NICE no longer recommends aspirin alone for reducing risk of stroke in AF patients


Updated UK’s National Institute for Health and Care Excellence (NICE) guidelines no longer recommend aspirin use alone, solely, to reduce the risk of stroke in patients with atrial fibrillation (AF).

It is estimated that up to 40% of patients diagnosed with AF have been prescribed aspirin. While some patients with AF may be taking aspirin for other co-morbidities, many are likely to have been prescribed aspirin solely for stroke prevention. Multiple anticoagulant treatments are recommended by NICE, yet in 2013 only 36% of patients with known AF admitted to hospital with a stroke were taking an anticoagulant. 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 CHADS-VASc2 score of two or more, taking bleeding risk into account.

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. The data showed that antiplatelet therapy has limited benefit and anticoagulation treatment compared to antiplatelet treatment is more clinically beneficial. The data reviewed included multiple studies of warfarin versus aspirin which demonstrated warfarin as superior to aspirin. In addition, a large prospective, double-blind, double-dummy, randomised published study of apixaban versus aspirin (AVERROES) was also included in the NICE review. 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 guideline on the management of AF now aligns to the latest guidelines issued by the European Society of Cardiology (ESC) in 2012. 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 patients’ treatment should be reviewed vary considerably among those surveyed, with only a fifth (21%) of cardiologists saying immediately (within a month).

Martin Cowie, professor of cardiology at Imperial College London and honorary consultant cardiologist at the Royal Brompton Hospital, London, UK, comments: “Now that aspirin is no longer recommended for stroke prevention in AF in the updated NICE guidelines, coordinated multidisciplinary efforts by cardiologists, GPs and specialist nurses are needed to ensure that the changes are reflected in clinical practice as early as possible. We need to make sure all recommended anticoagulant treatment options are available and discussed with patients to determine the most suitable option for them.”

“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,” says Cowie. “As cardiologists we need to ensure our expertise in the management of stroke prevention in AF is cascaded to other healthcare professionals who are at the forefront of AF management.”