Don’t add aspirin for associated stable vascular disease in a patient with atrial fibrillation receiving anticoagulation

doi:10.1136/bmj.39351.706586.AD

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Gregory Y H Lip, professor of cardiovascular medicine

¹University Department of Medicine, City Hospital, Birmingham B18 7QH

g.y.h.lip{at}bham.ac.uk

Key points

Adding aspirin to warfarin does not seem to prevent stroke and vascular events in patients with atrial fibrillation and stable vascular disease
Bleeding risks are much higher in patients prescribed both warfarin and aspirin
We should stop prescribing aspirin plus warfarin to prevent stroke and vascular events in stable patients with atrial fibrillation who are receiving anticoagulation treatment

The clinical problem

Atrial fibrillation is the commonest cardiac arrhythmia, with increasing prevalence and incidence.1 Adjusted dose oral anticoagulation (such as with warfarin) is the most effective treatment for stroke prevention in high risk patients with atrial fibrillation.2

However, common practice is to add aspirin (or other antiplatelet treatment) to warfarin in atrial fibrillation if there is associated chronic stable coronary or peripheral artery disease.2 This is despite relatively little evidence that adding aspirin to warfarin reduces stroke or other vascular events in patients with atrial fibrillation.

I propose here that we should not add aspirin for associated stable vascular disease in a patient with atrial fibrillation receiving anticoagulation, given the lack of evidence for benefit and the potential for harm.

The evidence for change

Randomised clinical trials in patients with atrial fibrillation using combinations of anticoagulation and aspirin either compared fixed dose (or low intensity, international normalised ratio (INR) <1.5) anticoagulation …