gastroenterol Hepatol. 2017;29(10):1118-25. doi: 10.1097/MEG.0000000000000934.
2. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimsky P, Group ESCSD. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-77. doi: 10.1093/eurheartj/ehx393.
3. Yasuda H, Matsuo Y, Sato Y, Ozawa S, Ishigooka S, Yamashita M, Yamamoto H, Itoh F. Treatment and prevention of gastrointestinal bleeding in patients receiving antiplatelet therapy. World J Crit Care Med. 2015;4(1):40-6. Epub 20150204. doi: 10.5492/wjccm.v4.i1.40.
4. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK, Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial I. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345(7):494-502. doi: 10.1056/NEJMoa010746.
5. Abraham NS, Noseworthy PA, Inselman J, Herrin J, Yao X, Sangaralingham LR, Cornish G, Ngufor C, Shah ND. Risk of Gastrointestinal Bleeding Increases With Combinations of Antithrombotic Agents and Patient Age. Clin Gastroenterol Hepatol. 2020;18(2):337-46 e19. Epub 20190518. doi: 10.1016/j.cgh.2019.05.017.
6. Buresly K, Eisenberg MJ, Zhang X, Pilote L. Bleeding complications associated with combinations of aspirin, thienopyridine derivatives, and warfarin in elderly patients following acute myocardial infarction. Arch Intern Med. 2005;165(7):784-9. doi: 10.1001/archinte.165.7.784.
7. Garcia Rodriguez LA, Lin KJ, Hernandez-Diaz S, Johansson S. Risk of upper gastrointestinal bleeding with low-dose acetylsalicylic acid alone and in combination with clopidogrel and other medications. Circulation. 2011;123(10):1108-15. Epub 20110228. doi: 10.1161/CIRCULATIONAHA.110.973008.
8. Sun Y, Feng L, Li X, Wang Z, Gao R, Wu Y. In-hospital major bleeding in patients with acute coronary syndrome medically treated with dual anti-platelet therapy: Associated factors and impact on mortality. Front Cardiovasc Med. 2022;9:878270. Epub 20221031. doi: 10.3389/fcvm.2022.878270.
9. Bhatt DL, Cryer BL, Contant CF, Cohen M, Lanas A, Schnitzer TJ, Shook TL, Lapuerta P, Goldsmith MA, Laine L, Scirica BM, Murphy SA, Cannon CP, Investigators C. Clopidogrel with or without omeprazole in coronary artery disease. N Engl J Med. 2010;363(20):1909-17. Epub 20101006. doi: 10.1056/NEJMoa1007964.
10. Sehested TSG, Carlson N, Hansen PW, Gerds TA, Charlot MG, Torp-Pedersen C, Kober L, Gislason GH, Hlatky MA, Fosbol EL. Reduced risk of gastrointestinal bleeding associated with proton pump inhibitor therapy in patients treated with dual antiplatelet therapy after myocardial infarction. Eur Heart J. 2019;40(24):1963-70. doi: 10.1093/eurheartj/ehz104.
11. Shin JM, Sachs G. Pharmacology of proton pump inhibitors. Curr Gastroenterol Rep. 2008;10(6):528-34. doi: 10.1007/s11894-008-0098-4.
12. Tantry US, Kereiakes DJ, Gurbel PA. Clopidogrel and proton pump inhibitors: influence of pharmacological interactions on clinical outcomes and mechanistic explanations. JACC Cardiovasc Interv. 2011;4(4):365-80. doi: 10.1016/j.jcin.2010.12.009.
13. Maideen NMP. Adverse Effects Associated with Long-Term Use of Proton Pump Inhibitors. Chonnam Med J. 2023;59(2):115-27. Epub 20230525. doi: 10.4068/cmj.2023.59.2.115.
14. Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB, Furberg CD, Johnson DA, Kahi CJ, Laine L, Mahaffey KW, Quigley EM, Scheiman J, Sperling LS, Tomaselli GF. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. 2010;56(24):2051-66. doi: 10.1016/j.jacc.2010.09.010.
15. Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O’Gara PT, Sabatine MS, Smith PK, Smith SC Jr. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease. Circulation. 2016;134(10):e123-55. Epub 20160329. doi: 10.1161/CIR.0000000000000404.
16. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Circulation. 2011;124(23):e574-651. Epub 20111107. doi: 10.1161/CIR.0b013e31823ba622.
17. Hartman J, Nauka PC, Priyanka S, Chao J, Whitson MJ. Proton Pump Inhibitors Are Underprescribed in Patients Discharged on Dual Antiplatelet Therapy After Acute Coronary Syndrome. Gastroenterology. 2018;155(1):E37.
18. Chatrattanakulchai B, Hirunrassamee S, Kanchanaphibool I. Antisecretory drug use for prophylaxis of upper gastrointestinal bleeding in patients receiving aspirin together with clopidogrel. Veridian E-Journal, Science and Technology Silpakorn University. 2018;5(2):65-76.
19. Morneau KM, Reaves AB, Martin JB, Oliphant CS. Analysis of gastrointestinal prophylaxis in patients receiving dual antiplatelet therapy with aspirin and clopidogrel. J Manag Care Pharm. 2014;20(2):187-93. doi: 10.18553/jmcp.2014.20.2.187.
20. Baik M, Jeon J, Kim J, Yoo J. Proton Pump Inhibitor for Gastrointestinal Bleeding in Patients with Myocardial Infarction on Dual-Antiplatelet Therapy: A Nationwide Cohort Study. J Epidemiol Glob Health. 2024. Epub 20240624. doi: 10.1007/s44197-024-00267-9.
21. Shi W, Ni L, Yang J, Fan X, Yu M, Yang H, Yu M, Yang Y, China Acute Myocardial Infarction Registry study g. Appropriateness of gastrointestinal prophylaxis use during hospitalization in patients with acute myocardial infarction: Analysis from the China Acute Myocardial Infarction Registry. Clin Cardiol. 2021;44(1):43-50. Epub 20201119. doi: 10.1002/clc.23449.
22. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Juni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B, Group ESCSD. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-826. doi: 10.1093/eurheartj/ehad191.
23. Thai Heart Association CIAoT. Thai Atherosclerosis society. Thai acute coronary syndromes guideline. Bangkok: Nextstep D-sign; 2020.
24. Jinadu T, Radhakrishnan A, Fan L. Improving use of proton pump inhibitors with dual antiplatelet therapy in patients admitted with acute coronary syndrome. BMJ Open Qual. 2022;11(4). doi: 10.1136/bmjoq-2022-001956.
25. Marx N, Federici M, Schutt K, Muller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N, Group ESCSD. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J. 2023;44(39):4043-140. doi: 10.1093/eurheartj/ehad192.
26. Moukarbel GV, Signorovitch JE, Pfeffer MA, McMurray JJ, White HD, Maggioni AP, Velazquez EJ, Califf RM, Scheiman JM, Solomon SD. Gastrointestinal bleeding in high risk survivors of myocardial infarction: the VALIANT Trial. Eur Heart J. 2009;30(18):2226-32. Epub 20090625. doi: 10.1093/eurheartj/ehp256.
27. Yusof F, Sanguanhong S, Soorapan S, Pongwecharak J. Trends in prescribing volumes and costs of proton pump inhibitors in three outpatient specialties: a three-year retrospective study in a tertiary hospital in Thailand. Int J Pharm Pract. 2023;31(1):80-5. doi: 10.1093/ijpp/riac104.
28. Jensen BES, Hansen JM, Larsen KS, Junker AB, Lassen JF, Jensen SE, Schaffalitzky de Muckadell OB. Randomized clinical trial: the impact of gastrointestinal risk factor screening and prophylactic proton pump inhibitor therapy in patients receiving dual antiplatelet therapy. Eur J Gastroenterol Hepatol. 2017;29(10):1118-25. doi: 10.1097/MEG.0000000000000934.
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Jan 9, 2026
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Use of proton pump inhibitors in patients with acute coronary syndrome treated with dual antiplatelet therapy: a tertiary care observation. Pharm Pract (Granada) [Internet]. 2026 Jan. 9 [cited 2026 Jan. 25];23(4):1-8. Available from: https://www.pharmacypractice.org/index.php/pp/article/view/3290
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How to Cite
1.
Use of proton pump inhibitors in patients with acute coronary syndrome treated with dual antiplatelet therapy: a tertiary care observation. Pharm Pract (Granada) [Internet]. 2026 Jan. 9 [cited 2026 Jan. 25];23(4):1-8. Available from: https://www.pharmacypractice.org/index.php/pp/article/view/3290