Why Aspirin Should Not Be Used for Atrial Fibrillation Stroke Prevention — Video Interview with Dr. Albert Waldo
June 27, 2012
- Summary: Aspirin should no longer play a role in the prevention of stroke in atrial fibrillation according to this video interview with a leading expert, Dr. Albert Waldo.
- Reading and watching time is approximately 4 minutes
In this video interview at Heart Rhythm 2012, Dr. Albert Waldo, one of the world’s foremost atrial fibrillation treatment experts, discusses why aspirin no longer plays a role in stroke prevention in atrial fibrillation and how aspirin has already been removed from various guidelines around the world. He cites that numerous studies have found aspirin to be no better than a placebo, and to have greater bleeding risks than the newer anticoagulants.
View the video interview with Dr. Waldo (less than 4 minutes)
About Albert Waldo, MD:
Professor of Medicine
Case Western Reserve University
For more information, see Dr. Waldo’s CV
Mellanie True Hills: Dr. Waldo, here at Heart Rhythm 2012, you’ve talked a lot about the role of aspirin in stroke prevention for atrial fibrillation. Would you share that with the patient community?
Dr. Waldo: Sure. It’s really important because the guidelines — particularly the guidelines in North America — have given aspirin a role in patients with a CHADS2 score of 0 or 1, but the data really don’t support that. The only study that has shown that aspirin is better than placebo is an outlier, and that study is the study that drives most of the meta-analyses that have suggested that aspirin is certainly not as good as warfarin, but better than placebo. The truth of the matter is that aspirin has very little use in preventing stroke in atrial fibrillation.
The important thing is also to emphasize that the original study that supported this was published in 1991, so two decades ago, at a time when prothrombin time ratio was being used, so there was a real concern for bleeding. Because there was a higher rate of bleeding than people expected, the hope was that aspirin would have less bleeding but still would provide efficacy in some patients with low stroke risk.
It turns out, now that we have the INR (International Normalized Ratio) to go by, you keep the INR in therapeutic range — that’s the best thing you can do — or you take one of the new oral anticoagulants that are all better than aspirin. The new drugs have even shown that they’re not only more effective than aspirin, but that they have less bleeding – that was particularly the AVERROES study with apixaban, which will probably be approved in the near future. I just think that there’s really no reason to support aspirin for virtually any role in preventing stroke in atrial fibrillation.
I want to emphasize that that’s not just my opinion — the Japanese have taken it out of their guidelines, the European Society of Cardiology is about to remove it from their guidelines, the recent American College of Chest Physicians Guidelines have demoted aspirin so that even with a CHADS2 [score of] 1 they don’t recommend aspirin, and the same with the Canadians. The message should be this: even if you take an oral anticoagulant, there’s always a risk of bleeding; most of the bleeding is manageable; when there is a risk of stroke, the risk of stroke is almost always significantly greater than the risk of bleeding. One always has to consider both on an individual basis in their patient; but most of the time if there’s a risk of stroke, that outweighs the risk of bleeding. The patient should be treated with a real oral anticoagulant if you’re worried about stroke.
Hills: So what you’re really saying to us is that this is a conversation between the patient and the doctor to determine what is the optimal situation based on the individual patient.
Dr. Waldo: Absolutely right.
Hills: Dr. Waldo, thank you so much for sharing this with us. For StopAfib.org, this is Mellanie True Hills. Thank you.
Dr. Waldo: Thank you.