Letter

Long term anticoagulation or antiplatelet treatment

BMJ 2001; 323 doi: 10.1136/bmj.323.7306.233/a (Published 28 July 2001)
Cite this as: BMJ 2001;323:233.2

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Only warfarin has been shown to reduce stroke risk in patients with atrial fibrillation

  1. John G F Cleland, foundation chair in cardiology,
  2. Gerry C Kaye, consultant cardiologist
  1. School of Medicine, Academic Department of Cardiology, University of Hull, Hull HU16 5JQ
  2. Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham B15 2TT
  3. University Department of Medicine, City Hospital, Birmingham B18 7QH, UK
  4. Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham B15 2TT
  5. School of Pharmacy, Faculty of Health Science, University of Tasmania, GPO Box 252-26, Hobart, Australia 7001
  6. Medical Department, Pharmacia, 20152 Milan, Italy
  7. Herlev University Hospital, DK-2730 Herlev, Denmark
  8. Bispebjeg University Hospital, DK-2400 Copenhagen, Denmark
  9. Division of Neurological Rehabilitation, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark
  10. Guy's, King's and St Thomas' School of Medicine, London SE5 9PJ
  11. Bushey Health Centre, Bushey, Hertfordshire WD23 2NN
  12. Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW
  13. Department of Haematology, University College London Hospitals, London WC1E 6DB
  14. Department of Social Medicine, University of Bristol, Bristol BS8 2HU

    EDITOR—The conclusions of Taylor et al about the use of aspirin for atrial fibrillation are misleading and potentially dangerous for clinical practice.1

    Firstly, when considering anticoagulation or aspirin for the management of heart failure it is appropriate first to compare each against placebo. Overall, aspirin has no effect compared with placebo in preventing thromboembolic events or death among patients with atrial fibrillation, whereas warfarin exerts a significant reduction in both outcomes compared with placebo.2

    Secondly, Taylor et al excluded a key study, stroke prevention in atrial fibrillation (SPAF) III, from their analysis.3 This study showed that full dose warfarin versus low dose warfarin combined with aspirin exerted a significantly greater reduction in stroke (1.7% v 5.6%; P=0.0007) with a trend to reduced total mortality (5.9% v 7.2%).3

    Thirdly, the BMJ has previously published the mortality data from the aspirin (28 deaths) and placebo (30 deaths) arms of the AFASAK study, allowing mortality in the warfarin arm (13 deaths) to be calculated.4 Thus, the all cause mortality data from AFASAK is available contrary to the assertions of Taylor et al. Only warfarin has been shown to reduce the risk of stroke in atrial fibrillation, and only warfarin seems to reduce mortality in patients with atrial fibrillation. If the risk associated with atrial fibrillation is considered low enough to warrant treatment with aspirin then there is insufficient evidence to recommend any antithrombotic treatment at all.

    Footnotes

    • Competing interests None declared.

    References

    1. 1.↵
      1. Taylor FC,
      2. Cohen H,
      3. Ebrahim S
      .Systematic review of long term anticoagulation or antiplatelet treatment in patients with non-rheumatic atrical fibrillation.BMJ2001;322: 321–326. (10 February.)
      OpenUrlFREE Full Text
    2. 2.↵
      1. Cleland JGF,
      2. Cowburn PJ,
      3. Falk RH
      .Should all patients with atrial fibrillation receive warfarin? Evidence from randomised clinical trials.Eur Heart J1996;17:674–681.
      OpenUrlFREE Full Text
    3. 3.↵
      1. McBride R
      .Adjusted-dose warfarin versus low-intensity, fixed doses warfarin plus aspirin for high-risk patients with atrial fibrillation: stroke prevention in atrial fibrillation III randomised clinical trial.Lancet1996;348:633–638.
      OpenUrlCrossRefMedlineWeb of Science
    4. 4.↵
      1. The Antiplatelet Trialists' Collaboration Collaborative overview of randomised trials of antiplatelet therapy—1: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients
      .BMJ1994;308:81–106.

    Inclusion criteria determine results of review

    1. Jonathan Mant, senior lecturer,
    2. David Fitzmaurice, senior lecturer,
    3. Ellen Murray, research fellow,
    4. Gregory Y H Lip, reader in medicine,
    5. F D Richard Hobbs, professor
    1. School of Medicine, Academic Department of Cardiology, University of Hull, Hull HU16 5JQ
    2. Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham B15 2TT
    3. University Department of Medicine, City Hospital, Birmingham B18 7QH, UK
    4. Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham B15 2TT
    5. School of Pharmacy, Faculty of Health Science, University of Tasmania, GPO Box 252-26, Hobart, Australia 7001
    6. Medical Department, Pharmacia, 20152 Milan, Italy
    7. Herlev University Hospital, DK-2730 Herlev, Denmark
    8. Bispebjeg University Hospital, DK-2400 Copenhagen, Denmark
    9. Division of Neurological Rehabilitation, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark
    10. Guy's, King's and St Thomas' School of Medicine, London SE5 9PJ
    11. Bushey Health Centre, Bushey, Hertfordshire WD23 2NN
    12. Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW
    13. Department of Haematology, University College London Hospitals, London WC1E 6DB
    14. Department of Social Medicine, University of Bristol, Bristol BS8 2HU

      EDITOR—We agree with Taylor et al that questions remain unanswered over the relative benefits of anticoagulation and antiplatelet treatment for non-rheumatic atrial fibrillation.1 Uncertainty remains over the optimum treatment of elderly patients, who were underrepresented in the anticoagulation trials, and in whom pathophysiological reasons and empirical evidence suggest higher risk of haemorrhage on warfarin.2 There is …

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