Histamine2-receptor antagonists are an alternative to proton pump inhibitor in patients receiving clopidogrel

Abstract

Background & Aims Previous observational studies reported that concomitant use of clopidogrel and proton pump inhibitors (PPIs) in patients with prior acute coronary syndrome (ACS) was associated with adverse cardiovascular outcomes. We investigated whether H2-receptor antagonist (H2RA) is an alternative to PPI in patients with ACS. Methods We conducted a population-based retrospective cohort study of 6552 patients in Taiwan discharged for ACS between 2002 and 2005. Patients were divided into 5 cohorts: clopidogrel plus H2RA (n = 252), clopidogrel plus PPI (n = 311), clopidogrel alone (n = 5551), H2RA alone (n = 235), and PPI alone (n = 203). The primary outcome was rehospitalization for ACS or all-cause mortality within 3 month of rehospitalization. Results The 1-year cumulative incidence of the primary outcome was 26.8% (95% CI: 21.5%33.0%) in the clopidogrel plus H2RA cohort and 33.2% (95% CI: 27.8%39.4%) in the clopidogrel plus PPI cohort, compared with 11.6% (95% CI: 10.8%12.5%) in the clopidogrel alone cohort (P < .0001). No significant difference was observed between the PPI alone cohort (11.0%; 95% CI: 7.1%16.8%), the H2RA alone cohort (11.8%; 95% CI: 8.2%16.8%), and the clopidogrel alone cohort in terms of the primary outcome. The number needed to harm was 7 with concomitant H2RA and 5 with concomitant PPI. On multivariate analysis, concomitant H2RA and PPI were independent risk factors predicting adverse outcomes (adjusted hazard ratios, 2.48 and 3.20, respectively; P < .0001). Conclusions Concomitant use of clopidogrel and H2RA or PPI after hospital discharge for ACS is associated with increased risk of adverse outcomes. © 2010 AGA Institute.