Maagbescherming bij vaatbescherming?

Abstract

Otten MH. Stomach Protection for Vascular Protection. Huisarts Wet 2007;50(5):210-4. Daily intake of low-dose acetylsalicylic acid (ASA) is an established recommendation for prevention of cardiovascular ischaemic events. Its drawback lies in substantial side effects such as dyspepsia (28%) and gastro-intestinal (GI) bleeding (2.7%). The side effects are mainly caused by inhibition of cyclo-oxygenase (COX I) in the mucosa of the digestive tract. Clopidogrel (Plavix) is known to give better secondary cardiovascular prevention, fewer side effects and it does not inhibit COX I. For this reason it has been regarded over the years as an attractive alternative to ASA and, at the same time, less damaging for the gastric mucosa. Recently, however, it has been reported that clopidogrel may also induce the risk of GI bleeding. A possible explanation is the reduced healing of silent gastric background ulcers. Patients with a history of bleeding have somewhat similar annual re-bleeding rates with ASA (15%) and clopidogrel (12%). These findings suggest that in cases of an increased risk profile for GI bleeding, whether with ASA or clopidogrel, adequate prophylaxis with a proton pump inhibitor must be given. This is especially warranted when the combination of ASA and clopidogrel is used after an acute coronary syndrome or percutaneous coronary intervention with or without stent placement. However, it is irrational to conclude that clopidogrel would no longer be indicated in cases of gastro-intestinal complications. The true indication for clopidogrel is not to reduce GI bleeding but to provide better secondary prevention for cardiovascular ischaemic events.