Aspirin in atrial fibrillation
Do not offer aspirin monotherapy solely for stroke prevention to people with atrial fibrillation (1) Aspirin monotherapy is not associated with a lower risk of ischemic events, while significantly associated with a higher risk of bleeding events. Patients with AF are unlikely to benefit from aspirin monotherapy. (2)
Use a direct oral anticoagulant (DOAC) in preference to a vitamin K antagonist.
- the long-term risk of stroke in valvular atrial fibrillation (AF) depends on clinical predictors, which are collectively assessed in the CHADS2 scoring scheme, an acronym for Congestive heart failure, hypertension, Age>75, Diabetes mellitus, and prior Stroke (1):
Anticoagulation based on the CHADS2 score
Score | Risk | Anticoagulation Therapy | Considerations |
0 | Low | Aspirin or no treatment | No antithrombotic therapy (or aspirin) |
1 | Moderate | Aspirin or Warfarin | Aspirin daily or raise INR to 2.0-3.0, depending on factors such as patient preference |
2 or greater | Moderate or High | Warfarin | Raise INR to 2.0-3.0, unless contraindicated (e.g. clinically significant GI bleeding, inability to obtain regular INR screening) |
To complement the CHADS2 score, by the inclusion of additional 'stroke risk modifier' risk factors, the CHA2DS2-VASc score has been proposed (1)
- these additional 'clinically relevant non-major' stroke risk factors include age 65-74, female gender and vascular disease
- in the CHA2DS2-VASc score score, 'age 75 and above' also has extra weight, with 2 points
CHA2DS2-VASc score for stroke risk in atrial fibrillation
Feature | Score |
Congestive Heart Failure | 1 |
Hypertension | 1 |
Age >75 years | 2 |
Age between 65 and 74 years | 1 |
Stroke/TIA/TE | 2 |
Vascular disease (previous MI, peripheral arterial disease or aortic plaque) | 1 |
Diabetes mellitus | 1 |
Female | 1 |
Reference:
- NICE. Atrial fibrillation: diagnosis and management. NICE guideline NG196. Published April 2021, last updated June 2021
- Wang N et al. Patients with Atrial Fibrillation are Unlikely to Benefit from Aspirin Monotherapy. Int J Gen Med. 2024 May 22:17:2337-2345
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