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Peripheral Artery Disease: causes and consequences

Coronary Artery Disease: causes and consequences

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

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


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

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