Clopidogrel with proton pump inhibitors: safe or not?

Gastrointestinal (GI) bleeding is a serious complication associated with use of antiplatelet therapy, and proton pump inhibitors (PPIs) are known to be beneficial in decreasing such risk. Several studies in the recent past have suggested concerns regarding interaction between clopidogrel and PPIs, presumably due to inhibition of clopidogrel activity and thus attenuation of its antiplatelet activity. A web-based literature and guidelines search was done using the keywords "clopidogrel," "omeprazole," "proton pump inhibitors" and "interaction." Of the available results, relevant studies (n = 11) were then systematically reviewed and summarized. The studies were categorized based on their retrospective or prospective nature. Most of the retrospective, observational studies suggested a link between the 2; however, recent prospective studies have shown no interaction, as well as a positive influence of PPIs in preventing the GI side effects of antiplatelet therapy. There is currently insufficient clinical evidence to suggest interaction between clopidogrel and PPIs and decision to add PPI therapy to clopidogrel should be guided by its clinical indications rather than as a routine prophylactic measure.

Non-ST-segment elevation myocardial infarction in the setting of sexual intercourse following the use of cocaine and sildenafil.

Acute myocardial infarction (MI) in the setting of sexual intercourse following the concomitant use of cocaine, alcohol, and sildenafil has not been previously reported. We present a case of a middle-aged patient with no previous history of angina pectoris or coronary artery disease who presents with severe ischemic chest pain and an MI induced by cocaine, alcohol, sildenafil, and sexual intercourse.

Positive vasodilator stress ECG with normal myocardial perfusion imaging and its correlation with coronary angiographic findings in African Americans and Hispanics.

BACKGROUND: Ischemic electrocardiographic (ECG) changes during vasodilator stress testing (VST) in the presence of abnormal myocardial perfusion imaging (MPI) are uncommon and are associated with presence of multivessel coronary artery disease (CAD). However, there is a paucity of data regarding the significance of ischemic ECG changes during VST with normal MPI in general, and especially among African Americans and Hispanics. HYPOTHESIS: Ischemic changes during VST with normal MPI are associated with significant CAD. METHODS: A retrospective review was done of 2945 patients undergoing VST. RESULTS: Only 20 patients (0.7%) had positive ECG changes with normal MPI. Their demographics were: 60% Hispanic, 40% African American; 85% female; mean age 63 ± 11 years; history of hypertension 80%, diabetes 50%, and dyslipidemia 75%; smokers 30%; atypical chest pain 60%, and typical chest pain 40%. Of these 20 patients, 12 patients underwent coronary angiography. All 12 had significant CAD; nine (75%) had multivessel disease and 3 (25%) had single-vessel disease. Prevalence of clinical variables and risk factors for CAD were similar among both the groups who did and did not undergo coronary angiography. CONCLUSIONS: Among African Americans and Hispanics, ischemic ECG changes during VST with normal MPI are likely to be associated with significant CAD and may warrant coronary angiography to assess presence and extent of CAD.

Accuracy of the ratio of triglycerides to high-density lipoprotein cholesterol for predicting low-density lipoprotein cholesterol particle sizes, phenotype B, and particle concentrations among Asian Indians.

Asian Indians have unusually high rates of coronary artery disease. Small low-density lipoprotein (LDL) particle predominance (phenotype B) is associated with a fourfold atherogenic risk. This study examined the accuracy of a triglyceride/high-density lipoprotein cholesterol (HDL) ratio of > or =3.8 (determined from the Adult Treatment Panel III guidelines, normal triglycerides <150 mg/dl and HDL >40 mg/dl) for predicting phenotype B in Asian Indians. Fasting blood samples were collected from 150 healthy Asian Indians. LDL size analysis was performed by nuclear magnetic resonance spectroscopy. The triglyceride/HDL cholesterol ratio correlated inversely with the LDL size and positively with the particle concentration. A triglyceride/HDL cholesterol ratio of > or =3.8 had 76% sensitivity, 93% specificity, and 83% positive and 89% negative predictive values for predicting phenotype B.

Differences by age and race/ethnicity in knowledge about hypercholesterolemia.

This investigation sought to identify gaps in patients' knowledge about hypercholesterolemia and lipid-lowering therapy in an inner-city US population. Chart reviews and interviews were conducted for drug-treated hypercholesterolemic patients at 3 hospital-based cardiology practices in Bronx, NY. Univariate and multivariate analyses were used to assess whether race/ethnicity, sex, and age were predictors of knowledge. Subjects (n = 467, age 65.3 years) were 55% female, 38% Hispanic, 32% black, and 25% white. Most recognized hypercholesterolemia as a cause of heart disease (88%) and stroke (76%), although older subjects (>70 years) and Hispanic subjects, particularly non-English speakers, were significantly less likely to know about cardiovascular disease risks associated with hypercholesterolemia. Only 14% recalled their recent cholesterol levels, and recall was significantly lower among black, Hispanic, and older subjects. Overall, 31% expected to require lipid-lowering medications indefinitely in the future, while 66% did not know how long they would need to continue using medications. Blacks and Hispanics were significantly less likely to believe that they would need to continue taking medications indefinitely. Achieved lipid levels and self-reported medication adherence were relatively favorable although were unrelated to knowledge levels. In summary, among hypercholesterolemic patients in an urban population, relatively few knew their own cholesterol levels or expected to require medications indefinitely in the future. Older patients, black and Hispanic patients, and non-English speakers were significantly less likely to have accurate knowledge about hypercholesterolemia. Therefore, patient and community education efforts targeted to specific populations may lead to improved management of hypercholesterolemia in inner-city regions.

Effect of leisure time exercise on high-density lipoprotein cholesterol, its subclasses, and size in Asian Indians.

Asian Indians have a greater prevalence and incidence of coronary artery disease than other ethnic groups, despite similar routine lipid profiles. High-density lipoprotein (HDL) cholesterol, particularly the large subclass, is predominantly associated with coronary artery disease protection. Exercise reduces coronary artery disease risk by improving HDL cholesterol levels. The effect of exercise on HDL cholesterol concentrations, subclasses, and size, measured by nuclear magnetic resonance spectroscopy, was assessed in 388 healthy Asian Indians. Exercise was associated with significantly greater concentrations of total HDL cholesterol, entirely due to significant increases in the cardioprotective large HDL subclass and larger HDL cholesterol particle sizes.

Comparison of high-density and low-density lipoprotein cholesterol subclasses and sizes in Asian Indian women with Caucasian women from the Framingham Offspring Study.

BACKGROUND: Asian Indian women have a higher rate of coronary artery disease (CAD) than do other ethnic groups, despite similar conventional risk factors and lipid profiles. Smaller high-density lipoprotein cholesterol (HDL-C) particle size is associated with reduced cardiac protection or even an increased risk of CAD. Exceptional longevity correlates better with larger HDL-C particle sizes. HYPOTHESIS: Higher rates of CAD among Asian Indian women may partly be explained by the differenes in the prevalence of atherogenic HDL-C and low-density lipoprotein cholesterol (LDL-C) sizes and their subclass concentrations among Asian Indian women compared with Caucasian women. METHODS: We measured HDL-C concentrations and sizes by nuclear magnetic resonance spectroscopy in 119 relatively healthy Asian Indian women and compared them with those of 1752 Caucasian women from the Framingham Offspring Study (FOS). RESULTS: Asian Indian women were significantly younger (47.9 +/- 11.2 vs. 51.0 +/- 10.1 years, p = 0.0001), leaner (body mass index 24.0 +/- 4.7 vs. 26.0 +/- 5.6, p = < 0.0002), less likely to be postmenopausal (32 vs. 54%, p = < 0.0001), or smoke (< 1 vs. 20%, p = < 0.0001); nevertheless, prevalence of CAD was higher in Asian Indian women (4.2 vs. 1%, p = 0.0006). Asian Indian women had similar HDL-C (53 +/- 13 vs. 53 +/- 13 mg/dl, p = 0.99), smaller HDL-C particle size (8.9 +/- 0.35 vs. 9.4 +/- 0.44 nm, p = < 0.0001), higher total cholesterol (209 +/- 40 vs. 199 +/- 42 mg/dl, p = 0.01), and similar triglyceride (120 +/- 77 vs. 108 +/- 110 mg/d, p = 0.24) levels. Low-density lipoprotein cholesterol, particle concentrations and sizes, as well as prevalence of pattern B were similar. CONCLUSIONS: Compared with the FOS, Asian Indian women have significantly smaller overall HDL particle size and similar levels of HDL-C, which may reflect impaired, reverse cholesterol transport. Total cholesterol was higher, whereas triglyceride and LDL-C levels were similar. This may partly explain the higher CAD rates in Asian Indian women. Further large scale, prospective, long-term studies are warranted.

Comparison of levels of large and small high-density lipoprotein cholesterol in Asian Indian men compared with Caucasian men in the Framingham Offspring Study.

Asian Indians have a higher incidence of coronary artery disease (CAD) than do other ethnic groups, despite similar standard risk factors and lipid profiles. The large subclass of high-density lipoprotein (HDL) cholesterol is predominantly associated with protection against coronary artery disease. We compared various lipoprotein concentrations and sizes in 211 healthy Asian Indian men with those in 1,684 Caucasian men from the Framingham Offspring Study as measured by nuclear magnetic resonance spectroscopy. Concentrations of HDL cholesterol were similar in the 2 groups, but concentrations of large HDL cholesterol were lower and concentrations of small HDL cholesterol were significantly higher in Asian Indian than in Caucasian men. HDL particle size was smaller in Asian Indians. Levels of low-density lipoprotein cholesterol, low-density lipoprotein particle size, and prevalence of pattern B were similar in the 2 groups.

Race, ethnicity, and sociocultural characteristics predict noncompliance with lipid-lowering medications.

BACKGROUND: Sociocultural factors that predict noncompliance with lipid-lowering medications are not well understood. METHODS: Interviews and medical record review were conducted for 510 patients treated with lipid-lowering medications. Compliance with lipid-lowering medications was measured by patients' self-assessment of medication-taking practices. RESULTS: Adjusted for age and sex, there was a higher frequency of noncompliance among Black and Hispanic subjects. Adjusted for age, sex, and race/ethnicity, noncompliance was associated with medication side effects, feelings of sadness or depression, fair or poor health status, primary use of a language other than English, single or divorced status, fewer and less frequent contact with friends, children in the household, and lower education. Independent predictors of noncompliance in multivariate models were side effects (OR = 3.9, P < 0.01), sadness or depression (OR = 1.9, P = 0.05), Black (OR = 3.7, P < 0.01, vs. White), Hispanic (OR = 6.3, P < 0.01, vs. White), single or divorced (OR = 2.1, P < 0.01), children in the household (OR = 1.5 per child, P < 0.01), and lack of health insurance (OR = 2.4, P = 0.05). CONCLUSIONS: Unmarried status, feelings of sadness or depression, lack of insurance, and children in the household were independently associated with poorer compliance with lipid-lowering medications in this urban population. Nonetheless, higher noncompliance among minority patients persisted independently of these and other specific social, cultural, and economic factors.

Aortic sclerosis--a marker of coronary atherosclerosis.

Aortic valve sclerosis is defined as calcification and thickening of a trileaflet aortic valve in the absence of obstruction of ventricular outflow. Its frequency increases with age, making it a major geriatric problem. Of adults aged > 65 years, 21-29% exhibit aortic valve sclerosis. Incidence of aortic sclerosis increases with age, male gender, smoking, hypertension, high lipoprotein (Lp) (a), high low-density lipoprotein (LDL), and diabetes mellitus. Aortic valves affected by aortic sclerosis contain a higher amount of oxidized LDL cholesterol and show increased expression of metalloproteinases. Clinically, it can be suspected in the presence of soft ejection systolic murmur at the aortic area, normal split of the second heart sound, and normal volume carotid pulse, but it can be best detected by echocardiography. Aortic sclerosis may be accompanied by mitral annulus calcification up to 50% of cases. It is associated with an increase of approximately 50% in the risk of death from cardiovascular causes and the risk of myocardial infarction. The mechanism by which aortic sclerosis contributes to or is associated with increased cardiovascular risk is not known. Aortic sclerosis is associated with systemic endothelial dysfunction, and a small percentage of cases may progress to aortic stenosis. Lowering of LDL cholesterol by 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors have been shown to decrease progression of aortic valve calcification. Aortic sclerosis is not a mere benign finding. Once diagnosis of aortic sclerosis has been made, it should be considered a potential marker of coexisting coronary disease. Aggressive management of modifiable risk factors, especially LDL cholesterol lowering, may slow progression of the disease.

Association of heart rate response with scan and left ventricular function on adenosine myocardial perfusion imaging.

To evaluate the association of heart rate (HR) response with abnormal scan and/or left ventricular (LV) function in patients undergoing adenosine myocardial perfusion imaging, we retrospectively studied 188 consecutive patients who underwent a standard adenosine stress test (without exercise) and myocardial perfusion imaging (MPI) using technetium-99m sestamibi radioisotope. Change in HR was calculated by subtracting HR at rest from peak HR. The percentage change in HR was calculated. All patients underwent stress and resting single-photon emission computed tomography (SPECT) imaging. LV ejection fraction (EF) was calculated using gated SPECT. Mean age was 60 +/- 12 years and 135 of the patients (72%) were women. We divided the patients into 2 groups: group 1 (142 patients, 75%) had normal scans and group 2 (46 patients, 25%) had abnormal scans; abnormal scans were defined as presence of either fixed defects, reversible defects, or both. Average HR increased by 29 beats/min in the normal scan group compared with 19 beats/min in the abnormal scan group (p = 0.0004). Forty-seven patients (25%) had reduced EF (<45%). This group had an average HR and percentage HR increase of 20 beats/min (29%) compared with an increase of 29 beats/min (44%) in patients with normal EF (p = 0.002 and p = 0.002, respectively). Thus, a diminished HR response had a significant association with both an abnormal scan and reduced EF on adenosine MPI.