Managing the anticoagulated patient with atrial fibrillation at high risk of stroke who needs coronary interventionBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.39533.570602.BE (Published 12 September 2008) Cite this as: BMJ 2008;337:a840
All rapid responses
In the uncertainties page about the management of the anticoagulated
patient with atrial fibrillation at high risk of stroke who needs coronary
intervention (1)Dr. Lip mention that when warfarin is combined with
aspirin in patients with peripheral vascular disease, the absolute risk of
life threating bleeding is increased. We would like to comment that the
hemorrhagic risk of combining antiplatelet therapy with oral
anticoagulation probably is not the same for all antiplatelet drugs. In
this sense it should be mentioned the study NASPEAF (2), in which patients
with chronic or documented paroxysmal atrial fibrillation were stratified
in two groups of thromboembolism risk. Patients in the intermediate-risk
group were randomized to one of three arms: oral anticoagulation with
acenocoumarol with a targeted INR of 2 to 3, triflusal (an antiplatelet
drug)600 mg daily, or a combination of both with a targeted INR of 1.25 to
2. In the high-risk group, the triflusal only arm was omitted and subjects
were assigned to anticoagulation with a targeted INR of 2 to 3 or the
combination therapy with a targeted INR of 1.4 to 2.4. Primary outcome was
a composite of vascular death, transient ischemick attack and nonfatal
stroke or embolism, whichever came first.
One thousand two hundred nine patients were included and 1159
patients were evaluated for efficacy. After a median follow-up of 2.76
years, primary outcome was lower in the combined therapy than in the
anticoagulant arm in both the intermediate (HR: 0.33; 95% CI: 0.12 to
0.91; p = 0.02) and the high-risk group (HR: 0.51; 95% CI: 0.27 to 0.96; p
= 0.03). Mean INR values in the combined arms were 1.93 and 2.17 in the
intermediate and high-risk groups, respectively.
Concerning severe bleeding, the rates per cent person-years in the
intermediate-risk group were 1.80 and 0.92 in the acenocoumarol and the
combined arms, respectively, whereas in the high risk group the rates per
cent-person-years were in the acenocoumarol and the combined arms 2.13 and
In conclusion,in this study triflusal combined with oral
anticoagulation at a trageted INR next to 2 was more effective than
standard anticoagulation in patients with atrial fibrillation without
increase the hemorrhagic risk.
Although the paper of Dr. Lip was refered to a different kind
patients than those included in the NASPEAF study (2), the results of this
study contribute to the knowledge when combination of anticoagulant and
antiplatelet drugs is necessary.
1) Lip G Y H. Managing anticoagulated patients with atrial
fibrillation at high risk of stroke who needs coronary intervention. Br
Med J 2008; 337: 110-12.
2) Pérez-Gómez F, Alegría E, Berjón J, Iriarte J A, Zumalde J,
Salvador A, et al. Comparative effects of antiplatelet, anticoagulant, or
combined therapy in patients with valvular and nonvalvular atrial
fibrillation. J Am Coll Cardiol 2004; 44: 1557-66.
Javier Borja, Iñaki Izquierdo and Catalina Bonet are employees of J Uriach Y Compañía, S.A., the pharmaceutical company that deleloped and market triflusal.
Competing interests: No competing interests