Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Opinion
  • Published:

The role of aspirin for stroke prevention in atrial fibrillation

Nature Reviews Cardiology volume 8, pages 602–606 (2011)Cite this article

Subjects

Abstract

Atrial fibrillation (AF) is a major cause of stroke and thromboembolism, resulting in substantial morbidity and mortality. For the majority of patients with AF, aspirin has a limited role in stroke prevention, being an inferior strategy and not necessarily safer than the anticoagulant warfarin, especially in the elderly. Novel oral anticoagulant drugs, such as oral direct thrombin inhibitors and oral factor Xa inhibitors, might further diminish the role of aspirin for stroke prevention in AF. Nonetheless, aspirin use should continue in the early stages following presentation of a patient with AF and acute coronary syndrome, and after stenting, in combination with oral anticoagulant drugs and clopidogrel, as appropriate. Notably, aspirin combined with clopidogrel shows only modest benefit in stroke prevention compared with aspirin monotherapy in patients with AF who refuse oral anticoagulant drugs (including warfarin), or in those individuals who have difficulties in anticoagulation monitoring, and can be used where bleeding risk is not excessive.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Design of the Stroke Prevention in Atrial Fibrillation (SPAF-1) trial.

Similar content being viewed by others

References

  1. Camm, A. J. et al. Guidelines for the management of atrial fibrillation: The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur. Heart J. 31, 2369–2429 (2010).

    Article  Google Scholar 

  2. Hart, R. G., Pearce, L. A. & Aguilar, M. I. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann. Intern. Med. 146, 857–867 (2007).

    Article  Google Scholar 

  3. Go, A. S. et al. Anticoagulation therapy for stroke prevention in atrial fibrillation: how well do randomized trials translate into clinical practice? JAMA 290, 2685–2692 (2003).

    Article  CAS  Google Scholar 

  4. Watson, T., Shantsila, E. & Lip, G. Y. Mechanisms of thrombogenesis in atrial fibrillation: Virchow's triad revisited. Lancet 373, 155–166 (2009).

    Article  CAS  Google Scholar 

  5. Eckman, M. H., Singer, D. E., Rosand, J. & Greenberg, S. M. Moving the tipping point: the decision to anticoagulate patients with atrial fibrillation. Circ. Cardiovasc. Qual. Outcomes 4, 14–21 (2011).

    Article  Google Scholar 

  6. The Stroke Prevention in Atrial Fibrillation Investigators. Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation 84, 527–539 (1991).

  7. The Stroke Prevention in Atrial Fibrillation Investigators. A differential effect of aspirin in prevention of stroke on atrial fibrillation. J. Stroke Cerebrovasc. Dis. 3, 181–188 (1993).

  8. Aguilar, M. & Hart, R. Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD001925. doi:10.1002/14651858.CD001925.pub2 (2005).

  9. Serebruany, V. L. et al. Analysis of risk of bleeding complications after different doses of aspirin in 192,036 patients enrolled in 31 randomized controlled trials. Am. J. Cardiol. 95, 1218–1222 (2005).

    Article  CAS  Google Scholar 

  10. ACTIVE Writing Group of the ACTIVE Investigators et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 367, 1903–1912 (2006).

  11. ACTIVE Investigators et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N. Engl. J. Med. 360, 2066–2078 (2009).

  12. Connolly, S. et al. Apixaban in patients with atrial fibrillation. N. Engl. J. Med. 364, 806–817 (2011).

    Article  CAS  Google Scholar 

  13. Mant, J. et al. Warfarin versus aspirin for stroke prevention in atrial fibrillation in the elderly community population: the Birmingham Atrial Fibrillation Treatment of the Aged Study (BAFTA), a randomised controlled trial. Lancet 370, 493–503 (2007).

    Article  CAS  Google Scholar 

  14. Rash, A. et al. A randomised controlled trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation (WASPO). Age Ageing 36, 151–156 (2007).

    Article  Google Scholar 

  15. van Walraven, C. et al. Effect of age on stroke prevention therapy in patients with atrial fibrillation: the atrial fibrillation investigators. Stroke 40, 1410–1416 (2009).

    Article  CAS  Google Scholar 

  16. Healey, J. S. et al. Risks and benefits of oral anticoagulation compared with clopidogrel plus aspirin in patients with atrial fibrillation according to stroke risk: the atrial fibrillation clopidogrel trial with irbesartan for prevention of vascular events (ACTIVE-W). Stroke 39, 1482–1486 (2008).

    Article  CAS  Google Scholar 

  17. Gorin, L. et al. Antithrombotic treatment and the risk of death and stroke in patients with atrial fibrillation and a CHADS2 score=1. Thromb. Haemost. 103, 833–840 (2010).

    Article  CAS  Google Scholar 

  18. Lee, B. H. et al. The effect and safety of the antithrombotic therapies in patients with atrial fibrillation and CHADS score 1. J. Cardiovasc. Electrophysiol. 21, 501–507 (2010).

    Article  Google Scholar 

  19. Sato, H. et al. Low-dose aspirin for prevention of stroke in low-risk patients with atrial fibrillation: Japan Atrial Fibrillation Stroke Trial. Stroke 37, 447–451 (2006).

    Article  CAS  Google Scholar 

  20. Fowkes, F. G. et al. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial. JAMA 303, 841–848 (2010).

    Article  CAS  Google Scholar 

  21. Ogawa, H. et al. Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial. JAMA 300, 2134–2141 (2008).

    Article  CAS  Google Scholar 

  22. Belch, J. et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ 337, a1840 (2008).

    Article  Google Scholar 

  23. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 324, 71–86 (2002).

    Article  Google Scholar 

  24. Lane, D. A., Kamphuisen, P. W., Minini, P., Büller, H. R. & Lip, G. Y. Bleeding risk in atrial fibrillation patients: The AMADEUS study. Chest 140, 146–155.

  25. Leon, M. B. et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N. Engl. J. Med. 339, 1665–1671 (1998).

    Article  CAS  Google Scholar 

  26. Lip, G. Y. et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/stenting. Thromb. Haemost. 103, 13–28 (2010).

    Article  CAS  Google Scholar 

  27. Lip, G. Y. et al. Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis. Europace 13, 723–746 (2011).

    Article  Google Scholar 

  28. Hansen, M. L. et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch. Intern. Med. 170, 1433–1441 (2010).

    Article  CAS  Google Scholar 

  29. van Staa, T. P., Setakis, E., Di Tanna, G. L., Lane, D. A. & Lip, G. Y. A comparison of risk stratification schemes for stroke in 79,884 atrial fibrillation patients in general practice. J. Thromb. Haemost. 9, 39–48 (2011).

    Article  CAS  Google Scholar 

  30. Olesen, J. B. et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ 42, d124 (2011).

    Article  Google Scholar 

  31. Boriani, G. et al. Improving stroke risk stratification using the CHADS2 and CHA2DS2-VASc risk scores in paroxysmal atrial fibrillation patients by continuous arrhythmia burden monitoring. Stroke 42, 1768–1770 (2011).

    Article  Google Scholar 

  32. Cairns, J. A. et al. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter. Can. J. Cardiol. 27, 74–90 (2011).

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Dudley Road, Birmingham, B18 7QH, UK

    Gregory Y. H. Lip

Authors
  1. Gregory Y. H. Lip
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Competing interests

Gregory Y. H. Lip was clinical adviser to the UK National Institute of Clinical Excellence guidelines on atrial fibrillation management, and a member of the Task Force that wrote the 2010 European Society of Cardiology guidelines. He is currently Deputy Editor ('content expert') for the 9th American College of Chest Physicians guidelines on antithrombotic therapy in atrial fibrillation. He has been a consultant or speaker for the following companies: Astellas Pharma, AstraZeneca, Bayer, Biotronik, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Merck, Pfizer, Portola Pharmaceuticals, and Sanofi. Additionally, he has received grant or research support from Bayer and Sanofi.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lip, G. The role of aspirin for stroke prevention in atrial fibrillation. Nat Rev Cardiol 8, 602–606 (2011). https://doi.org/10.1038/nrcardio.2011.112

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrcardio.2011.112

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing