Is proton pump inhibitor use increasing for Chinese patients with acute coronary syndrome?

Proton pump inhibitors (PPIs) are commonly prescribed to protect the stomach in patients with acute coronary syndrome (ACS) who take blood thinners. In China, PPI use has been rising significantly over the past decade. A single-center study found that PPI prescriptions at discharge increased from 21.3% in 2010-2012 to 63.5% in 2016-2018 ⁶. A larger national registry from 2017-2018 reported that 63.9% of ACS patients received PPIs within 24 hours of admission ⁹. This trend is notable because some research suggests PPIs may increase the risk of gastrointestinal bleeding and cardiovascular events when used with certain antiplatelet drugs ⁹¹⁰.

What the research says

A cross-sectional study at Beijing Tongren Hospital analyzed 531 Chinese patients with both ACS and atrial fibrillation (AF) from 2010 to 2018. PPI use at discharge rose sharply from 21.3% in the earliest period (2010-2012) to 63.5% in the latest period (2016-2018), with an overall rate of 47.8% ⁶. This upward trend was statistically significant ⁶. Another large study from the Improving Care for Cardiovascular Disease in China-ACS project included 25,567 patients from 172 hospitals in 2017-2018 and found that 63.9% were prescribed PPIs within 24 hours of admission ⁹. Together, these data confirm that PPI use is both common and increasing among Chinese ACS patients ⁶⁹. The reasons for this increase may include growing awareness of gastrointestinal bleeding risk with dual antiplatelet therapy (DAPT), but the trend also raises concerns. In the registry study, patients who received PPIs actually had a higher rate of in-hospital gastrointestinal bleeding (1.0% vs. 0.5%), and after adjusting for other factors, early PPI use was associated with a 58% higher risk of GI bleeding ⁹. A meta-analysis of 159,998 patients also found that combining PPIs with clopidogrel was linked to a higher risk of major cardiovascular events and recurrent ACS ¹⁰. However, these findings are observational and may be influenced by the fact that sicker patients are more likely to receive PPIs ⁹.

What to ask your doctor

• Given my ACS diagnosis and antiplatelet regimen, do I need a PPI for stomach protection?
• What are the potential risks and benefits of taking a PPI with my specific blood thinner (e.g., clopidogrel, ticagrelor)?
• Are there alternatives to PPIs, such as H2 blockers or lifestyle changes, that might be safer for me?
• How long should I take a PPI if it is prescribed? Is it safe to stop after a certain period?
• Should I be monitored for any side effects or drug interactions if I take a PPI long-term?