practice guidelines ischemia; secondary duodenal stenosis; and gastric, hepatic, and splenic infarction. Revised recommendation: Patients with bleeding peptic ulcers should be tested for Helicobacter pylori and receive eradication therapy if it is present, with confirmation of eradication. (Grade: 1A) New recommendation: Negative H. pylori diagnostic tests obtained in the acute setting should be repeated. (Grade: 1B) Diagnostic tests for H. pylori (e.g., serology, histology, urea breath test, rapid urease test, stool antigen, culture) may show increased false-negative rates in patients with acute bleeding; therefore, repeat testing after an initial negative result is needed. Postdischarge, Aspirin, and NSAIDs New recommendation: In patients with previous ulcer bleeding who require a nonsteroidal anti-inflammatory drug (NSAID), treatment with a traditional NSAID plus PPI or a cyclooxygenase-2 (COX-2) inhibitor alone is associated with a clinically important risk of recurrent bleeding. (Grade: 1B) New recommendation: In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk of recurrent bleeding compared with COX-2 inhibitors alone. (Grade: 1B) Adding a PPI to traditional NSAID therapy is recommended to
reduce the risk of upper GI complications, although the combination of a COX-2 inhibitor plus a PPI was associated with the greatest reduction in risk. Other studies found a decreased risk of endoscopic ulcers with a COX-2 inhibitor plus a PPI, compared with a COX-2 inhibitor alone. New recommendation: In patients who take lowdose aspirin and develop acute ulcer bleeding, aspirin therapy should be restarted as soon as the risk of cardiovascular complication is thought to outweigh the risk of bleeding. (Grade: 1B) Discontinuing aspirin therapy for an extended period increases thrombotic risk in patients who require cardio-protective aspirin therapy. One meta-analysis showed that nonadherence or withdrawal of aspirin therapy is associated with a threefold risk of major adverse cardiac events. According to the American Heart Association, the decision to discontinue aspirin therapy in patients with acute ulcer bleeding should be made on an individual basis. New recommendation: In patients with previous ulcer bleeding who require cardiovascular prophylaxis, clopidogrel (Plavix) alone has a higher risk of rebleeding than aspirin combined with a PPI. (Grade: 1B) Two RCTs showed a significant reduction in rebleeding in patients taking aspirin plus a PPI compared with those receiving clopidogrel alone, although there was no significant effect on mortality. n
n
n
(...Cont’d from page 237) 6. Antoniucci D, Valenti R, Migliorini A, et al. Comparison of rheolytic thrombectomy before direct infarct artery stenting versus direct stenting alone in patients undergoing percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol 2004;93:1033-5.
for acute myocardial infarction: a meta-analysis of randomized trials. Am Heart J 2007;153(3):343-53. 8. Thrombus Aspiration with Export Catheter in ST Elevation Myocardial Infarction. Journal of Interventional Cardiology published online: 30 January 2007.
7. De Luca G, Suryapranata H, Stone GW, Antoniucci D, Neumann FJ, Chiariello M. Adjunctive mechanical devices to prevent distal embolization in patients undergoing mechanical revascularization
9. Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehensive meta-analysis of randomize trials. Eur Heart J 2008;29:2989-3001.
n
242
n
n
Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011