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NICE advises against aspirin for cutting stroke risk in AF patients

The National Institute for Health and Care Excellence has recommended that people with atrial fibrillation are prescribed an anticoagulant instead of aspirin to reduce their risk of stroke.

The revised guidance said using warfarin, dabigatran etexilate, apixaban or rivaroxaban instead of aspirin could prevent more arrhythmia patients having a stroke.

Clinicians have also been advised to use a new tool – the CHA2DS2-VASc – to assess a patient’s risk of stroke in order to determine whether or not they need to be prescribed anticoagulants.

In addition, patients with atrial fibrillation will be able to use a new Patient Decision Aid to weigh up the advantages and disadvantages of different treatment options so they can make more informed choices.

“Around 7,000 strokes and 2,000 premature deaths could be avoided every year through effective detection and protection with anticoagulant drugs”

Mark Baker

Since 2012 a number of drugs belonging to a new generation of oral anticoagulants have been approved by NICE.

Known as novel oral anticoagulants, they do not require such regular monitoring and dose adjustments as warfarin. However, there is evidence that these drugs are not being as widely prescribed as they could, according to NICE.

The guideline makes a strong recommendation that aspirin should not be offered to people with AF solely on account of increased risk of stroke.

It used to be thought that aspirin is much safer in the older population because of the increased risk in this patient group of both bleeding and haemorrhagic stroke associated with anticoagulants.

But NICE said new evidence showed aspirin was not as effective as anticoagulants at preventing stroke in people with AF who are at increased risk of stroke, and is also not as safe in terms of causing bleeding.

Professor Mark Baker, NICE’s director of clinical practice, said: “Around 7,000 strokes and 2,000 premature deaths could be avoided every year through effective detection and protection with anticoagulant drugs that prevent blood clots forming.

“Unfortunately only half of those who should be getting these drugs are. This needs to change if we are to reduce the numbers of people with AF who die needlessly or suffer life-changing disability as a result of avoidable strokes.”

Mark Baker

Mark Baker

Amy Thompson, senior cardiac nurse at the British Heart Foundation, said: “The new NICE guidelines reflect the growing body of evidence that warfarin and the newer anticoagulants are much more effective at preventing stroke than aspirin.

“But this does not mean aspirin is not an effective means of preventing heart attacks and strokes in other circumstances,” she added.

The guidelines also address the best ways to slow a patient’s heart rate, restore or maintain normal heart rhythm if symptoms of AF continue once their heart rate has been controlled, or if a heart rate-control strategy has not worked.

“If a particular management step should fail, the patient should be referred back for consideration of more specialised management options within a four week period”

Campbell Cowan

Dr Campbell Cowan, chair of the NICE Guideline Development Group, said: “The guideline outlines the role of various therapies in the management of AF, including: drug therapy, cardioversion and ablation.

“These treatments are often employed sequentially. For example, a patient might first undergo cardioversion, and then receive drug therapy to help maintain normal rhythm and then be considered for ablation if he or she continues to experience symptomatic arrhythmia.

“There is a concern with such sequential management, that there may be undue delays at each step in the process,” he said.

“The new guideline makes the important recommendation, that if a particular management step should fail, the patient should be referred back for consideration of more specialised management options within a four week period,” he added.

The guideline on the management of atrial fibrillation is available on the NICE website.

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