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Patients with atrial fibrillation ‘at risk' from outdated aspirin prescribing practice

Aspirin is still being widely prescribed to patients with atrial fibrillation when it offers no benefit and may even be harmful, a leading UK expert on stroke prevention has warned.

Professor Gregory Lip, professor of cardiovascular medicine at the University of Birmingham, said his Europe-wide study showed cardiologists are too often continuing to prescribe aspirin in patients with atrial fibrillation, despite the fact it is no longer recommended in clinical guidelines and could lead to patients suffering serious bleeding events.

For the study, published in the American Journal of Medicine, Professor Lip’s team analysed thrombotic prescribing among 3,119 patients, across nine countries, who had recently been diagnosed with atrial fibrillation.

Of 902 patients admitted to hospital, who did not undergo cardioversion or catheter ablation, 41% were prescribed aspirin either alone or in combination with an anticoagulant.

Aspirin use was particularly common among patients with CHD, whereas the authors stressed that anticoagulation is the best option in patients with stable CHD.

Professor Lip commented: ‘The perception that aspirin is a safe and effective drug for preventing strokes in atrial fibrillation needs to be dispelled.

‘If anything, you could say that giving aspirin to patients with atrial fibrillation is harmful, because it is minimally or not effective, yet the risk of major bleeding or intracranial haemorrhage is not significantly different to well-managed oral anticoagulation.’

He added that contemporary guidelines say that aspirin should not be used for the prevention of stroke in patients with atrial fibrillation.

NICE draft guidance on the management of atrial fibrillation recently brought its advice into line with European Society of Cardiology guidance that aspirin should no longer be prescribed for patients considered at risk of stroke, which should now be determined by their CHA2DS2-VASc score.

However the QOF still uses the CHADS2 score and rewards GPs for putting patients on either aspirin or an anticoagulant, for those with a score of 1.

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Readers' comments (5)

  • Vinci Ho

    This is major change in our culture in prescribing for stroke prophylaxis in AF.
    CHA2DS2-VASc should be used instead .
    Problem is paroxysmal AF with infrequent attacks with a score of 1.....

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  • Until Rat poison is not the only other cost effective choice, aspirin will continue to be looked at as the easier option, though I accept it is not necessarily best practice from the latest evidence.

    Warfarin is not a popular choice with patients for multiple reasons including the hassle of monitoring (Not to mention cost), and the multiple interactions with it, and the risk of under/over treatment and potential side effects.

    Only people with a vested interest in running Warfarin monitoring services see it having any future.

    Once the newer anticoagulation treatments come off patent, and there will be a safe antidote long before then, Warfarin use will become obsolete like bed rest for Heart attacks.

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  • in reply to anonymous: we can't afford to wait that long - and others will say we can't afford not to wait that long....

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  • Dabigatran replaces Warfarin, it does not need the stringent monitoring and has few side effects. I have been taking this many months now, having flatyy refused Warfarin, and my quality fo life has doubled!

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  • Vinci Ho:
    Using Chadsvasc scoring almost eliminates the score of 1 with PAF as most pts score at least 2 and highlights the need to treat pts in PAF the same as pts in persitant or permanent AF.
    The fibrillating atrium can also lead to atrial stasis and abnormalities of haemostasis, platelets and endothelial dysfunction, which confers a hypercoagulable state, present in both permanent and paroxysmal AF.
    Nonvalvular AF confers a substantial risk for stroke and thromboembolism, which is estimated to be between 4.5% and 12% per year, depending on associated risk factors.
    NOACS offer choice and cost evens out once we eliminate the INR monitoring cost.
    Appropriate anti-coagulation of all patients with recognised AF would prevent approximately 4,500 strokes per year and prevent 3,000 deaths.
    A Department of Health cost benefit analysis suggests that for stroke patients with AF there are around:
    • 4,300 deaths in hospital
    • 3,200 discharges to residential care
    • 8,500 deaths within the first year.
    The treatment of AF with oral anticoagulant reduces risk of stroke by 50-70%
    The estimated total cost of maintaining one patient on warfarin for one year, including monitoring, is £483.
    The cost per stroke due to AF is estimated to be £11,900 in the first year after stroke occurrence.

    “Risk of stroke with AF” 2007
    Food for thought.

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