Which PPI is safe for myocardial infarction patients on DAPT?

Three proton pump inhibitors (PPIs) demonstrate cardiovascular safety in patients with acute myocardial infarction (MI) receiving dual antiplatelet therapy (DAPT), according to a study. Moreover, use of lansoprazole contributes to a reduced risk of gastrointestinal bleeding.

Using electronic health record data, the investigators emulated target trials comparing the efficacy and safety of three commonly used PPIs in clinical practice. Gastrointestinal bleeding was the efficacy outcome, and composite cardiovascular events served as the safety outcome.

Cox proportional hazards model was used to calculate the hazard ratios (HRs) with 95 percent confidence intervals (CIs) between individuals PPIs. Additionally, XGBoost-based prognostic models were used to assess treatment effect heterogeneity across strata of predicted baseline risk.

A total of 51,072 patients with MI treated with DAPT were analysed. Of these, 22,671 received rabeprazole, 18,081 pantoprazole, and 10,320 lansoprazole.

At 1-year follow-up, pantoprazole (HR, 1.05, 95 percent CI, 0.97‒1.13) and lansoprazole (HR, 0.99, 95 percent CI, 0.91‒1.09) demonstrated a similar cardiovascular risk to rabeprazole. However, pantoprazole use appeared to elevate the risk of recurrent MI (HR, 1.20, 95 percent CI, 1.07‒1.35).

Notably, treatment with lansoprazole resulted in a reduced risk of gastrointestinal bleeding (HR, 0.81, 95 percent CI, 0.70‒0.93) compared with rabeprazole.

“Results were robust in multiple sensitivity analyses, and treatment effect heterogeneity showed gastrointestinal benefits of lansoprazole increase with the rising baseline bleeding risk,” the investigators said.

“External validation is warranted to examine these findings,” they added.