Lifelong antiplatelet treatment is recommended as secondary prevention in patients who have had a vascular ischemic event. Treatment with proton pump inhibitors reduces the risk of upper gastrointestinal (GI) bleeding associated with antiplatelet therapy. However, current guidelines do not make recommendations regarding the use of these agents, and uptake in practice has been low. Few patients ages 75 or older have been included in trials of antiplatelet treatment, and little is known about bleeding risks and outcomes in older patients.

A population-based cohort study was designed to determine the age-specific risks, time course, and outcomes of bleeding complications in patients receiving antiplatelet agents for the secondary prevention of vascular events. Nearly 3,200 patients who had a first transient ischemic attack, ischemic stroke, or myocardial infarction and received antiplatelet treatment were enrolled in the study. Of these patients, 50% were ages 75 or older.

The risk of nonmajor bleeds wasn't related to age, and the risk of major bleeds didn't increase with age in patients younger than age 70. By contrast, the risk of major bleeds increased sharply in patients older than age 70. Patients 75 years or older had more severe bleeds than younger patients, with a 10 times higher long-term risk of disabling or fatal upper GI bleeds. Also, the risks of major bleeding were more sustained in patients age 75 or older.

The authors provided estimates of the likely effect on older patients of the routine use of proton pump inhibitors on the prevention of major upper GI bleeds. The numbers needed to treat with proton pump inhibitors to prevent one disabling or fatal upper GI bleed over five years was 338 for people younger than 65 years of age, but only 25 for those ages 85 or older.

The authors conclude that age 75 is a reasonable threshold for the coprescription of proton pump inhibitors in patients receiving antiplatelet treatment.

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