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Antiplatelet Therapy
This section examines the current use of antiplatelet therapy/ASA for stroke prevention in patients with AF, and discusses the most recent guideline recommendations
In this section:
Current usage
The use of antiplatelet therapy (including ASA, aspirin) for stroke prevention in AF is increasingly limited:
- Although antiplatelet agents reduce the risk of stroke in patients with AF,1,2 they are less effective than anticoagulant therapy3
- In the AVERROES study, apixaban was superior to ASA for stroke prevention and was associated with a similar rate of major bleeding3
Guideline recommendations
Recent guidelines have highlighted the limited risk–benefit of antiplatelet therapy for stroke prevention based on the efficacy profile and potential for causing serious bleeding events:
- American College of Chest Physicians (ACCP) 2012 guidelines limit the recommendation for ASA to an option for patients with AF with a low risk of stroke (although oral anticoagulation is preferred), or patients with AF and no stroke risk factors (with no antithrombotic therapy preferred over ASA therapy)4
- ESC 2016 guideline update: Antiplatelet therapy is not recommended for stroke prevention in patients with AF5
- In contrast, the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) 2014 guidelines for the management of patients with AF still include ASA as an option for patients with a moderate risk of stroke6
Antiplatelet agents used for stroke prophylaxis in patients with atrial fibrillation
| Drug | Target | Dose/regimen | Supporting study/ substudies |
|---|---|---|---|
| ASA | Irreversibly inhibits the COX-1 enzyme | 75–325 mg once daily | ACTIVE-W1 ACTIVE-A2 Meta-analysis3 |
| Clopidogrel | Thienopyridine – irreversibly binds to the adenosine diphosphate receptor P2Y7 | 75 mg once daily, administered in combination with ASA 75–100 mg daily |
References
- Connolly S, Pogue J, Hart R 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 2006;367:1903–1912. Return to content
- The ACTIVE Investigators. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med 2009;360:2066–2078. Return to content
- Connolly SJ, Eikelboom J, Joyner C et al. Apixaban in patients with atrial fibrillation. N Engl J Med 2011;364:806–817. Return to content
- You JJ, Singer DE, Howard PA et al. Antithrombotic therapy for atrial fibrillation: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141:e531S–e575S. You JJ, Singer DE, Howard PA et al. Antithrombotic therapy for atrial fibrillation: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141:e531S–e575S. Return to content
- Kirchhof P, Benussi S, Kotecha D et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37:2893–2962. Return to content
- January CT, Wann LS, Alpert JS et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014;64:e1–e76. Return to content
- Lip GYH, Nieuwlaat R, Pisters R et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor based approach: The Euro Heart Survey on Atrial Fibrillation. Chest 2010;137:263–272. Lip GYH, Nieuwlaat R, Pisters R et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor based approach: The Euro Heart Survey on Atrial Fibrillation. Chest 2010;137:263–272. Return to content
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