CYP2C19 loss-of-function alleles and use of omeprazole or esomeprazole increase the risk of cardiovascular outcomes in patients using clopidogrel

Our aim was to investigate in a real-life prospective patient cohort how CYP2C19 loss-of-function (LOF) variants and CYP2C19 inhibitor omeprazole or esomeprazole influence the incidence of cardiovascular events in patients using clopidogrel. Data based simultaneously on these factors are conflicting and sparse. A cohort of prospective patients (n=1972) with acute coronary syndrome (ACS) (n=1302) or symptomatic chronic coronary disease (n=656) was followed for 365 days after hospitalization with information on purchased prescription drugs, hospital discharge, death and genotype for CYP2C19*2, CYP2C19*3, and CYP2C19*8 LOF variants. The primary study outcome measurement was cardiovascular death or recurring myocardial infarction or stroke. Altogether, 608 patients (30.8%) carried CYP2C19 LOF alleles. During the 365-day follow-up 252 patients (12.8%) had an ischemic vascular event. Cardiovascular events were significantly more frequent in carriers of CYP2C19 LOF alleles [14.8% (95% CI, 11.7-17.8)] than in non-carriers [10.8% (95% CI, 9.0-12.6)] (P = .0159). Omeprazole or esomeprazole use was similar among LOF allele carriers (n=131, 21.5%) and non-carriers (n=250, 18.3%) (P = .185). Cardiovascular events were significantly more common in a composite group consisting of all CYP2C19 LOF carriers regardless of PPI use status and non-carriers using omeprazole or esomeprazole than in non-carriers not using omeprazole or esomeprazole: 14.8% (95% CI, 12.2-17.3) vs. 9.9% (95% CI, 8.0-11.9) (P = .00173). We observed significantly more cardiovascular events in carriers of CYP2C19 LOF variants and in non-carriers using omeprazole or esomeprazole. For optimal patient care, both genetics and concomitant medication should be considered.