Real-Life Practices in the Management of Concurrent Peptic Ulcer Bleeding and Myocardial Infarctions

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Background. Patients with myocardial infarctions (MI) are at risk of peptic ulcer disease (PUD) bleeding given the routine use of anti-platelet agents and anticoagulants. To date, the real-life practices in the management of PUD bleeding in patients with myocardial infarctions have not been documented. Methods: Patients who experienced both a myocardial infarction and PUD bleeding in the same hospitalization between January 1999–January 2006 were evaluated from two university-affiliated institutions. Coronary care practices, PUD bleeding care, and patient outcomes were determined. Results: A total of 87 patients were evaluated. Many patients were already on ASA (n = 40, 46%) and NSAIDS (n = 22, 25%) prior to hospitalization. Only 10 (17%) patients were on a proton pump inhibitor prior to hospitalization. A proportion of patients received ASA (n = 74, 85%) and clopidogrel (n = 49, 56%) during the MI. One third of patients had high risk stigmata lesions (n = 29) and two-thirds had low risk lesions (n = 58). Once PUD bleeding was diagnosed, 32% (n = 28) continued on ASA therapy without interruption, 34% (n = 30) had ASA therapy held temporarily, and 33% (n = 29) were never restarted on ASA therapy in hospital. Patients who were continued on ASA after PUD bleeding were more likely to have low risk stigmata (82%) compared to patients where ASA was not continued immediately (60%, p < 0.05). In patients with low risk stigmata who continued ASA, there was no significant difference in the rebleeding rate compared to those who did not restart ASA immediately (0% vs 6%, NS). In patients with high risk stigmata, continuing ASA did not significantly increase the rebleeding risk compared to those who did not restart ASA (40% vs 30%, NS). Conclusions: A large proportion of patients with MI who develop PUD bleeding are on ASA or NSAIDs prior to hospitalization. Immediate continuation of ASA does not appear to increase PUD rebleeding rates when given with concurrent acid suppressive therapy. One-third of patients are managed without a plan to restart ASA therapy post-MI.