Aspirin use de-prioritised

Updated NICE guidelines no longer recommend aspirin use alone, solely to reduce the risk of stroke in patients with atrial fibrillation (AF).(1,2)
It is estimated that up to 40% of patients diagnosed with AF have been prescribed aspirin.(3) While some patients with AF may be taking aspirin for other comorbidities, many are likely to have been prescribed aspirin solely for stroke prevention.

Updated NICE guidelines no longer recommend aspirin use alone, solely to reduce the risk of stroke in patients with atrial fibrillation (AF).(1,2)
It is estimated that up to 40% of patients diagnosed with AF have been prescribed aspirin.(3) While some patients with AF may be taking aspirin for other comorbidities, many are likely to have been prescribed aspirin solely for stroke prevention.
Multiple anticoagulant treatments are recommended by NICE,(1,4,5,6,) yet in 2013 only 36% of patients with known AF admitted to hospital with a stroke were taking an anticoagulant.(7) In the updated guideline, non-vitamin K oral anticoagulants (NOACs) – apixaban, dabigatran and rivaroxaban – are recommended as first-line treatment options for stroke prevention in non-valvular AF alongside warfarin, for patients with a CHA₂DS₂-VASc score of two or more, taking bleeding risk into account.(1)
The National Institute for Health and Care Excellence (NICE) assessed the evidence for benefit and cost-effectiveness of anticoagulation and antiplatelet agents both alone and in combination to help reduce the risk of stroke in patients with AF.(1) The data showed that antiplatelet therapy has limited benefit and anticoagulation treatment compared with antiplatelet treatment is more clinically beneficial.(1) The data reviewed included multiple studies of warfarin versus aspirin that demonstrated warfarin as superior to aspirin.(1) In addition, a large prospective, double-blind, double-dummy, randomised published study of apixaban versus aspirin (AVERROES) was also included in the NICE review.(1,8) Apixaban is the only NOAC to have demonstrated superior efficacy for a composite endpoint of stroke or systemic embolism against a pre-specified aspirin treatment arm in such a study.
The de-prioritisation of aspirin within the NICE guidelines on the management of AF now aligns to the latest guidelines issued by the European Society of Cardiology (ESC) in 2012.(9) New research conducted by the BMS-Pfizer Alliance shows that 91% of healthcare professionals surveyed believe the de-prioritisation of aspirin for stroke prevention in AF within the NICE guideline could impact clinical practice. However, healthcare professional perceptions on how urgently a patient’s treatment should be reviewed vary considerably among those surveyed, with less than one-quarter (23%) saying immediately (within a month).(2)
Dr Charles Alessi, Chairman, National Association of Primary Care, NHS Confederation comments: “Many AF patients are currently not adequately protected against the risk of stroke by being prescribed aspirin solely for stroke prevention, which has proven to be less effective, in comparison to anticoagulation therapies, as well as carrying a risk of bleeding. The fact that aspirin use is no longer recommended in the updated NICE guideline could represent a huge change in how stroke prevention in AF is managed. It is vitally important that as GPs we are aware of the latest guideline from NICE and ensure that patients currently taking aspirin solely for stroke prevention are urgently reviewed and discuss the most appropriate options for anticoagulation.”
NOACs are the first major innovation in the management of stroke prevention in NVAF in more than 50 years(10) and do not require international normalisation ratio (INR) monitoring. However, despite being launched in the UK in advance of several other European countries, NOAC uptake in the UK lags significantly behind its European contemporaries.(11) The new research also showed that less than a third of GPs (27%) surveyed felt confident in describing the differences between NOACs.
Cardiologists can play an important role in supporting AF education, yet 55% of healthcare professionals surveyed believe that communication between primary and secondary care requires improvement.(12)
Professor Martin Cowie, Professor of Cardiology at Imperial College London and Honorary Consultant Cardiologist at the Royal Brompton Hospital, London commented: “GPs play a vital role in the management and care of patients with AF. There is widespread consensus that aspirin offers limited benefit in terms of stroke prevention in AF, and for the first time this will be reflected in national guidelines. As healthcare professionals we need to work closely together to overcome any communication or treatment barriers that may exist to ensure all recommended treatment options, including all three NOACs, are available for appropriate patients and collectively consider the best approach to ensure the implementation of the new NICE guideline at a local level.”
Patients with AF are five times more likely to suffer a stroke than those without the condition.(12) AF-related strokes are associated with a 20% increased likelihood of death and 60% increased likelihood of disability compared with non-AF related strokes.(13) More than one million people are affected by AF in the UK.(14) Experts estimate that from 2010 to 2060, the number of adults 55 years and over with AF in the European Union will more than double.(15)

1. Clinical Guideline 36: The Management of Atrial Fibrillation, National Institute for Health and Care Excellence. June 2014. http://nice.org.uk/ (accessed 18 June 2014).
2. Instar research, NICE Guideline and Aspirin Study, May 2014.
3. CSD Patient Data, Cegedim Strategic Data UK Ltd, April 2014.
4. Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation. NICE technology appraisal guidance 249. March 2012. http://guidance.nice.org.uk/ta249 (accessed 10 June 2014).
5. Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation. NICE technology appraisal guidance. May 2012. http://guidance.nice.org.uk/TA256 (accessed 10 June 2014).
6. Apixaban for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation. NICE technology appraisal guidance. May 2012. http://publications.nice.org.uk/TA275 (accessed 16 May 2014).
7. Clinical Effectiveness and Evaluation Unit on behalf of the Intercollegiate Stroke Working Party. Sentinel Stroke National Audit Programme. Royal College of Physicians Clinical Audit First Public Report. August 2013. http://www.rcplondon.ac.uk/sites/default/files/ssnap_pilot_report_1_jan-march_2013.pdf (accessed 10 June 2014).
8. Connolly SJ et al. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011;364(9):806–17.
9. Camm J, et al, Focused update of the ESC Guidelines for the management of atrial fibrillation. Eur Heart J 2012;33:2719–47.
10. Evidence of failure of NICE implementation: NOACs, including apixaban, for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation (primary and secondary care), October 2013, Association of British Pharmaceutical Industry.
11. IMS Health, MIDAS, August 2013 (data on file).
12. Savelieva I et al., Stroke in atrial fibrillation: update on pathophysiology, new antithrombotic therapies, and evolution of procedures and devices. Ann Med 2007;39:371–91.
13. Lin HJ et al., Stroke severity in atrial fibrillation: the Framingham study. Stroke 1996;27:1760–4.
14. What is atrial fibrillation? Atrial Fibrillation Association. Available at http://www.atrialfibrillation.org.uk/patient-information/atrial-fibrillation.html (accessed 10 June 2014).
15. Krijthe BP et al., Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J 34(35):2746–51