Less is more in atrial fibrillation stroke prevention — please, drop the aspirin

A recent study in the Journal of the American College of Cardiology shed more light on the commonly used drug combination of aspirin and a vitamin-K antagonist (such as warfarin).  It was a small registry study from one region of France but I believe it offered confirmatory evidence against this dangerous practice.

Investigators followed patients with stable coronary artery disease (no recent events) for 2 years to assess the incidence and outcomes of major bleeding episodes. They found that overall rates of major bleeding were less than 1%, but those patients on the combination of aspirin and an anticoagulant drug were almost five times more likely to suffer major bleeds. In fact, the combination was the major predictor of bleeding–more than two-fold greater than diabetes.

The reason why I point you to this study is that the practice of combining clot-preventing drugs in patients with AF is one I see so frequently. And I’m not an outlier, registry studies suggest up to 40% of AF patients are taking the combination.

This is a bad idea. It needs to stop.

Screen Shot 2014-09-30 at 7.07.47 AMThe French study aligns well with prior evidence on combining drugs. In March of 2013, I published this review of the existing data on theHeart.org. My conclusion was that, in the great majority of patients, there was no evidence for added stroke protection but there was a compelling signal of higher bleeding. Only three subgroups of patients fell out of this general statement. The ratio of benefit to harm may be positive in patients with AF and mechanical heart valves, AF and recent stents or AF and recent acute coronary syndrome. That’s it.

The vast majority of AF patients taking this combination likely should not be.

I do a lot of deprescribing these days. Aspirin, when used in AF patients who are on anticoagulant drugs, is perhaps the most common drug I deprescribe.

Look at the data yourself and see if you come to a different conclusion. My article on theHeart.org has references.

JMM

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