Optimal management of antiplatelet therapy and proton pump inhibition following percutaneous coronary intervention

OPINION STATEMENT: Dual antiplatelet therapy (aspirin and a P2Y(12) antagonist) is required after the insertion of a coronary artery stent. If the stent has been inserted in the context of an acute coronary syndrome (ACS), then clopidogrel or a high-potency P2Y(12) antagonist such as prasugrel or ticagrelor should be considered. Current indications for the use of prasugrel in this situation include ST elevation, diabetes, or previous stent thrombosis on clopidogrel therapy. If the stent has been inserted electively for stable ischemic heart disease, then the patient should normally receive clopidogrel. Next, it is important to consider the patient's bleeding risk. The CRUSADE score can be used to determine the likelihood of a subsequent gastrointestinal (GI) bleed. For patients treated with aspirin and clopidogrel who are at high risk of a GI bleed, the current evidence suggests that a proton pump inhibitor (PPI) is the most effective way to reduce this risk. There is evidence that omeprazole may attenuate the pharmacodynamic effect of clopidogrel and, therefore, it would be reasonable to use an alternative PPI that has less risk of negative pharmacokinetic and pharmacodynamic interaction, such as pantoprazole. If a patient is at moderate or low risk of bleeding, then a PPI should be avoided in combination with clopidogrel as the risk of negative interaction is greater than the risk of GI bleeding. There is no substantive evidence that PPIs attenuate the therapeutic effect of prasugrel or ticagrelor; therefore, patients at moderate or high risk of GI bleeding should be offered a PPI.