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Reply to ‘Screening for Helicobacter pylori infection in patients with cardiovascular and gastrointestinal disease’

Nature Reviews Cardiology volume 21, pages 594–595 (2024)Cite this article

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We appreciate the interest by Jonatan Wärme and colleagues (Wärme, J. et al. Screening for Helicobacter pylori infection in patients with cardiovascular and gastrointestinal disease. Nat. Rev. Cardiol. https://doi.org/10.1038/s41569-024-01028-8, 2024)1 in our Review (Talasaz, A. H. et al. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat. Rev. Cardiol. https://doi.org/10.1038/s41569-024-01003-3, 2024)2. They propose that routine H. pylori screening and eradication might be a modifiable risk factor for gastrointestinal bleeding (GIB) in patients receiving antithrombotic agents. We find this hypothesis interesting and plausible but, for the reasons outlined below, we have reservations about consideration of H. pylori as an actionable treatment target to reduce the risk of bleeding in these patients.

Our reservations are largely related to the scarcity of high-quality data to show that the screening approach can both be used to identify individuals with a clinically important excess risk of bleeding in adjusted analyses of patients receiving antithrombotic agents (including anticoagulants) and is something to act on using proven tools that, when implemented, reduce the risk of bleeding. The assertion that H. pylori infection increases the risk of GIB is plausible but uncertain. One reference provided by Wärme et al. for this statement is for a retrospective cohort study in 1,719 patients with peptic ulcer bleeding and uncomplicated peptic ulcer disease diagnosed by endoscopy who were identified in the digital archive of a single hospital in Germany over a 10-year period3. H. pylori-positive status was associated with an increased risk of peptic ulcer bleeding in patients receiving aspirin (odds ratio 2.23) but not among those receiving anticoagulants3. The study, although interesting, has limitations with internal and external validity3. The other reference is a meta-analysis on the effect of H. pylori infection on the incidence of peptic ulcers in patients receiving low-dose aspirin4. Although the reported odds ratio for peptic ulcers in patients who were receiving low-dose aspirin and who were H. pylori-positive compared with those who were H. pylori-negative was 1.68 (95% CI 1.40–2.02)4, the annual risk of bleeding from a peptic ulcer was reported in another meta-analysis to be only 1%5, indicative of a low magnitude of risk.

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References

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  2. Talasaz, A. H. et al. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat. Rev. Cardiol. https://doi.org/10.1038/s41569-024-01003-3 (2024).

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Acknowledgements

B.B. was supported by the Scott Schoen and Nancy Adams IGNITE Award and is supported by the Mary Ann Tynan Research Scientist award from the Mary Horrigan Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital, and the Heart and Vascular Center Junior Faculty Award from Brigham and Women’s Hospital.

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Authors and Affiliations

  1. Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA

    Azita H. Talasaz

  2. Department of Pharmacy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA

    Azita H. Talasaz

  3. Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA

    Azita H. Talasaz

  4. Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Behnood Bikdeli

  5. Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Behnood Bikdeli

  6. Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA

    Behnood Bikdeli

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  1. Azita H. Talasaz
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  2. Behnood Bikdeli
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Correspondence to Behnood Bikdeli.

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Competing interests

B.B. reports that he was a consulting expert, on behalf of the plaintiff, for litigation related to two specific brand models of inferior vena cava (IVC) filters. B.B. has not been involved in the litigation in 2022–2024 nor has he received any compensation in 2022–2024. B.B. reports that he is a member of the Medical Advisory Board for the North American Thrombosis Forum and serves in the Data Safety and Monitory Board of the NAIL-IT trial funded by the National Heart, Lung, and Blood Institute, and Translational Sciences. B.B. is a collaborating consultant with the International Consulting Associates and the US Food and Drug Administration in a study to generate knowledge about utilization, predictors, retrieval and safety of IVC filters. Unrelated to this article, B.B. is supported by a Career Development Award from the American Heart Association and VIVA Physicians (#938814). A.H.T. declares no competing interests.

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Talasaz, A.H., Bikdeli, B. Reply to ‘Screening for Helicobacter pylori infection in patients with cardiovascular and gastrointestinal disease’. Nat Rev Cardiol 21, 594–595 (2024). https://doi.org/10.1038/s41569-024-01029-7

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