geoffrey modest medical blogs

A prospective population-based cohort study of patients with vascular disease and on antiplatelet therapy (mainly low-dose aspirin) found a dramatic increase in the risk of bleeds in those over 75 years old, raising the question of whether we should be using proton-pump inhibitor (PPI) prophylaxis (s ee  aspirin secondary prophyl add PPI lancet2017  in dropbox, or  doi.org/10.1016/S0140-6736(17)30770-5 ) Details: -- 3166 patients with vascular disease (defined as a 1 st  TIA, ischemic stroke, or MI and placed on antiplatelet therapy) in the Oxford Vascular Study from 2002 to 2012 were followed until 2013. 50% of the cohort were greater than 75 years old -- for the subgroup of patients < 75 years old:     -- mean age 61, 65% male, 32% ischemic stroke/30% TIA/21% NSTEMI/17% STEMI, 97% on aspirin/3% nonaspirin antiplatelet therapy -- for those > 75 years old:     -- mean age 83, 43% male, 42% ischemic stroke/27% TIA/23%...

A rather common clinical conundrum in patients with/at high risk for cardiovascular disease is whether to reinstate aspirin after a GI bleed. A recent retrospective study from Hong Kong suggested that the benefit outweighs the risk for lower GI bleeds ( see  aspirin after lower gi bleed gastro2016  in dropbox , or doi.10.1053/j.gastro.2016.04.013). They reviewed their data on patients with documented lower GI bleed (melena or hematochezia and absence of upper GI source) from 2001-2008. Details: --295 patients who were on aspirin at the time of the lower GI bleed, followed up to 5 years --93% were considered to be of "high cardiovascular risk", using the Antithrombotic Trialists' Collaborative definition: history of unstable angina, acute MI, prior MI, stroke, or TIA --non-users were defined as taking aspirin <20% of the follow-up period (n=121; 87% actually took aspirin <10% of the follow-up period); users were those with cumulative use ...

one of the many unanswered clinical questions is what to do with patients who have atrial fibrillation, are anticoagulated, but have a GI bleed. do i just stop the anticoagulation? should i bite my lip (but not too hard) and reinstate anticoagulation after the bleed? a recent observational study looked at this question, utilizing the great Danish clinical database (see  a fib gi bleed and recurrent stroke bmj2015  in dropbox, or  BMJ  2015 Nov 16; 351:h5876​). details: --Danish cohort included all patients with atrial fibrillation (AF) from 1996-2012 who had a gastrointestinal (GI) bleed while on antithrombotic therapy. they then compared the patients who restarted therapy vs those who remained off therapy, beginning 90 days after the incident bleed --4406 patients (mean age 78; 45% women; 24% on oral anticoagulation, 53% on antiplatelet agents, 19% on both; 25% on NSAIDs within 90 days of bleed, 15% on PPIs; 23% with prior s...

A recent Spanish study looked at the risk of peptic ulcer bleeding in patients with H Pylori (HP) infection and in patients also using NSAIDs/low-dose aspirin ( see  hpylori gi bleed asa nsaid amjgastro 2015  in dropbox, or Am J Gastroenterol 2015; 110:684–689). This case-control study looked at 666 patients with endoscopically-confirmed major peptic ulcer bleeding and 666 controls (matched by age, sex, month of admission), assessing medication use in the prior 7 days. HP was assessed by serology. results: --mean age 60; 29% female; with cases having significantly more smokers, ulcer history, dyspepsia, use of aspirin or NSAIDs, being on anticoagulants, not being on PPIs, and having HP infections (the latter being in 74.3% of cases and 54.8% of controls,   [ R R: 2.6  (CI:  2.0-3.3) ]) --results:     ​--aspirin use (<300 mg/d) was associated with 15.8% of c...

a recent article brought up the issue of H Pylori eradication in patients on low-dose aspirin (see  hpylori gi bleed asa gastro 2013  in dropbox). this is an observational, prospective study looking at 3 groups of patients on low-do se  asa.  followed up to10 years (5K patient-yrs), primary endpoint is recurrence of gastroduod bleed.   -- group 1:  250 pts with Hpylori and bleeding ulcer, had their Hpylori eradicated and continued with asa after the ulcer healed. - -group 2:120  Hpylori negative asa users who developed bleeding ulcers. put on enteric-coated asa after ulcer healed --group 3: 540 pts (considered their "average risk group") new pts on asa without a hx of ulcers   results: incidence of ulcer bleed, per 100-pt yrs -no diff in incidence of bleeding between group 1 (0.97 per 100 pt-yrs) and group 3 (0.66) -group 2 (bleeding despite being h. pylori neg) with 5.22 (ie 8.5x that of the average risk group)   ...