Title: Outcomes With Concurrent Use of Clopidogrel and Proton-Pump Inhibitors: A Cohort Study
Topic: General Cardiology
Date Posted: 4/8/2010
Author(s): Ray WA, Murray KT, Griffin MR, et al.
Citation: Ann Intern Med 2010;152:337-345.
Clinical Trial: No
Study Question: What are the clinical outcomes (gastrointestinal bleeding and cardiovascular [CV] events) in patients treated with both clopidogrel and proton pump inhibitors (PPIs)?
Methods: This was a retrospective cohort study of 20,596 patients (including 7,593 concurrent users of clopidogrel and PPIs) hospitalized between 1999 and 2005 for myocardial infarction, coronary artery revascularization, or unstable angina pectoris. Baseline and follow-up drug use was assessed from automated records of dispensed prescriptions. Primary outcomes were hospitalizations for gastroduodenal bleeding and serious CV disease (fatal or nonfatal myocardial infarction or sudden cardiac death, stroke, or other CV death).
Results: Pantoprazole and omeprazole accounted for 62% and 9% of concurrent PPI use, respectively. Adjusted incidence of hospitalization for gastroduodenal bleeding in concurrent PPI users was 50% lower than that in nonusers (hazard ratio, 0.50; 95% confidence interval, 0.39-0.65). For patients at highest risk for bleeding, PPI use was associated with an absolute reduction of 28.5 (CI, 11.7-36.9) hospitalizations for gastroduodenal bleeding per 1,000 person-years. The hazard ratio associated with concurrent PPI use for risk for serious CV disease was 0.99 (CI, 0.82-1.19) for the entire cohort and 1.01 (CI, 0.76-1.34) for the subgroup of patients who had percutaneous coronary interventions with stenting during the qualifying hospitalization.
Conclusions: The authors concluded that in patients with serious coronary heart disease treated with clopidogrel, concurrent PPI use was associated with a reduced incidence of hospitalizations for gastroduodenal bleeding without an increase in serious CV events.
Perspective: Patients with CV disease on clopidogrel are commonly also treated with PPIs. Because some PPIs have been shown to inhibit activity of the enzyme responsible for biotransformation of clopidogrel, CYP2C19, concern has been raised that PPI coadministration may reduce the effectiveness of clopidogrel, resulting in increased CV events. This is particularly relevant in patients following stent placement, where clopidogrel is effective in reducing stent thrombosis. While some studies have shown this interaction is clinically significant, recent data from TRITON-TIMI 38 found no increased CV risk associated with PPI use. The current study also supports the concept that the benefits of PPI use in patients at risk of gastrointestinal bleeding outweigh potential adverse CV risks in patients on clopidogrel. Data from additional trials will be helpful to clarify CV risk estimates associated with concomitant PPI and clopidogrel use. Daniel T. Eitzman, M.D., F.A.C.C.
Title: Food Price and Diet and Health Outcomes: 20 Years of the CARDIA Study
Topic: Prevention/Vascular
Date Posted: 4/9/2010
Author(s): Duffey KJ, Gordon-Larsen P, Shikany JM, Guilkey D, Jacobs DR Jr, Popkin BM.
Citation: Arch Intern Med 2010;170:420-426.
Clinical Trial: No
Related Resources
Trial: Coronary Artery Risk Development in Young Adults (CARDIA)
Study Question: Is there a relationship between food prices and individual intake of “healthy” versus “unhealthy” choices, and are there potential health benefits?
Methods: A 20-year longitudinal study included 12,123 respondent days from 5,115 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Associations between food price, dietary intake, overall energy intake, weight, and homeostatic model assessment insulin resistance (HOMA-IR) scores were assessed using conditional log-log and linear regression models.
Results: The real price (inflated to 2006 US dollars) of soda and pizza decreased over time. The largest percentage decrease was for soda, falling from $2.71 to $1.42 (48% decrease; the price of whole milk increased). During periods with a 10% increase in the price of soda or pizza, there was a -7.12% or -11.5% change in energy from these foods, respectively. A $1.00 increase in soda price was also associated with lower daily energy intake (-124 kcal), lower weight (-1.05 kg), and lower HOMA-IR score (-0.42); similar trends were observed for pizza. A $1.00 increase in the price of both soda and pizza was associated with greater changes in total energy intake (-181.49 kcal), body weight (-1.65 kg), and HOMA-IR (-0.45).
Conclusions: Policies aimed at altering the price of soda or away-from-home pizza may be effective mechanisms to steer US adults toward a more healthful diet and help reduce long-term weight gain or insulin levels over time.
Perspective: This type of data likely influenced government policy regarding availability of soda and pizza in schools, and of course would encourage use of taxation to address the fattening of America. Melvyn Rubenfire, M.D., F.A.C.C.