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Combined aspirin and anticoagulant therapy in patients with atrial fibrillation

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Abstract

The combined use of aspirin and oral anticoagulant therapy in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) has been questioned due to an increased risk of major bleeding with little to no benefit in preventing ischemic events. (1) To better understand patterns and indications for combined antiplatelet and anticoagulant therapy and identify patients who might reasonably be treated with oral anticoagulant (OAC) therapy alone. (2) To perform an updated literature review regarding the use of combined antiplatelet and OAC therapy in patients with AF and stable CAD. Retrospective review. Patients within the University of Cincinnati Health System with a diagnosis of non-valvular AF, excluding those with acute coronary syndrome or revascularization within the last 12 months. Numbers and indications for combined antiplatelet and anticoagulant therapy and sequence of events leading to the initiation of each. Of 948 patients receiving OAC, 430 (45 %) were receiving concomitant OAC and aspirin. Among patients receiving combined antiplatelet and anticoagulant therapy, 49 and 42 % of patients respectively, had CAD or DM. In a more detailed analysis including chart review of 219 patients receiving combined OAC and aspirin, 27 % had a diagnosis of CAD and 14 % had a diagnosis of DM prior to the development of AF. These patients were initially treated with aspirin. Warfarin was added when they subsequently developed AF but aspirin wasn’t discontinued. A surprisingly large proportion of patients (22.8 %) had no obvious indication for dual therapy. Prior myocardial infarction, CAD, vascular disease and DM (among others) increase the likelihood of receiving combined antiplatelet and anticoagulant therapy among patients with AF. A literature review suggests this may lead to increased major bleeding with little benefit in decreasing either AF-related stroke or cardiovascular events.

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Funding

Support for this study came from the Pfizer Educational Group, Bristol-Myers Squibb/Pfizer Education Consortium, and NIH/NCATS grant 8 UL1 TR000077-05. The funding sources had no role in study design, data collection, data analysis, data interpretation, or writing of the manuscript. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Author contributions

MHE was responsible for the conception and design of the project; MHE, and CS were responsible for acquisition of data; MHE and CS were responsible for data analysis and interpretation; SO and MHE drafted the original article and made critical revisions, provided intellectual content, and approved the final draft.

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Authors and Affiliations

  1. Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, PO Box 670535, Cincinnati, OH, 45267-0535, USA

    Charlotte H. So & Mark H. Eckman

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  1. Charlotte H. So
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  2. Mark H. Eckman
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Correspondence to Mark H. Eckman.

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Conflict of interest

Mark H. Eckman—has investigator-initiated grant funding from Boehringer-Ingelheim/Heart Rhythm Society, Pfizer Educational Group, Bristol-Myers Squibb/Pfizer Education Consortium, and NIH/NCATS Grant 8 UL1 TR000077-05, and the Cystic Fibrosis Foundation. Charlotte H. So—has no conflicts of interest.

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So, C.H., Eckman, M.H. Combined aspirin and anticoagulant therapy in patients with atrial fibrillation. J Thromb Thrombolysis 43, 7–17 (2017). https://doi.org/10.1007/s11239-016-1425-5

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  • DOI: https://doi.org/10.1007/s11239-016-1425-5

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