Deans' stroke musings: Haphazard Aspirin Add-On: Not a Great Risk-Reward Tradeoff for DOAC Users

Changing stroke rehab and research worldwide now.Time is Brain! trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 523 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

My blog is not to help survivors recover, it is to have the 10 million yearly stroke survivors light fires underneath their doctors, stroke hospitals and stroke researchers to get stroke solved. 100% recovery. The stroke medical world is completely failing at that goal, they don't even have it as a goal. Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.

Tuesday, April 20, 2021

Haphazard Aspirin Add-On: Not a Great Risk-Reward Tradeoff for DOAC Users

The real solution is to create a test that identifies EXACTLY which persons are susceptible to bleeding from aspirin rather than these blanket prohibitions. In business you'd be fired for not going directly to and solving the root cause. But I'm not medically trained so don't listen to me.

Haphazard Aspirin Add-On: Not a Great Risk-Reward Tradeoff for DOAC Users

Group suggests deprescribing aspirin with no clear indication

by Nicole Lou, Staff Writer, MedPage Today April 19, 2021

Direct oral anticoagulant (DOAC) users without a clear indication for aspirin were often prescribed combination therapy only to wind up with a higher risk of bleeding and no reduction in thrombotic events, an observational study showed.

People with atrial fibrillation (Afib) or venous thromboembolism (VTE) -- but no recent MI or history of heart valve replacement -- were treated with concomitant aspirin atop their DOAC in 33.8% of cases, making this a "common" phenomenon, according to Jordan Schaefer, MD, of the University of Michigan in Ann Arbor, and colleagues.

Comparison between 1,047 matched pairs revealed that combination and DOAC monotherapy groups differed in some key outcomes over a median 12 months of follow-up:

All bleeding: 31.6 vs 26.0 per 100 patient-years (P=0.01)
Nonmajor bleeding: 26.1 vs 21.7 per 100 person-years (P=0.02)
Major bleeding: 4.95 vs 3.59 per 100 person-years (P=0.09)
Thrombotic events: similar at 2.5 vs 2.3 per 100 patient-years (P=0.80)
Hospitalizations: 9.1 vs 6.5 per 100 patient years (P=0.02)
Mortality: 3.8 vs 3.4 per 100 patient-years (P=0.76)

"Ultimately, while emerging data seem to suggest that anticoagulant monotherapy alone may be sufficient for some patients, further confirmation of these findings is necessary," Schaefer's group wrote in JAMA Internal Medicine.

"Efforts should be made to help clinicians identify and deprescribe ASA [aspirin] for patients taking a DOAC without an indication for ASA," they maintained.

The group had previously shown excess bleeding with combination aspirin and warfarin therapy in patients lacking a clear indication for aspirin.

"It is important to acknowledge that there are numerous patient subgroups and clinical scenarios where the role of combination therapy compared with that of anticoagulant monotherapy has not been sufficiently studied," Schaefer's group noted, citing examples such as people with vascular stents, myeloproliferative neoplasms, poorly controlled vascular risk factors, and thrombophilias.

"In such scenarios, shared decision-making and individualized care should remain standard," they stated.

The study relied on the Michigan Anticoagulation Quality Improvement Initiative for registry data from four anticoagulation clinics in Michigan.

Participants were 3,280 adults with Afib or VTE without a clear indication for aspirin (51.0% men; mean age 68.2). All had started taking a DOAC -- namely apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa), or rivaroxaban (Xarelto) -- in 2015-2019.

Main study results were largely supported by sensitivity analyses such as those that excluded patients with any history of MI, coronary artery disease, or peripheral artery disease; or excluded those who started or stopped aspirin after study enrollment.

Even so, investigators cautioned that the observational nature of the study left room for unmeasured confounding and was unable to capture changes in aspirin use during follow-up. Moreover, the study may not be generalizable to geographic areas outside Michigan.

"Finally, the overall rates of thrombosis and many bleeding subtypes were low. Accordingly, this study is likely underpowered to make conclusions about thrombotic outcomes and outcomes of some bleeding subtypes," according to Schaefer and colleagues.