
Quick relief from acute heartburn and its chronic cousin GERD is a good thing. But is it worth risking a heart attack? 
                      
                    
                    
That's the devil's choice that millions of 
Americans may be making   without realizing it. A large new "big data" 
study finds a strong   statistical link between 
proton pump inhibitors
 (PPIs) such as   Prilosec, Prevacid and Nexium (and their generic 
versions) and heart   attacks. It's big news because PPIs are the third 
most popular   prescription drugs and the second most popular 
over-the-counter drugs in   the country...used by 21 million Americans. 
And the increased risk for   heart attacks is not just to people with 
heart conditions or those   taking certain medications, but to 
everyone, healthy or sick, young or old.
                    
A CHORUS OF MEDICAL CONCERNS OVER PPIs--SUDDENLY LOUDER
PPIs, which temporarily turn off the body's ability to make stomach acid, reducing symptoms of 
gastroesophageal reflux disease
 (GERD) and other medical conditions, have been raising safety concerns 
for years. They interfere with the body's ability to absorb nutrients, 
increase the risk for fractures and make it difficult to treat 
gastrointestinal infections such as 
C. difficile.
                    
                    There has been ongoing concern about PPIs and the heart, too, but mostly for people who already 
have heart disease. Doctors have known for a long time that people who take both the blood thinner 
clopidogrel
 (Plavix) and PPIs are at higher risk for heart attacks and stroke. They
   suspected that PPIs blocked an enzyme that allows clopidogrel to do 
its   job.
                    But other researchers worried that the heart 
risks were broader.   There was a whisper in the data that suggested 
that even people 
not taking blood thinners were at increased 
heart risk. So the researchers   designed the latest study. And what has
 come back from the data was less   like a whisper and more like...a 
roar.
                    
A NEW DATA-MINING APPROACH FINDS A RISK THAT OTHER STUDIES MISSED
                    This new study was conducted using a "data-mining" 
method to search   through two large databases that contained the 
medical records of more   than three million patients. These included 
patients treated in doctor's   offices around the country as well as 
patients treated at Stanford   University Medical Center.
                    First, they identified adults diagnosed with 
GERD. Then they examined   their medical records to see whether they had
 received one of two main   types of acid-suppressing medication. Some 
are by prescription only,   others over-the-counter, and some are 
available both ways...
                    
- PPIs: Omeprazole (such as Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium), rabeprazole (AcipHex) and dexlansoprazole (Kapidex).
- Histamine blockers: Cimetidine (such as Tagamet), 
famotidine (Pepcid), 
nizatidine (Axid) and 
ranitidine (Zantac).
                    They excluded anyone taking the blood thinner 
clopidogrel. Then they   compared the patients with others who had GERD 
but did not take either   of these two classes of medication. These 
controls were matched to the   drug takers based on age, gender, length 
of follow-up and other   variables. Finally, the researchers looked for 
diagnosis codes in the   medical records of both GERD patients and 
controls indicating that they   had had heart attacks sometime after 
starting either sort of medication.
                    The researchers used two different databases, but
 each one showed a   similar result--PPIs increased heart attack risk 
substantially....
                    - PPI use overall was associated with 16% to 19% greater chance of heart attack.
                    - PPI use by people 55 or younger was associated with 25% to 40% increased risk.
                    - Among all the drugs, pantoprazole had the 
strongest association   with increased heart attack risk, a 34% higher 
risk when averaged across   age groups.
                    - Esomeprazole had the weakest association with increased heart attack risk--8% higher risk.
                    - Histamine blocker use was 
not associated with increased heart attack risk in either set of data.
                    Then the researchers looked at the data from the 
other side. Instead   of looking at people who took these GERD drugs, 
they looked at those who   had had coronary angiograms after having 
abnormal cardiac stress tests,   chest pain or shortness of 
breath--indicating the probability of heart   disease. Amongst these 
cardiac patients, after adjusting for all known   risk factors, those 
who had used PPIs had 
double the risk of dying from a cardiovascular cause such as a heart attack, heart failure or stroke compared
   with cardiac patients who hadn't used PPIs. Again in this case,   
histamine blockers were not associated with increased risk.
                    
All of these results, whether 
reached by looking   first for people who took PPIs or first for people 
who had heart   trouble, look like very bad news for the safety of PPIs!
TAKING PPIs? WHAT TO DO NOW
                    How might PPIs damage the cardiovascular system? 
The researchers note   that these drugs suppress an enzyme needed for 
the body to make nitric   acid, which relaxes and protects arteries and 
veins. In short, PPIs may   lead to constriction of blood vessels, 
causing heart disease.
                    It's not proof, to be sure. Like any statistical 
study, even this   large study can show only an association. The 
researchers acknowledged   that their analysis didn't account for 
several factors, including use of   other types of over-the-counter 
drugs and the presence of other medical   conditions, that could 
contribute to risk for heart attacks. They note   that future 
epidemiological studies may find different risk percentages,   so 
comparing one PPI to another isn't an exact science. But they   
emphasize that their analysis indicates that there is 97.5% chance that 
  the PPI/heart attack association they identified is real.
                    Some day, a large, randomized, placebo-controlled
 study with   thousands of patients may be powerful enough to prove (or 
disprove) that   PPIs cause heart attacks. But you don't have to wait to
 protect   yourself whether you have GERD or are using a PPI for any 
other   condition. PPIs are prescribed for many conditions besides 
heartburn,   such as stomach ulcers, including those caused by 
H. pylori
 bacteria and those brought on by chronic use of nonsteroidal   
anti-inflammatories (for arthritis pain, for example)...Crohn's   
disease...and complications of certain gastrointestinal cancers such as 
  Zollinger-Ellison syndrome. If your doctor has prescribed a PPI to you
   for a specific medical condition other than GERD, make it a point to 
  have a discussion about whether there are alternate approaches worth  
 exploring now.
                    
If it's GERD, there are safer 
ways to get relief.   Even before this study, the official advice was to
 use PPIs for no more   than two weeks at a time or for more than three 
times in a year. But   once you stop taking them, your stomach may 
respond by temporarily   making even more acid than before, so your 
symptoms might get worse. In   other words, it's easy to get hooked. 
It's also possible that your GERD   got worse while you were on PPIs for
 a long time--they don't cure GERD or   stop its progression. 
Whether you have taken PPIs or not, a lifestyle approach to managing GERD is key...
                    -  Cut back on coffee and other sources of caffeine.
                    - Cut back on fatty foods.
                    - Eat smaller, more frequent meals rather than a few one large ones
                    - Cut back on alcohol.
                    - Wait three hours after eating and drinking before lying down.
                    - Elevate the head of your bed so that gravity keeps stomach acid in your stomach.
                    - Lose weight if you need to.
                    - Don't smoke.