Aspirin Still Overprescribed for Stroke Prevention in Atrial Fibrillation

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Aspirin is still overprescribed for stroke prevention in atrial fibrillation (AF) despite the potential for dangerous side effects, according to a study published in the American Journal of Medicine.“The perception that aspirin is a safe and effective drug for preventing strokes in AF needs to be dispelled,” said lead author Gregory Y.H. Lip, MD, University of Birmingham, Birmingham, United Kingdom. “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 major bleeding or intracranial haemorrhage is not significantly different to well-managed oral anticoagulation.”
“All the contemporary guidelines say that aspirin should not be used for the prevention of stroke in patients with AF,” he added”. And yet our study shows that aspirin is still overprescribed in these patients.”
Prevention of strokes in patients with AF is based on identification of risk factors. 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 1 or more risk factors should be offered effective stroke prevention, and thus be given an oral anticoagulant. The use of aspirin, either alone or in combination with an oral anticoagulant, is not recommended.
The study 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). The data are from the EORP Atrial Fibrillation General Pilot Registry of more than 3,100 patients in 9 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.
“Novel oral anticoagulant uptake is still a bit low, probably because of differences in regulatory approval, costs and access to drugs in different countries,” said Dr. Lip. “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 8-fold.
“Aspirin is still overused for stroke prevention in AF,” said Dr. Lip. “ESC guidelines say concomitant aspirin should not be given to anticoagulated patients with AF 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 under-prescribed in elderly patients, with aspirin alone more commonly prescribed.
“Elderly patients are at the highest risk for stroke and yet they are given aspirin which is not recommended and potentially harmful,” said Dr. Lip. “There is a perception that elderly patients do not do well on anticoagulation. But a number of studies now, including BAFTA, 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 with patients with permanent AF.
“Cardiologists are continuing to under-prescribe anticoagulation in paroxysmal AF and the belief that these patients are at less risk is another myth,” said Dr. Lip. “ESC guidelines say that AF patients with stroke risk factors should receive oral anticoagulation irrespective of the type of AF. 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.”
SOURCE: European Society of Cardiology