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

BMJ 2008; 336 doi: 10.1136/bmj.39351.706586.AD (Published 13 March 2008)
Cite this as: BMJ 2008;336:614

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  1. Gregory Y H Lip, professor of cardiovascular medicine
  1. 1University Department of Medicine, City Hospital, Birmingham B18 7QH
  1. 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 …

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