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To the Editor: In their retrospective cohort study of concomitant clopidogrel and PPI use, Dr Ho and colleagues¹ reported on the increased risk of adverse outcomes among patients using these agents together after hospitalization for acute coronary events. There were substantial differences in baseline characteristics between those discharged on clopidogrel without PPI and those who were either discharged on clopidogrel and PPI or had a PPI added to clopidogrel therapy during follow-up.

One major risk not reported in the baseline characteristics or identified in the article is tobacco use status. It is estimated that 11% of total global cardiac deaths are related to cigarette smoking.² A significant difference in smoking rates between the cohorts could explain the observed difference in outcomes. Additionally, those individuals who smoke might be more likely to have a PPI prescribed to counter risk factors for peptic ulcer disease in users of clopidogrel and aspirin.

Financial . . . [Full Text of this Article]

Stephen Hayes, MD
hayess@mmc.org
Maine Medical Center
Portland

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