Recent evidence suggests that proton pump inhibitors (PPIs) might be linked with adverse cardiac events, but a causal relationship is unproven.
We applied the self-matched case series method to two studies using population-based health care data from Ontario, Canada between 1996 and 2008. The first included subjects aged 66 years or older hospitalized for acute myocardial infarction within 12 weeks following initiation of PPI, while the second included subjects hospitalized for heart failure. In both studies we designated the primary risk interval as the initial 4 weeks of therapy and the control interval as the final 4 weeks. To test the specificity of our findings we examined use of histamine H2 receptor antagonists and benzodiazepines, drugs with no plausible causal link to adverse cardiac events.
During the 13-year study period, we identified 5550 hospital admissions for acute myocardial infarction and 6003 admissions for heart failure within 12 weeks of commencing PPI therapy. In the main analyses, we found that initiation of a PPI was associated with a higher risk of acute myocardial infarction (odds ratio 1.8; 95% confidence interval 1.7 to 1.9) and heart failure (odds ratio 1.8; 95% confidence interval 1.7 to 1.9). However, secondary analyses revealed similar risk estimates histamine H2 receptor antagonists and benzodiazepines, drugs with no known or suspected association with adverse cardiac events.
PPIs are associated with a short-term risk of adverse cardiac events, but similar associations are seen with other drugs exhibiting no known cardiac toxicity. Collectively these observations suggest that the association between PPIs and adverse cardiac events does not represent reflect cause-and-effect.
Citation: Juurlink DN, Dormuth CR, Huang A, Hellings C, Paterson JM, Raymond C, et al. (2013) Proton Pump Inhibitors and the Risk of Adverse Cardiac Events. PLoS ONE 8(12): e84890. doi:10.1371/journal.pone.0084890
Editor: Antonio Abbate, Virginia Commonwealth University, United States of America
Received: February 1, 2013; Accepted: November 28, 2013; Published: December 27, 2013
Copyright: © 2013 Juurlink et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was supported by a grant from the Canadian Institutes of Health Research to the Canadian Drug Safety and Effectiveness Research Network (CDSERN) and by the Institute for Clinical Evaluative Sciences (ICES), a non-profit research institute funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: Muhammad Mamdani has the following conflicts: he has served on Advisory Boards for Hoffman La Roche, Glaxo Smith Kline, Eli Lilly and Company, Bristol-Myers Squibb, Novartis, Novo Nordisk, AstraZeneca and Pfizer. The authors used the Drug Product and Therapeutic Class Database from Brogan Inc., Ottawa in this study. There are no further patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.
Proton pump inhibitors (PPIs) are among the most widely prescribed medications in North America, with up to a third of older patients in some jurisdictions taking these drugs for treatment of peptic ulcer disease, gastroesophageal reflux or prevention of NSAID gastropathy [1,2]. Although these drugs are generally perceived to be safe, recent reports suggest they may be risk factors for interstitial nephritis, osteoporosis and Clostridium difficile–associated disease [3-5].
A small number of observational studies have also suggested that PPIs might be independently associated with adverse cardiac events [3,4]. A post-hoc analysis of the PLATelet inhibition and patient Outcomes (PLATO) trial reached similar conclusions , although the investigators conducted several supplemental analyses suggesting that the findings were likely to reflect bias or confounding. Indeed, there is little biologic plausibility to support the notion that PPIs might directly cause adverse cardiac events. One ex vivo study found that physiologic concentrations of pantoprazole impaired myocardial contraction in human and rabbit cardiac muscle in a dose-dependent fashion , but healthy volunteers display no overt impairment in left ventricular systolic function following administration of the drug intravenously .
Using population-based healthcare databases, we examined the potential association between PPI use and hospitalization for acute myocardial infarction (AMI) or heart failure (HF).
The study was approved by the institutional review board at Sunnybrook Health Sciences Centre, Toronto, Ontario. For the purposes of this research informed consent was not required. The Institute for Clinical Evaluative Sciences (ICES) is named as a prescribed entity in Section 45 of the Personal Health Information Protection Act (PHIPA - Regulation 329/04, Section 18). Under this designation, ICES can receive and use health information without consent for purposes of analysis and compiling statistical information about the Ontario health care system.
We used the self-matched case-series method described by Farrington8 to explore the temporal association between initiation of PPI therapy and adverse cardiac events (AMI or HF) among Ontario residents aged 66 years and older from January 1, 1996 to December 31, 2008. This approach is increasingly used to explore short-term adverse effects of drug exposure, and is conditional on both exposure and occurrence of the adverse outcome of interest within a predefined period. A major advantage of this design is that patients serve as their own controls, implicitly controlling for fixed patient factors and thereby eliminating unmeasured confounding that can sometimes threaten the validity of case-control and cohort studies.
Prescription drug records were obtained from the Ontario Drug Benefit Claims Database, and information on hospital admissions was collected using the Canadian Institute for Health Information’s Discharge Abstract Database (CIHI-DAD). Demographic information was derived from the Registered Persons Database, which contains an entry for each resident of Ontario who has been issued a health card. Finally, the Ontario Health Insurance Plan Database provided information regarding claims for physician services. These databases are linked anonymously using encrypted health card numbers, and are routinely used to study drug safety [9-11]. For most common cardiovascular diagnoses, the coding quality in the CIHI-DAD is very good to excellent.
Assessment of Exposure and Outcome
We defined the index date as the date of a first prescription for a PPI. We examined the risk of hospitalization for all patients hospitalized for AMI (International Classification of Disease (ICD-9) codes 410, 411, 414 or ICD-10 codes I21, I240, I241, I248, I249, I254) or HF (ICD-9 code 428 and ICD-10 code I50). These codes have been validated previously [12-15]. For patients hospitalized with AMI, we excluded those discharged within 3 days under the assumption that a true AMI was unlikely .
In keeping with the self-matched case series design, we included only those hospitalizations occurring within 12 weeks of initiation of PPI treatment, reasoning that susceptible patients would manifest adverse effects shortly after the start of treatment. For the primary analysis, we excluded patients with a previous hospitalization for AMI or HF within one year preceding the index date. Because AMI and HF are both associated with substantial mortality, we conducted secondary analyses limited to patients who were alive at the end of the 12-week follow-up period.
Additional analyses examined the risk of hospitalization for a cardiac event among patients who had a history of AMI or HF, as they are likely to be at increased risk. For this analysis, we considered a patient to have a history of the condition if there was a hospitalization for either AMI or HF in the 6 to 12 month period preceding the initiation of a PPI. (For this supplementary analysis, we did not include patients hospitalized in the 6 months prior to the start of PPI therapy, because this would have interfered with our ability to reliably ascertain the timing of PPI initiation.)
To test the robustness and specificity of our findings, we conducted several additional analyses. We performed “tracer” analyses using prescriptions for histamine H2 receptor antagonists and benzodiazepines. Neither of these drug classes has a plausible causal link to adverse cardiac events, and we reasoned that a null finding with these drugs would enhance the argument for a cause-and-effect relationship in our main analysis. Finally, we replicated all analyses using risk and reference intervals of two weeks duration rather than four, separated by a washout period of two weeks.
For analytical purposes, we divided each patient’s follow-up into three identical 4-week intervals. The first 4-week period following initiation of a PPI was considered the primary risk interval (Figure 1), during which time admissions for AMI or HF might reflect an unintended consequence of drug therapy. The final 4-week interval defined the control interval; its remoteness from the exposure renders a causal association with drug therapy highly unlikely. The odds ratio of AMI or HF during the risk period compared to the control period was estimated using a fixed-effects logistic regression model that included exposure and control period terms, and an indicator variable for each patient that allowed each individual to serve as his or her own control. These analyses were replicated using a random effects logistic regression model. All analyses were performed using SAS version 9.2 (SAS Institute, Cary, North Carolina)
The observation period for each patient begins with initiation of a proton pump inhibitor (PPI) and continues for 12 weeks. All patients were admitted to hospital for an acute myocardial infarction or heart failure at some point during the 12-week observation period, which for analytical purposes is divided into three identical 4-week intervals. The first of these is the risk interval, and the final interval defined the control interval.
Over the 13-year study period, we identified 5550 hospitalizations for AMI within 12 weeks of the initiation of a PPI. The median age of these patients was 77 years (interquartile range 72 to 82), 49% were female, and 956 (17.2%) died during the 12-week observation period. In the primary analysis, the estimated odds ratio of hospitalization due to AMI during the risk interval compared with the control interval was 1.8 (95% confidence interval 1.7 to 1.9) (Table 1). The risk was slightly accentuated among patients with any history of AMI (estimated odds ratio 2.1; 95% confidence interval 1.6 to 2.7)
|Analysis||Admissions for Cardiac Event during Risk Interval (N)||Admissions for Cardiac Event during Control Interval (N)||Odds Ratio (95% CI)|
|AMI||2595||1439||1.8 (1.7 to 1.9)|
|HF||2713||1534||1.8 (1.7 to 1.9)|
|AMI (excluding deaths)*||2039||1316||1.5 (1.4 to 1.7)|
|HF (excluding deaths)*||1985||1378||1.4 (1.3 to 1.5)|
|History of AMI||175||85||2.1 (1.6 to 2.7)|
|History of HF||204||116||1.8 (1.4 to 2.2)|
We also identified 6003 subjects hospitalized for HF within 12 weeks of initiation of a PPI. The mean age of these patients was 80 years (interquartile range 74 to 85), 55% were female, and 1235 (20.6%) died during follow-up. In the primary analysis, the estimated odds ratio of HF during the first 4 weeks following initiation of a PPI was 1.8 (95% confidence interval 1.7 to 1.9) (Table 1). The risk was similar among patients with a history of HF (estimated odds ratio 1.8; 95% confidence interval 1.4 to 2.2).
We found similar results when we examined the risk of hospitalization for AMI and HF in patients without history of these conditions within 12 weeks of the initiation of histamine H2 receptor antagonists (estimated odds ratio 1.8, 95% CI, 1.7 to 1.9 and 1.5, 95% CI, 1.4 to 1.6, respectively) or benzodiazepines (estimated odds ratio 1.3, 95% CI 1.3 to 1.4 and 1.6, 95% CI 1.5 to 1.7, respectively) (both analyses shown in Table 2).
|Analysis||Admissions for Cardiac Event during Risk Interval (N)||Admissions for Cardiac Event during Control Interval (N)||Odds Ratio (95% CI)|
|H2 receptor antagonists|
|AMI (excluding deaths)||2384||1336||1.8 (1.7 to 1.9)|
|HF (excluding deaths)||1910||1287||1.5 (1.4 to 1.6)|
|AMI (excluding deaths)||2100||1569||1.3 (1.3 to 1.4)|
|HF (excluding deaths)||2782||1760||1.6 (1.5 to 1.7)|
Because some PPIs – omeprazole in particular - can interfere with the bioactivation of clopidogrel [17,18], we performed several post-hoc sensitivity analyses to examine the specificity of our findings. The association between omeprazole use and MI or heart failure (odds ratio 1.6; 95% confidence interval 1.6 to 2.0 for both analyses) was no different than that seen with pantoprazole, which does not alter the response to clopidogrel (AMI odds ratio 1.7; 95% confidence interval 1.4 to 2.0; HF odds ratio 1.7; 95% confidence interval 1.5 to 2.0). And while only 283 subjects in our sample were taking clopidogrel at the time they commenced a PPI, these individuals had no differential risk of AMI (odds ratio 1.6; 95% confidence interval 1.0 to 2.5) or HF (odds ratio 2.2; 95% confidence interval 1.5 to 3.3) relative to patients not taking clopidogrel (odds ratio 1.8; 95% confidence interval 1.7 to 1.9 for both MI and HF).
To test the robustness of our conclusions, we replicated our analyses using a random effects model, which tends to yield less precise estimates relative to fixed effects models. In each instance, the conclusions generated in our primary analysis held (data not shown). Finally, we replicated our analyses using risk, washout and control periods of two weeks each rather than four weeks. In each instance, the results were consistent with our main analysis (Table S1, Table S2, Table S3, Table S4).
Using population-based healthcare records over a 13-year period, we found a nearly two-fold higher risk of hospitalization for AMI or HF following the initiation of a PPI in a large cohort of older Ontarians. These findings accord with other lines of evidence suggesting an association between PPI therapy and cardiac events. However, we also found similar risks with histamine H2 receptor antagonists and benzodiazepines, drugs with no plausible causal link to adverse cardiac events. Collectively, these findings imply that cause-and-effect is an unlikely explanation for the observed association between PPIs and adverse cardiac events.
Protopathic bias may partially explain the observed association between PPIs and adverse cardiac events observed in our study. These drugs are often used to treat peptic ulcer disease and esophagitis, conditions that can cause symptoms that may be confused with those of cardiac ischemia. While this is also true of H2 antagonist therapy, it is less likely to explain the observed association between benzodiazepines and adverse cardiac events. Another important limitation of our study is that we restricted the risk period to the first 4 weeks following the initiation of a PPI, reasoning that this would facilitate the detection of any safety signal if one existed, and also because the often-intermittent nature of PPI therapy would render studies of longer-term follow-up less reliable. Finally, PPIs may be used sporadically, particularly in patients with gastroesophageal reflux. However, this would tend to attenuate any effects in our analyses.
Our study has several notable strengths. We utilized more than a decade of population-based hospital records, studying patients in real-world practice. We employed a self-matched design, implicitly controlling for fixed patient characteristics, unlike other observational designs that are more susceptible to selection bias and unmeasured confounding. Finally, we conducted several sensitivity analyses using other medications, all of which yielded similar results. Some limitations also merit emphasis, including a lack of information on drug dose and adherence, as well as risk factors for cardiovascular disease including obesity and smoking. However, the importance of these limitations is lessened by the self-matched nature of the design.
In summary, in a large population-based study, we found that initiation of PPI therapy was associated with a short-term risk of AMI and HF. However, a risk of similar magnitude was seen with other drugs not suspected of exerting cardiac toxicity, suggesting that the association identified with PPIs is spurious and does not reflect cause-and-effect. These findings should reassure patients and clinicians that use of PPIs when clinically indicated is not associated with adverse cardiac events, even in patients with a history of cardiac disease.
Hospitalization for adverse cardiac events within two weeks of initiation of a proton pump inhibitor (fixed effects logistic regression model).
Hospitalization for adverse cardiac events within two weeks of initiation of a H2 receptor antagonist or benzodiazepine (fixed effects logistic regression model).
Hospitalization for adverse cardiac events within two weeks of initiation of a proton pump inhibitor (random effects logistic regression model).
Risk of hospitalization for an adverse cardiac event following the initiation of a H2 receptor antagonist or benzodiazepine (random effects logistic regression).
We thank Brogan Inc., Ottawa for use of their Drug Product and Therapeutic Class Database.
Conceived and designed the experiments: DNJ CD JMP MMM CH. Performed the experiments: AH. Analyzed the data: DNJ AH CH JMP MMM CR AK YM CD EMM. Wrote the manuscript: DNJ AH CH JMP MMM CR AK YM CD EMM.
- 1. Hungin AP, Rubin GP, O'Flanagan H (1999) Long-term prescribing of proton pump inhibitors in general practice. Br J Gen Pract 49(443): 451-453. PubMed: 10562744.
- 2. van Vliet EP, Otten HJ, Rudolphus A, Knoester PD, Hoogsteden HC et al. (2008) Inappropriate prescription of proton pump inhibitors on two pulmonary medicine wards. Eur J Gastroenterol Hepatol 20(7): 608-612. doi:10.1097/MEG.0b013e3282f52f95. PubMed: 18679061.
- 3. Charlot M, Grove EL, Hansen PR, Olesen JB, Ahlehoff O et al. (2011) Proton pump inhibitor use and risk of adverse cardiovascular events in aspirin treated patients with first time myocardial infarction: nationwide propensity score matched study. BMJ 342: d2690. doi:10.1136/bmj.d2690. PubMed: 21562004.
- 4. Charlot M, Ahlehoff O, Norgaard ML, Jørgensen CH, Sørensen R et al. (2010) Proton-pump inhibitors are associated with increased cardiovascular risk independent of clopidogrel use. Ann Intern Med 153(6): 378-386. doi:10.7326/0003-4819-153-6-201009210-00005. PubMed: 20855802.
- 5. Goodman SG, Clare R, Pieper KS, Nicolau JC, Storey RF et al. (2012) Association of Proton Pump Inhibitor Use on Cardiovascular Outcomes with Clopidogrel and Ticagrelor: Insights from PLATO. Circulation 125 (8): 978-986. doi:10.1161/CIRCULATIONAHA.111.032912. PubMed: 22261200.
- 6. Schillinger W, Teucher N, Sossalla S, Kettlewell S, Werner C et al. (2007) Negative inotropy of the gastric proton pump inhibitor pantoprazole in myocardium from humans and rabbits: evaluation of mechanisms. Circulation 116(1): 57-66. doi:10.1161/CIRCULATIONAHA.106.666008. PubMed: 17576869.
- 7. Schillinger W, Hörnes N, Teucher N, Sossalla S, Sehrt D et al. (2009) Recent in vitro findings of negative inotropy of pantoprazole did not translate into clinically relevant effects on left ventricular function in healthy volunteers. Clin Res Cardiol 98(6): 391-399. doi:10.1007/s00392-009-0012-6. PubMed: 19301059.
- 8. Farrington CP, Nash J, Miller E (1996) Case series analysis of adverse reactions to vaccines: a comparative evaluation. Am J Epidemiol 143(11): 1165-1173. doi:10.1093/oxfordjournals.aje.a008695. PubMed: 8633607.
- 9. Zinman L, Thoma J, Kwong JC, Kopp A, Stukel TA et al. (2009) Safety of influenza vaccination in patients with myasthenia gravis: a population-based study. Muscle Nerve 40(6): 947-951. doi:10.1002/mus.21440. PubMed: 19902540.
- 10. Antoniou T, Gomes T, Juurlink DN, Loutfy MR, Glazier RH et al. (2010) Trimethoprim-sulfamethoxazole-induced hyperkalemia in patients receiving inhibitors of the renin-angiotensin system: a population-based study. Arch Intern Med 170(12): 1045-1049. doi:10.1001/archinternmed.2010.142. PubMed: 20585070.
- 11. Wright AJ, Gomes T, Mamdani MM, Horn JR, Juurlink DN (2011) The risk of hypotension following co-prescription of macrolide antibiotics and calcium-channel blockers. CMAJ 183(3): 303-307. doi:10.1503/cmaj.100702. PubMed: 21242274.
- 12. Lee DS, Donovan L, Austin PC, Gong Y, Liu PP et al. (2005) Comparison of coding of heart failure and comorbidities in administrative and clinical data for use in outcomes research. Med Care 43(2): 182-188. doi:10.1097/00005650-200502000-00012. PubMed: 15655432.
- 13. Jong P, Gong Y, Liu PP, Austin PC, Lee DS et al. (2003) Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists. Circulation 108(2): 184-191. doi:10.1161/01.CIR.0000080290.39027.48. PubMed: 12821540.
- 14. So L, Evans D, Quan H (2006) ICD-10 coding algorithms for defining comorbidities of acute myocardial infarction. BMC Health Serv Res 6: 161. doi:10.1186/1472-6963-6-161. PubMed: 17173686.
- 15. Saczynski JS, Andrade SE, Harrold LR, Tjia J, Cutrona SL et al. (2012) A systematic review of validated methods for identifying heart failure using administrative data. Pharmacoepidemiol Drug Saf 21 (Suppl 1): 129-140. doi:10.1002/pds.2313. PubMed: 22262599.
- 16. Tu JV, Naylor CD, Austin P (1999) Temporal changes in the outcomes of acute myocardial infarction in Ontario, 1992-1996. CMAJ 161(10): 1257-1261. PubMed: 10584086.
- 17. Sibbing D, Morath T, Stegherr J, Braun S, Vogt W et al. (2009) Impact of proton pump inhibitors on the antiplatelet effects of clopidogrel. Thromb Haemost 101(4): 714-719. PubMed: 19350116.
- 18. Angiolillo DJ, Gibson CM, Cheng S, Ollier C, Nicolas O et al. (2011) Differential effects of omeprazole and pantoprazole on the pharmacodynamics and pharmacokinetics of clopidogrel in healthy subjects: Randomized, placebo-controlled, crossover comparison studies. Clin Pharmacol Ther 89(1): 65-74. doi:10.1038/clpt.2010.219. PubMed: 20844485.