title: Provision of gastroprotective medication and bleeding risk following acute coronary syndrome.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Cardiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom. alan.bagnall@nuth.nhs.uk
authors.forename: Athar
authors.initials: A
authors.lastname: Badar
authors.forename: Jennifer
authors.initials: J
authors.lastname: Scaife
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Yan
authors.forename: Simon D
authors.initials: SD
authors.lastname: Robinson
authors.forename: Azfar G
authors.initials: AG
authors.lastname: Zaman
authors.forename: Ian F
authors.initials: IF
authors.lastname: Purcell
authors.forename: Javed M
authors.initials: JM
authors.lastname: Ahmed
authors.forename: Mohaned
authors.initials: M
authors.lastname: Egred
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Edwards
authors.forename: Ioakim
authors.initials: I
authors.lastname: Spyridopoulos
authors.forename: Bernard D
authors.initials: BD
authors.lastname: Keavney
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Bagnall
mesh_terms: D054058:Acute Coronary Syndrome / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D000077144:Clopidogrel; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D062645:Percutaneous Coronary Intervention; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D054328:Proton Pump Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine