Systematic review of long term anticoagulation or antiplatelet treatment in patients with non-rheumatic atrial fibrillation

doi:10.1136/bmj.322.7282.321

BMJ 2001;322:321-326 ( 10 February )

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Systematic review of long term anticoagulation or antiplatelet treatment in patients with non-rheumatic atrial fibrillation

F C Taylor, systematic review training fellow, ^a H Cohen, consultant in haematology, ^b S Ebrahim, professor in epidemiology of ageing. ^c

^a Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW, ^b Department of Haematology, University College London Hospitals, London WC1E 6DB, ^c Department of Social Medicine, Canynge Hall, Bristol BS8 2HU

Correspondence to: F Taylor f.c.taylor{at}bristol.ac.uk

Objective: To examine the benefits and risks of longterm anticoagulation (warfarin) compared with antiplatelet treatment(aspirin/indoprofen) in patients with non-rheumatic atrialfibrillation.
Methods: Meta-analysis of randomised controlled trialsfrom Cochrane library, Medline, Embase, Cinhal, and Sigle from1966 to December 1999. Odds ratios (95% confidence intervals)calculated to estimate treatmenteffects.
Outcome measures: Fatal and non-fatal cardiovascular events,reductions of which were classified as benefits. Fatal and majornon-fatal bleeding events classified asrisks.
Results: No trials were found from before 1989. Therewere five randomised controlled trials published between 1989-99.There were no significant differences in mortality between thetwo treatment options (fixed effects model: odd ratio 0.74 (95%confidence interval 0.39 to 1.40) for stroke deaths; 0.86 (0.63to 1.17) for vascular deaths). There was a borderline significantdifference in non-fatal stroke in favour of anticoagulation (0.68(0.46 to 0.99)); and 0.75 (0.50 to 1.13) after exclusion of onetrial with weak methodological design. A random effects modelshowed no significant difference in combined fatal and non-fatalevents (odds ratio 0.79 (0.61 to 1.02)). There were more majorbleeding events among patients on anticoagulation than on antiplatelettreatment (odds ratio 1.45 (0.93 to 2.27)). One trial was stoppedprematurely after a significant difference in favour of anticoagulationwas observed. The only trial to show a significant differencein effect (favouring anticoagulation) was methodologically weakerin design than theothers.
Conclusions: The heterogeneity between the trials and thelimited data result in considerable uncertainty about the valueof long term anticoagulation compared with antiplatelet treatment.The risks of bleeding and the higher cost of anticoagulation makeit an even less convincing treatmentoption.

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