Vol.:(0123456789) 1 3 Internal and Emergency Medicine https://doi.org/10.1007/s11739-018-1827-9 THE CUTTING EDGE: RESEARCH UPDATE Is proton pump inhibitors’ prophylaxis indicated for patients on antiplatelet therapy? Lorenzo Porta 1  · Francesca Baorda 2  · Alessandra Fusco 2  · Gruppo di Autoformazione Metodologica (GrAM) Received: 1 March 2018 / Accepted: 8 March 2018 © SIMI 2018 Background In USA and Europe, more than 50% of adults aged 75 years old or older are taking a lifelong antiplatelet treatment, of which half are for secondary prevention of vascular diseases [1]. The major side efect of the aforementioned therapy is the risk of major bleeding, particularly from the upper gas- trointestinal tract. However, clinical guidelines on second- ary prevention of vascular events do not recommend proton pump inhibitors (PPIs), which could reduce the incidence of bleeding by 70–90%. This is probably due to the adverse effects of the PPIs, as stated in a recent Mayo Clinic’s review [2], and because in aspirin trials, the gastrointestinal bleeds have a low mortality and permanent disability rates. However, most of the populations of the aspirin trials were younger than 75 years of age, and thus, up to now, the age- specifc risk of bleeding in patients on long-term antiplate- let treatment after vascular events has not been sufciently studied. Summary The prospective population-based cohort study conducted by Li et al. aims to determine the age-specifc risks, site, severity, outcomes, time course, and predictors of bleeding complications in secondary prevention of vascular events. Furthermore, they aim to compare the aforementioned risks with those of recurrent ischaemic events and those reported in the previous randomised trials, and to estimate the potential efect of routine PPIs use on reducing bleed- ing [3]. Criteria of eligibility for the study were to have had a frst ischaemic stroke, myocardial infarction, or transient ischaemic attack, and currently being on antiplatelet therapy. On the contrary, patients starting or continuing oral antico- agulants after the vascular event were excluded from the study. A face-to-face follow-up was conducted at 30 days, 6 months, and years 1, 5, and 10. The authors include in the study only bleeding events for which the patient sought medical attention or that were fatal before emergency inter- vention, while all the minor bleeds were excluded, as well as those secondary to major trauma, surgical procedures, or haematological malignancy. The average annual risk is 3.36% [95% confdence interval (CI) 3.04–3.70] for all bleeds and 1.46% (95% CI 1.26–1.68) for major bleeds. While the average annual risk of major bleeding in patients younger than 75 years during the frst 3 years of follow- up (1.1%, 95% CI 0.7–1.6) is analogous to the one being reported in the previous trials, it increases rapidly above age 70 years, reaching more than 4% at age 85 years or older. Above all sites, the aforementioned risk is most prominent for upper gastrointestinal bleeds. Patients aged 75 years or older have more severe bleeds, worse outcome, and higher post-event disability rate than those aged younger than 75 years. This result is independent of gender, history of vas- cular disease or peptic ulcer, and vascular risk factors. The ratio of major bleeds to ischemic events is similar to the ratio in the previous aspirin trials (0.20 and 0.19, respectively) in patients younger than 75 years, while it increases with age (75–84 years 0.32; ≥ 85 years 0.46). The authors calculated the NNT, using the estimate of a published meta-analysis of randomised trials of PPIs versus placebo in patients taking antiplatelet drugs, where PPIs use reduced upper gastroin- testinal bleeding by 74%. At the 5 year follow-up, the NNT with PPIs to prevent one event of major upper gastrointes- tinal bleed decreased with increasing age: 80 for patients younger than 65 years, 75 for patients aged 65–74 years, 23 for patients aged 75–84 years, and 21 for patients aged * Lorenzo Porta lorenzo.porta1992@gmail.com 1 Dipartimento di scienze Biomediche e Cliniche, Ospedale “L. Sacco”, Università degli Studi di Milano, Milan, Italy 2 Dipartimento di Medicina Interna, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy