Author + information
- Martine Gilard, MD⁎ (, )
- Jean-Christophe Cornily, MD and
- Jacques Boschat, MD
- ↵⁎Département de Cardiologie, CHU de la Cavale Blanche, Boulevard Tanguy Prigent, 29609 Brest Cedex, France
We thank Dr. Pezalla and colleagues for their interest in our article (1). We are highly interested in the strong link reported between proton pump inhibitor (PPI) use and clinical coronary artery adverse events in patients under clopidogrel therapy, according to their medical and pharmacy databases.
Our study showed that omeprazole significantly decreased the clopidogrel inhibitory effect on platelet P2Y12 as assessed by the vasodilator-stimulated phosphoprotein (VASP) phosphorylation test. This study has opened the way to a clinical validation of this concept. A first step was reached by a report from another French team showing a sensitivity of 100% of the VASP test in predicting major adverse cardiac events (MACE) (2). Moreover, Bonello et al. (3) showed that adjusting the clopidogrel loading dose according to the VASP index, before PCI, in daily clinical practice improved the clinical outcome after coronary stenting.
Data reported in the letter by Dr. Pezalla and colleagues tend to confirm that adding PPI to an antiplatelet therapy with clopidogrel increases MACE.
A strong link seems to exist between clopidogrel–PPI interaction, VASP index, and clinical outcomes. However, some questions remain. Are all PPIs equal? When co-prescription of clopidogrel and PPI is mandatory, what is the best attitude? A VASP test may be performed and clopidogrel dose may be adjusted to obtain a VASP index higher than 50% (4–6). According to Bonello et al. (3), an additional bolus dose of clopidogrel may decrease clinical events, but how long should high doses be maintained?
Additional randomized trials with clinical end points must be performed. Nevertheless, biological data from our randomized double-blind trial, confirmed by clinical results of registries such as the one reported in the letter by Dr. Pezalla and colleagues, should lead us to avoid systematic addition of PPI when clopidogrel is prescribed.
- American College of Cardiology Foundation
- Gilard M.,
- Arnaud B.,
- Cornily J.C.,
- et al.
- Bonello L.,
- Camoin-Jau L.,
- Arques S.,
- et al.
- Schumacher W.A.,
- Bostwick J.S.,
- Ogletree M.L.,
- et al.