在正在服用抗栓藥和非甾體抗炎藥(NSAID)的心肌梗死後患者中，質子泵抑製劑(PPI)對其胃腸道出血風險的影響如何?多國學者們聯合開展了一項研究，結果表明，心肌梗死後患者的出血並發症與抗栓治療和NSAID治療均有關;而無論這類患者服用何種抗栓治療方案和何種類型的NSAID，當前應用任何PPI均與其胃腸道出血風險減少獨立相關。相關論文近期發表於《英國醫學雜誌》(簡稱BMJ)上。

該項全國性隊列研究基於丹麥所有醫院相關聯的管理登記數據。納入年齡在30歲及以上的患者，這些患者在首次心梗出院後存活至少30天。根據NSAID聯合抗栓治療，利用校正時間依賴的Cox比例模型評估PPI與胃腸道出血風險的相關性。

結果顯示，應用PPI與同時服用抗栓藥和NSAID的心梗後患者胃腸道出血風險減少獨立相關。在82995例心梗後患者中(平均年齡67.4歲，男性64%)，所有的人都正在接受單一或雙重抗栓治療，42.5%(35233例)接受至少一個NSAID的處方治療，且45.5%(37771例)接受PPI治療。在平均隨訪的5.1年中，共發生了3229例胃腸道出血事件。以事件/100人-年計算，NSAID聯合抗栓治療的患者中，服用PPI的患者和未服用PPI的患者粗略出血發生率分別為1.8和2.1。無論患者使用何種抗栓治療方案，何種類型的NSAID以及何種PPI，PPI的應用可降低出血校正風險(危險比0.72，95%置信區間0.54-0.95)。

參考文獻：Anne-Marie Schjerning Olsen,et al. BMJ 2015;351:h5096 doi: 10.1136/bmj.h5096

Impact of proton pump inhibitor treatment on gastrointestinal bleeding associated with non-steroidal anti-inflammatory drug use among post-myocardial infarction patients taking antithrombotics: nationwide study

Anne-Marie Schjerning Olsen, medical doctor,corresponding author1,2 Jesper Lindhardsen, medical doctor,1 Gunnar H Gislason, professor,1,3,4 Patricia McGettigan, senior clinical lecturer,2 Mark A Hlatky, professor,5 Emil Fosbøl, medical doctor,6 Lars Køber, professor,6 Christian Torp-Pedersen, professor,7 and Morten Lamberts, medical doctor8

Abstract
Study question What is the effect of proton pump inhibitors (PPIs) on the risk of gastrointestinal bleeding in post-myocardial infarction patients taking antithrombotics and treated with non-steroidal anti-inflammatory drugs (NSAIDs)?

Methods This was a nationwide cohort study based on linked administrative registry data from all hospitals in Denmark between 1997 and 2011. The study included patients aged 30 years and over admitted with a first myocardial infarction who survived at least 30 days after discharge. The association between PPIs and risk of gastrointestinal bleeding according to NSAID plus antithrombotic therapy was estimated using adjusted time dependent Cox regression models.

Study answer and limitations The use of PPIs was independently associated with decreased risk of gastrointestinal bleeding in post-myocardial infarction patients taking antithrombotics and treated with NSAIDs. Of 82 955 post-myocardial infarction patients (mean age 67.4 years, 64% (n=53 070) men), all of whom were taking single or dual antithrombotic therapy, 42.5% (n=35 233) filled at least one prescription for NSAIDs and 45.5% (n=37 771) received PPIs. Over a mean follow-up of 5.1 years, 3229 gastrointestinal bleeds occurred. The crude incidence rates of bleeding (events/100 person years) on NSAID plus antithrombotic therapy were 1.8 for patients taking PPIs and 2.1 for those not taking PPIs. The adjusted risk of bleeding was lower with PPI use (hazard ratio 0.72, 95% confidence interval 0.54 to 0.95) regardless of antithrombotic treatment regimen, type of NSAID, and type of PPI used. The main limitation of the study is its observational non-randomised design. The results suggest that PPI treatment probably has a beneficial effect regardless of underlying gastrointestinal risk and that when NSAIDs cannot be avoided in post-myocardial infarction patients, physicians might prescribe a PPI as well. The study does not clarify whether PPIs might be safely omitted in specific subgroups of patients with a low risk of gastrointestinal bleeding.

What this study adds In post-myocardial infarction patients, bleeding complications have been associated with both antithrombotic and NSAID treatment. Concurrent use of PPIs was independently associated with a decreased risk of gastrointestinal bleeding in post-myocardial infarction patients taking antithrombotics and NSAID, regardless of antithrombotic treatment regimen, type of NSAID, and type of PPI used.

Funding, competing interests, data sharing AMSO has received a grant from the Danish Council of Independent Research (grant 12-132760). GHG is supported by an unrestricted research scholarship from the Novo Nordisk Foundation.