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

John G F Cleland, foundation chair in cardiology,
Gerry C Kaye, consultant cardiologist

School of Medicine, Academic Department of Cardiology, University of Hull, Hull HU16 5JQ
Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham B15 2TT
University Department of Medicine, City Hospital, Birmingham B18 7QH, UK
Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham B15 2TT
School of Pharmacy, Faculty of Health Science, University of Tasmania, GPO Box 252-26, Hobart, Australia 7001
Medical Department, Pharmacia, 20152 Milan, Italy
Herlev University Hospital, DK-2730 Herlev, Denmark
Bispebjeg University Hospital, DK-2400 Copenhagen, Denmark
Division of Neurological Rehabilitation, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark
Guy's, King's and St Thomas' School of Medicine, London SE5 9PJ
Bushey Health Centre, Bushey, Hertfordshire WD23 2NN
Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW
Department of Haematology, University College London Hospitals, London WC1E 6DB
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. 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.)
OpenUrl FREE Full Text
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.
OpenUrl FREE Full Text
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.
OpenUrl CrossRef Medline Web of Science
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

Jonathan Mant, senior lecturer,
David Fitzmaurice, senior lecturer,
Ellen Murray, research fellow,
Gregory Y H Lip, reader in medicine,
F D Richard Hobbs, professor

School of Medicine, Academic Department of Cardiology, University of Hull, Hull HU16 5JQ
Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham B15 2TT
University Department of Medicine, City Hospital, Birmingham B18 7QH, UK
Department of Primary Care and General Practice, Division of Primary Care, Public and Occupational Health, University of Birmingham B15 2TT
School of Pharmacy, Faculty of Health Science, University of Tasmania, GPO Box 252-26, Hobart, Australia 7001
Medical Department, Pharmacia, 20152 Milan, Italy
Herlev University Hospital, DK-2730 Herlev, Denmark
Bispebjeg University Hospital, DK-2400 Copenhagen, Denmark
Division of Neurological Rehabilitation, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark
Guy's, King's and St Thomas' School of Medicine, London SE5 9PJ
Bushey Health Centre, Bushey, Hertfordshire WD23 2NN
Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW
Department of Haematology, University College London Hospitals, London WC1E 6DB
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 …