Many Atrial Fibrillation Patients At Risk of Stroke Receive Aspirin Instead of Appropriate Anticoagulation Interview with:

Jonathan Hsu, MD, MAS, FACC, FAHA, FHRS Assistant Professor Cardiac Electrophysiology, Division of Cardiology University of California, San Diego (UCSD)

Dr. Jonathan Hsu

Jonathan Hsu, MD, MAS, FACC, FAHA, FHRS
Assistant Professor
Cardiac Electrophysiology, Division of Cardiology
University of California, San Diego (UCSD) What is the background for this study?

Response: Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and imparts significant stroke risk. In patients with AF determined to be at intermediate to high risk for thromboembolism, anticoagulation with warfarin (a vitamin K antagonist) or the newer non-vitamin K antagonist oral anticoagulants clearly reduces morbidity and mortality compared to aspirin. We sought to evaluate practice patterns of cardiovascular specialists in the United states to determine how often AF patients at risk for stroke are prescribed aspirin over oral anticoagulation, and predictors of this practice. What are the main findings?

Response: The main findings of our study is that in the PINNACLE Registry, a large, quality improvement registry of >200,000 outpatients with AF at intermediate to high stroke risk, approximately 40% were treated with aspirin alone instead of oral anticoagulant prescription. Specific patient characteristics predicted prescription of aspirin therapy over oral anticoagulant therapy, particularly comorbidities related to coronary atherosclerosis and its risk equivalent diseases, including hypertension, dyslipidemia, coronary artery disease, prior myocardial infarction, unstable and stable angina, recent CABG, and peripheral arterial disease. What should readers take away from your report?

Response: Despite a lack of evidence for aspirin’s use for thromboembolic prophylaxis in patients with atrial fibrillation at moderate to high risk of stroke, and clear benefit with the use of oral anticoagulants, nearly 1 in 3 of these patients in this large, quality improvement registry of cardiology outpatients with atrial fibrillation¬†at intermediate to high risk of stroke was prescribed aspirin alone. These data indicate a gap in care, most prominent in patients with or at risk for coronary artery disease, and should draw attention to a high rate of prescription of aspirin therapy in AF patients at risk for stroke, despite previous data that show aspirin to be inferior to oral anticoagulation in this population. What recommendations do you have for future research as a result of this study?

Response: As a result of our study, future research should investigate specific practitioner and patient reasons that prevent proper prescription of guideline-recommended oral anticoagulation to AF patients at risk for stroke. Additionally, our finding that a large proportion of patients prescribed oral anticoagulation are also prescribed aspirin therapy suggests that further studies evaluating cardiovascular outcomes in atrial fibrillation patients with stable coronary heart disease prescribed various antithrombotic strategies are needed. Future studies should also study the role of left atrial appendage exclusion devices in AF patients who are not treated with oral anticoagulation long-term. Is there anything else you would like to add?

Response: In contemporary practice, there continues to exist a gap in appropriate oral anticoagulation prescription in atrial fibrillation patients at risk for stroke. Our study highlights that in AF patients offered an antithrombotic agent, many are inappropriately prescribed aspirin, which has been shown to be inferior to oral anticoagulation for stroke risk reduction. Awareness of this continued gap in guideline-supported care of AF patients should warrant attention to provide more of these patients with oral anticoagulation. Additional studies on the role of left atrial appendage exclusion devices in patients not prescribed oral anticoagulation long-term is warranted. Thank you for your contribution to the community.


Hsu JC, Maddox TM, Kennedy K, et al. Aspirin Instead of Oral Anticoagulant Prescription in Atrial Fibrillation Patients at Risk for Stroke. J Am Coll Cardiol. 2016;67(25):2913-2923. doi:10.1016/j.jacc.2016.03.581.

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.
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Last Updated on June 22, 2016 by Marie Benz MD FAAD