Shi Wen-Ce, Gao Si-De, Yang Jin-Gang, Fan Xiao-Xue, Ni Lin, Su Shu-Hong, Yu Mei, Yang Hong-Mei, Yu Meng-Yue, Yang Yue-Jin
Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Medical Research and Biometrics Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
J Geriatr Cardiol. 2020 Nov 28;17(11):659-665. doi: 10.11909/j.issn.1671-5411.2020.11.008.
Proton pump inhibitors (PPIs) are recommended by the latest guidelines to reduce the risk of bleeding in acute myocardial infarction (AMI) patients treated with dual antiplatelet therapy (DAPT). However, previous pharmacodynamic and clinical studies have reported controversial results on the interaction between PPI and the PY inhibitor clopidogrel. We investigated the impact of PPIs use on in-hospital outcomes in AMI patients, aiming to provide a new insight on the value of PPIs.
A total of 23, 380 consecutive AMI patients who received clopidogrel with or without PPIs in the China Acute Myocardial Infarction (CAMI) registry were analyzed. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) defined as a composite of in-hospital cardiac death, re-infarction and stroke. Propensity score matching (PSM) was used to control potential baseline confounders. Multivariate logistic regression analysis was performed to evaluate the effect of PPIs use on MACCE and gastrointestinal bleeding (GIB).
Among the whole AMI population, a large majority received DAPT and 67.5% were co-medicated with PPIs. PPIs use was associated with a decreased risk of MACCE (Before PSM OR: 0.857, 95% CI: 0.742-0.990, = 0.0359; after PSM OR: 0.862, 95% CI: 0.768-0.949, = 0.0245) after multivariate adjustment. Patients receiving PPIs also had a lower risk of cardiac death but a higher risk of complicating with stroke. When GIB occurred, an alleviating trend of GIB severity was observed in PPIs group.
Our study is the first nation-wide large-scale study to show evidence on PPIs use in AMI patients treated with DAPT. We found that PPIs in combination with clopidogrel was associated with decreased risk for MACCE in AMI patients, and it might have a trend to mitigate GIB severity. Therefore, PPIs could become an available choice for AMI patients during hospitalization.
最新指南推荐使用质子泵抑制剂（PPI）以降低接受双联抗血小板治疗（DAPT）的急性心肌梗死（AMI）患者的出血风险。然而，既往的药效学和临床研究报道了PPI与P2Y12抑制剂氯吡格雷之间相互作用的矛盾结果。我们研究了PPI的使用对AMI患者院内结局的影响，旨在为PPI的价值提供新的见解。
分析了中国急性心肌梗死（CAMI）注册研究中总共23380例连续接受氯吡格雷治疗且使用或未使用PPI的AMI患者。主要终点是主要不良心血管和脑血管事件（MACCE），定义为院内心源性死亡、再梗死和卒中的复合事件。采用倾向评分匹配（PSM）来控制潜在的基线混杂因素。进行多因素逻辑回归分析以评估PPI的使用对MACCE和胃肠道出血（GIB）的影响。
在整个AMI人群中，绝大多数患者接受了DAPT，67.5%的患者同时使用了PPI。多因素调整后，使用PPI与MACCE风险降低相关（PSM前比值比：0.857，95%可信区间：0.742 - 0.990，P = 0.0359；PSM后比值比：0.862，95%可信区间：0.768 - 0.949，P = 0.0245）。接受PPI的患者心源性死亡风险也较低，但卒中并发症风险较高。当发生GIB时，PPI组观察到GIB严重程度有减轻趋势。
我们的研究是第一项全国范围内的大规模研究，显示了在接受DAPT治疗的AMI患者中使用PPI的证据。我们发现PPI联合氯吡格雷与AMI患者MACCE风险降低相关，并且可能有减轻GIB严重程度的趋势。因此，PPI可能成为AMI患者住院期间的一个可用选择。
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