Prevention of Gastrointestinal Bleeding in Patients With Severe Ischemic Heart Disease

Inclusion Criteria: * patients admitted for acute coronary syndrome or acute myocardial infarction requiring active treatment with aspirin clopidogrel and (enoxaparin or thrombolytics.) Exclusion Criteria: * known active peptic ulcer disease or gastrointestinal within 8 wk * known iron deficiency anemia with Hb \< 10 gm/dl * mechanical ventilation * active cancer, liver cirrhosis, end-stage renal failure * life expectancy \< 1 yr * known allergic to aspirin, clopidogrel, enoxaparin famotidine or esomeprazole * pregnancy, lactation, child-bearing potential in the absence of contraception, * co-prescription of NSAID, corticosteroid, or warfarin * non-oral feeding or impaired GI absorption e.g. vomiting * already on proton pump inhibitor for \> 1 day or another clinical trial drug for ulcer disease