Prescribing Long-Term Aspirin in Patients with AF
Case study:
A 72-year-old female patient with atrial fibrillation undergoes her index catheter ablation procedure. She has a CHADS2 score of 1. Should she be prescribed long-term aspirin to limit the risk of stroke?
Answer:
Although the latest clinical guidelines recommend the use of aspirin to limit stroke risk in patients with atrial fibrillation (AF) who have CHADS2 scores ≤ 2, controversy surrounds the use of aspirin in these low-risk patients, according to Victoria Jacobs, PhD, of the Intermountain Heart Institute in Salt Lake City, Utah.
Her recent study, which was designed to determine if long-term aspirin use provided any benefit to low-risk AF patients, included more than 56,000 patients with AF who had CHADS2 scores 0 to 1 (doi: 10.1111/jce.13327). The patients received aspirin, clopidogrel, or warfarin. After 5 years, 4.6% of patients on aspirin suffered a stroke, compared with 2.3% of patients who were not on aspirin. Additionally, 17.6% of patients on aspirin suffered significant bleeding, compared to 11.5% of non-aspirin users.
Aspirin provided no benefit for stroke reduction in low-risk patients and, in fact, it elevated bleeding risks, according to the study. “The general message is patients with low CHADS2 scores who undergo catheter ablation don’t benefit from taking aspirin,” said Dr. Jacobs.
How should providers decide between prescribing oral anticoagulation and no therapy for patients who don’t need aspirin? “That’s a very good question, and one we deal with in the clinic all the time,” commented Dr. Jacobs. She added that low-risk patients with AF who don’t benefit from aspirin might require oral anticoagulation if, for example, they develop hypertension and their CHADS2 score climbs to 2, she added.
The optimal therapy for reducing stroke in AF patients has to be made on a case-by-case basis after considering a patient’s comorbidities and overall health condition. For example, Dr. Jacobs said approximately 20% of patients with AF are concomitantly diagnosed with coronary artery disease. “That subset of patients definitely needs to take aspirin,” commented Dr. Jacobs. “They might also have to be on oral anticoagulation if their CHADS2 scores are high.”
—Dan Cook
