Aspirin still overprescribed for stroke prevention in atrial fibrillation

January 28, 2014

Aspirin is still overprescribed for stroke prevention in atrial fibrillation (AF) despite the potential for dangerous side effects, according to research published today.

Professor Gregory Y.H. Lip, lead author of the European Society of Cardiology (ESC) study, said: "The perception that is a safe and effective drug for preventing strokes in AF needs to be dispelled. If anything, you could say that giving aspirin to patients with AF is harmful because it is minimally or not effective at stroke prevention, yet the risk of or intracranial haemorrhage is not significantly different to well-managed oral anticoagulation."

He added: "All the contemporary guidelines1 say that aspirin should not be used for the prevention of stroke in patients with AF. And yet our study shows that aspirin is still overprescribed in these patients."

Stroke prevention is central to the management of patients with AF. As the most common cardiac rhythm disorder, AF occurs in 1.5-2% of the general population in the developed world and people over the age of 40 have a 1 in 4 lifetime risk of developing AF.2 Patients with AF have a five-fold risk of stroke, and when they do have strokes they lead to more death and disability.3

Prevention of strokes in patients with AF is based on identification of .2 Patients with no stroke risk factors (ie. CHA2DS2-VASc score of 0 in males or 1 in females) are considered 'low risk' and do not need any antithrombotic drugs. Patients with one or more risk factors should be offered effective stroke prevention, and thus be given an oral anticoagulant (warfarin or one of the novel oral anticoagulants). The use of aspirin, either alone or in combination with an oral anticoagulant, is not recommended.

The study published online today in the American Journal of Medicine provides the most up-to-date picture of European cardiologists' prescribing of antithrombotic treatment, which includes oral anticoagulation therapy (warfarin and the novel oral anticoagulants) and antiplatelet drugs (mainly aspirin).4 The data are from the EORP Atrial Fibrillation General Pilot Registry of more than 3 100 patients in nine countries.

Overall the study found that the use of oral anticoagulants has improved over the last decade since the last Euro Heart Survey was performed. Where oral anticoagulation was used, most patients (72%) were prescribed warfarin and just 8% were prescribed a new oral anticoagulant.

Professor Lip said: "Novel oral anticoagulant uptake is still a bit low, probably because of differences in regulatory approval, costs and access to drugs in different countries. But the main point is that overall oral anticoagulant uptake as a whole has improved in the last 10 years."

Aspirin was commonly prescribed, either alone or in combination with an oral anticoagulant, when patients had myocardial infarction or coronary artery disease. The strongest reason to prescribe both drugs was coronary artery disease, which increased the use of combined therapy by more than eight-fold.

Professor Lip said: "Aspirin is still overused for in AF. ESC guidelines say concomitant aspirin should not be given to anticoagulated AF patients with stable vascular disease. The combination of drugs does not reduce cardiovascular events and stroke but does increase the risk of bleeding."

Another worrying finding was that oral anticoagulants were underprescribed in , with aspirin alone more commonly prescribed. Professor Lip said: "Elderly patients are at the highest risk for stroke and yet they are given aspirin which is not recommended and potentially harmful. There is a perception that elderly patients do not do well on anticoagulation. But a number of studies now, including BAFTA,5 have shown that in elderly patients warfarin is far superior to aspirin in preventing stroke."

Patients with paroxysmal AF were less likely to receive oral anticoagulation compared to patients with permanent AF. Professor Lip said: "Cardiologists are continuing to underprescribe anticoagulation in paroxysmal AF and the belief that these patients are at less risk is another myth. ESC guidelines say that AF with stroke risk factors should receive irrespective of the type of AF."

Professor Lip concluded: "Our study of antithrombotic prescribing by cardiologists reveals a positive trend of increasing oral anticoagulant use. But worrying misconceptions and practices remain regarding aspirin, treatment of the elderly and paroxysmal AF."

Explore further: CHADS2 risk score assigns over one-third of stroke patients to low or intermediate stroke risk

More information: 1. Guidelines which advocate oral anticoagulation therapy for stroke prevention in AF and do not recommend aspirin have been published by the ESC, the Asia Pacific Heart Rhythm Society and most recently the UK National Institute for Health and Care Excellence (NICE) (draft version – see guidance.nice.org.uk/CG/Wave0/ … /Consultation/Latest).

2. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. Eur Heart J. 2012;33:2719.

3. Guidelines for the management of atrial fibrillation. Eur Heart J. 2010;31:2369.

4. Lip GYH, Laroche C, Dan GA, Santini M, Kalarus Z, Rasmussen LH, Popescu MI, Tica O, Boriani G, Cimaglia P, Hellum CF, Mortensen B, Maggioni AP. Antithrombotic treatment in 'real-world' patients with atrial fibrillation: A report from the Euro Observational Research Programme Pilot survey on Atrial Fibrillation. American Journal of Medicine. www.sciencedirect.com/science/ … ii/S0002934314000692

5. Mant J, Hobbs FD, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, Murray E; BAFTA investigators; Midland Research Practices Network (MidReC). Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007;370(9586):493-503.

Related Stories

CHADS2 risk score assigns over one-third of stroke patients to low or intermediate stroke risk

September 1, 2013
The CHADS2 stroke risk scores 0 or 1 assign more than one-third of patients in atrial fibrillation with stroke to low or intermediate risk not mandating oral anticoagulation, according to research presented at ESC Congress ...

Anticoagulation in patients with atrial fibrillation undergoing coronary stent implantation

September 2, 2013
A new article in the September 2013 issue of Thrombosis and Haemostasis strives to shed light on the optimal antithrombotic strategy in patients suffering from atrial fibrillation who undergo coronary stent implantation. ...

Management of atrial fibrillation still suboptimal in Europe

December 19, 2013
Results for a pilot registry on the management and treatment of atrial fibrillation (AF) in Europe were presented yesterday by the European Society of Cardiology (ESC). AF is the commonest cardiac rhythm disorder and each ...

GPs undertreat women with AF

September 1, 2013
General practitioners (GPs) undertreat women with atrial fibrillation (AF), according to research presented at ESC Congress 2013 today by Dr Pierre Sabouret from France. The analysis of more than 15,000 patients showed that ...

Omission of aspirin from antiplatelet regimen: The WOEST study

August 28, 2012
Lifelong anticoagulation is necessary for the prevention of stroke in patients with rhythm disturbances and with mechanical valves. Patients who have a coronary stent implanted also need the antiplatelet drugs aspirin and ...

Personalized AF management needed to close mortality gap

August 27, 2013
Personalised management is the only way to close the mortality gap for patients with atrial fibrillation (AF), according to an ESC consensus paper presented at ESC Congress 2013 by Professor Paulus Kirchhof (UK).

Recommended for you

Two studies support intensive blood pressure control for long-term health, quality of life

August 23, 2017
Two studies provide additional support for lowering systolic blood pressure to an intensive goal of 120 mmHg - far below the standard guidelines of 140 mmHg - to reduce the risk of heart disease in high-risk patients with ...

Brain activity may be predictor of stress-related cardiovascular risk

August 23, 2017
The brain may have a distinctive activity pattern during stressful events that predicts bodily reactions, such as rises in blood pressure that increase risk for cardiovascular disease, according to new proof-of-concept research ...

Dramatic new studies into inflammation in the infarcted heart could lead to changes in therapy

August 23, 2017
A medical research collaborative has demonstrated that the response of the human heart to an infarction is very different than previously thought. The study, led by cardiologist Borja Ibáñez and published as two independent ...

'Shapeshifter' that regulates blood clotting is visually captured for the first time

August 23, 2017
We are normally born with a highly sophisticated array of molecules that act as "sentries," constantly scanning our bodies for injuries such as cuts and bruises. One such molecular sentry, known as von Willebrand factor (VWF), ...

New molecule may hold the key to triggering the regeneration and repair of damaged heart cells

August 21, 2017
New research has discovered a potential means to trigger damaged heart cells to self-heal. The discovery could lead to groundbreaking forms of treatment for heart diseases. For the first time, researchers have identified ...

Researchers investigate the potential of spider silk protein for engineering artificial heart

August 18, 2017
Ever more people are suffering from cardiac insufficiency, despite significant advances in preventing and minimising damage to the heart. The main cause of reduced cardiac functionality lies in the irreversible loss of cardiac ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.