09 July 2015

Offer anticoagulants instead of aspirin for stroke prevention

Adults with atrial fibrillation (AF) should be prescribed newer medications instead of aspirin for the prevention of stroke, says NICE.

AF is a condition that affects the heart, causing it to beat irregularly and too fast. When this happens, blood does not flow properly through the heart and the rest of the body.

This means that people with AF may be at increased risk of blood clots. Clots can block blood vessels, and a stroke can occur if a blood vessel in the brain is blocked by a clot.

Aspirin has been used for years to help protect patients from strokes, but the risks of taking aspirin – which can cause stomach bleeds – now outweigh any benefits of taking the drug.

NICE’s latest quality standard, which sets out advice on the treatment and management of AF,  recommends that people with AF who have a CHA2DS2-VASC stroke risk score of 2 or above are offered newer anticoagulants, such as apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist like warfarin.

However, it is important to note that many adults with AF may already be taking aspirin for other conditions. If so, this may result in the patient taking aspirin as well as anticoagulants. If a patient chooses not to take anticoagulants, this decision and the reason for it should be documented by their doctor.

The quality standard, which is based on NICE’s AF guideline, also recommends that patients with AF who are prescribed anticoagulants discuss their options with their doctor at least once a year in order to improve adherence to treatment.

Patients should have their anticoagulation reassessed if they are taking a vitamin K antagonist and have poor anticoagulation control. 

A referral to specialist management within 4 weeks should be made for those symptoms have not been controlled by anticoagulation.

Dr Matthew Fay, a GP and specialist member of the committee that developed the standard, said: “The ineffectiveness of aspirin and the need to remove it from the AF patient pathway receives a much needed, and rare, negative statement. This should provide the impetus to those who still speculate on the value of aspirin from historic practice to have the discussion with their patients about the benefits of anticoagulation hopefully before, and not after a devastating stroke event.”

Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE said: “Atrial fibrillation can be a distressing condition and people with it have an increased risk of having a stroke. Therefore it’s important that people with AF have their condition managed effectively in order to eliminate the significant risk of stroke and prevent deterioration in their quality of life.”

Professor Beverley Hunt, Medical Director of Thrombosis UK and specialist member of the committee that developed the standard, added: “The NICE AF quality standard provides a minimum standard of care expected within NHS England. It demands that patients at high risk of stroke without a bleeding risk are offered blood thinners - either warfarin or the newer oral anticoagulants - but not aspirin.

“Every patient needs to decide with their health care professional which is most suitable for them and they should be reviewed annually. Those who self-monitor their warfarin with a home coagulometer should be supported. Lastly if treatment fails to control symptoms, then patients should be referred for specialist management within 4 weeks.

“These Quality Standards are important because without adequate blood thinners many patients would have a preventable stroke, and stroke can have a devastating impact on lives causing loss of movement, independent living and even death.”

This should provide the impetus to those who still speculate on the value of aspirin from historic practice to have the discussion with their patients about the benefits of anticoagulation

Dr Matthew Fay, GP who helped developed the standard

These Quality Standards are important because without adequate blood thinners many patients would have a preventable stroke

Prof Beverley Hunt, Thrombosis UK