Introduction

2. Dispelling the aspirin myth: Implications

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Dr Wolff and Fay explain the practical implications of improving the care of AF patients and the prevention of stroke with oral anticoagulation.

Strokes, not just atrial fibrillation strokes, have a huge impact on the cost to the NHS but also to the patents, their families and the wider community.  Patients with atrial fibrillation-related strokes have poorer quality of life, their rate of death within the first year of suffering a stroke is actually 68% which, of course, has huge impact on families.  Patient who survive atrial fibrillation-related stroke have a huge impact on society in terms of social care costs, loss of earning and loss of tax revenue. 

When we consider Professor Lip has told us about aspirin an its role in atrial fibrillation we can clearly see that this is a drug that is ineffective compared to an oral anticoagulant, but which carries the same risks.  Of course, we know from national audit that approximately 40% of those people at risk of AF-related stroke are currently receiving aspirin.  I feel, taking Professor Lip’s advice on board, what we should see is a dramatic change in the use of aspirin; converting people onto an oral anticoagulant.

The presentation from Professor Lip about exploding the aspirin myth is extremely important, and which need to be taken into account when trying to improve the care of patients with atrial fibrillation, in terms or stroke prevention.  Antiplatelet agents are widely used for stroke prevent, and there is little evidence that they prevent cardioembolic strokes caused by atrial fibrillation, which are the severe stroke which cause so much death and disability.  Aspirin has been show just to produce a 20% relative risk reduction, which wasn’t even statistically significant, whereas any form of anticoagulation reduced stroke risk by as much as two thirds.  Over an above that, aspirin has been shown to carry a similar bleeding risk to anticoagulation, and that’s true for very elderly patients and for patient who have been found to be unsuitable for warfarin.  So there is little point in using antiplatelet agents because they simply don’t work and they cause just as much bleeding.

Recently we’ve seen some real steps forward in how we can manage patients with AF to try to prevent the risk of stroke.  Firstly, there has been the general adoption by specialists of the CHA2DS2‑VASc  schema.  This schema, rather than trying to identify those at risk, who require intervention; it is actually trying to identify those who are at such low risk they don’t require intervention, thus ensuring everybody else is treated.  We are also in a situation where after 60 years of only having warfarin as an oral anticoagulant, we now have new anticoagulants coming to the market place, meaning that if you can’t take warfarin, or if you get unacceptable side effects; rather than receiving no therapy or aspirin, we can now consider a novel oral anticoagulant.

It can be quite challenging to change patients who have been taking aspirin for a very long time, and who often haven’t experienced a stroke yet, and to convince them that their risk is high enough that their treatment is changed to one that is perceived to carry more risk.  The challenge is to counsel the patients appropriately that the risk of bleeding is actually not increased by changing treatment, but that the protection is at least three times higher than the treatment they were taking previously.

Please find below additional resources that you might find useful when learning about stroke prevention in AF

GRASP the initiative

A report from October 2012 on the practicalities of GRASP-AF and its benefits for primary care practitioners.  The report incudes a national summary of GRASP-AF patient treatment and a series of recommendations for commissioners and practitioners on the how stroke risk among AF patients can be reduced.
Report download

The AF Report

An expert report on AF and the prevention of stroke in the UK.  The AF Report was written for a general audience and presents a thorough and current distillation of the evidence and issues in AF stroke prevention.  The report also identifies current challenges and areas where action is needed to improve the care of AF patients. Download report

The AF Stroke Risk Calculator

A simple online tool for the calculation of CHADS2 and CHADSVASc scores for AF patients.  The calculator was designed to be intuitive and sufficiently easy-to-use for patients to calculate their own risk of stroke.

NHS IQ: GRASP-AF

The NHS Improving Quality website contains a wealth of helpful, practical information on GRASP-AF

The videos

Below are video clips from Dr Matt Fat and Dr Andreas Wolff on several aspects of AF patient care and the reduction of stroke risk.