在正在服用抗栓药和非甾体抗炎药(NSAID)的心肌梗死后患者中，质子泵抑制剂(PPI)对其胃肠道出血风险的影响如何?多国学者们联合开展了一项研究，结果表明，心肌梗死后患者的出血并发症与抗栓治疗和NSAID治疗均有关;而无论这类患者服用何种抗栓治疗方案和何种类型的NSAID，当前应用任何PPI均与其胃肠道出血风险减少独立相关。相关论文近期发表于《英国医学杂志》(简称BMJ)上。

        该项全国性队列研究基于丹麦所有医院相关联的管理登记数据。纳入年龄在30岁及以上的患者，这些患者在首次心梗出院后存活至少30天。根据NSAID联合抗栓治疗，利用校正时间依赖的Cox比例模型评估PPI与胃肠道出血风险的相关性。

        结果显示，应用PPI与同时服用抗栓药和NSAID的心梗后患者胃肠道出血风险减少独立相关。在82995例心梗后患者中(平均年龄67.4岁，男性64%)，所有的人都正在接受单一或双重抗栓治疗，42.5%(35233例)接受至少一个NSAID的处方治疗，且45.5%(37771例)接受PPI治疗。在平均随访的5.1年中，共发生了3229例胃肠道出血事件。以事件/100人-年计算，NSAID联合抗栓治疗的患者中，服用PPI的患者和未服用PPI的患者粗略出血发生率分别为1.8和2.1。无论患者使用何种抗栓治疗方案，何种类型的NSAID以及何种PPI，PPI的应用可降低出血校正风险(危险比0.72，95%置信区间0.54-0.95)。

        参考文献：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.