Antiplatelet therapy is recommended for routine use in secondary cardiovascular disease (CVD) prevention guidelines and is also recommended for primary prophylaxis among people at increased risk for CVD, depending on patient characteristics. NSAIDs are another widely used class of medications used to treat fevers, pain, and inflammation. As the elderly population continues to age, it is expected that use of these therapies will increase, especially in those with CVD. “As such, managing GI risks associated with these therapies will become an increasingly relevant part of cardiovascular care,” says Deepak L. Bhatt, MD, MPH, FACC, FAHA, FSCAI. “Each of these medication classes can raise the risk of GI bleeding, including serious bleeding and hemorrhage. The independent risks, however, can be further compounded by the concomitant use of antiplatelet therapy and NSAIDs. Patients taking low-dose aspirin plus NSAIDs have a two- to four-fold increased risk of GI bleeding compared with those not taking these medications.”
Improving Patient Safety
There has been uncertainty about the most effective ways to prevent bleeding complications in patients receiving antiplatelet therapy and NSAIDs. Research has shown that patients are on these agents for longer periods than in the past. This can increase their risk of developing GI bleeding events over time. The American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), and the American College of Gastroenterology (ACG) recently collaborated to develop a new expert consensus document that aims to help providers manage GI bleeding risks in patients with CVD who are taking these drugs. Published in the October 2008 issue of Circulation, the intent of the document is to improve patient safety for individuals using these therapies.
“The ACCF, AHA, and ACG felt there was a significant need for a group consensus document to address these very common yet difficult issues,” says Dr. Bhatt, who co-chaired the writing group that created the consensus. “Many patients with CVD are often on antiplatelet drugs, anticoagulant therapy, NSAIDs, or a combination of these therapies. These are issues that come up frequently in clinical practice. Prior to the consensus, there wasn’t much guidance on how to prevent common GI complications or manage them when they occur for this patient group. The document can facilitate dialogue between two different specialty groups—cardiology and gastroenterology—so that patient safety can be improved.”
The consensus document from ACCF, AHA, and ACG describes several key recommendations for reducing GI bleeding risks for patient with CVD taking antiplatelet therapies and NSAIDs (Table). The document notes that gastroprotective strategies include the use of proton pump inhibitors (PPIs) in patients at high risk of GI bleeding. It also recommends the eradication of Helicobacter pylori infection—a common bacteria that contributes to the development of stomach ulcers—in patients with a history of ulcers. “It’s critical that practitioners pay attention to these recommendations,” Dr. Bhatt notes. “We must collaborate with other providers to weigh the ischemic and bleeding risks in patients who need antiplatelet therapy but are at risk for developing significant GI bleeding.”
Take A Stepwise Approach
The consensus document has provided an algorithm for reducing the risk of ulcers and GI bleeding among patients using NSAIDs along with antiplatelet agents (Figure). It is recommended to consider individual patient risk factors for possible GI complications, including age, previous history of ulcers or bleeding, presence of H pylori, and dyspepsia or GERD symptoms as well as the simultaneous use of NSAIDs, anticoagulants and/or corticosteroids. Recommendations for gastroprotection include the use of PPIs and testing for and eradication of H pylori. Dr. Bhatt says “cardiologists need to become more familiar with screening strategies for at-risk patients so that adjustments to treatment plans can be made to minimize GI complications. The algorithm can serve as a quick and easy assessment tool for busy practitioners in clinical practice.”
Communication Matters
The consensus document is not a guideline because more clinical trial data are needed before firm recommendations can be made. However, Dr. Bhatt says that the document may spur improvements in patient safety, identify knowledge gaps, and serve as a starting point for future investigations. “For now, our hope is that the document will foster better communication among cardiologists, gastroenterologists, and primary care physicians. It’s critical that all physicians collaborate so that patient safety can improve. This is a serious clinical problem for patients with CVD. As more data emerge from clinical trials, observational studies, and expert opinions, we will be better equipped to manage and even prevent this complication in the future.”
Deepak L. Bhatt, MD, MPH, FACC, FAHA, FSCAI, has indicated to Physician’s Weekly that he has worked as a consultant for Arena, Astellas, Astra Zeneca, Bayer, Bristol Myers Squibb, Cardax, Centocor, Cogentus, Daiichi-Sankyo, Eisai, Eli Lilly, Glaxo Smith Kline, Johnson & Johnson, McNeil, Medtronic, Millennium, Molecular Insights, Otsuka, Paringenix, PDL, Philips, Portola, Sanofi Aventis, Schering Plough, Scios, Takeda, The Medicines Company, and Vertex. He has also received grants/research aid from Bristol Myers Squibb, Eisai, Ethicon, Heartscape, Sanofi Aventis, and The Medicines Company.
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