Provision of gastroprotective medication and bleeding risk following acute coronary syndrome

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.

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.

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).

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.