Bruce Soloway, MD reviewing Li L et al. Lancet 2017 Jun 13.

In a patient older than 75 who takes antiplatelet drugs for secondary prevention, a proton-pump inhibitor should be strongly considered.

Recommendations for lifelong antiplatelet treatment after ischemic vascular events are based largely on short-term studies of younger patients (age, ≤75), but about half of patients who receive antiplatelet drugs for secondary prevention are older than 75. To determine the safety of antiplatelet treatment in older adults, British researchers followed a cohort of 3166 patients who started or continued on antiplatelet drugs after transient ischemic attacks, ischemic strokes, or myocardial infarctions. Half of enrollees were younger than 75; patients taking anticoagulants were excluded.

During as long as 10 years of follow-up, 187 major bleeds occurred, with 130 of them in patients older than 75 at baseline; annual risk for major bleeds in elders was ≈2% to 4%, increasing steeply with age. Compared with younger patients, those older than 75 were significantly more likely to experience nonfatal major bleeds (hazard ratio, 2.64), fatal bleeds (HR, 5.53), disabling bleeds (HR, 7.60), and fatal or disabling upper gastrointestinal (GI) bleeds (HR, 10.26). Using data on the effectiveness of proton-pump inhibitors (PPIs) for preventing major upper GI bleeds, the number of patients who would have to be treated with PPIs for 5 years to prevent 1 fatal or disabling upper GI bleed fell from 338 among patients younger than 65 to 25 among patients 85 or older.

CITATION(S):

Li L et al. Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: A population-based cohort study. Lancet 2017 Jun 13; [e-pub]. 

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