Manaktala R, Kluger J. Role of Antiplatelet Therapy in Stroke Prevention in Patients With Atrial Fibrillation. J Am Osteopath Assoc 2017;117(12):761–771. doi: 10.7556/jaoa.2017.148.
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Patients with atrial fibrillation are at increased risk of having a cardioembolic stroke. The use of oral anticoagulation is now well established to prevent strokes in patients with atrial fibrillation and a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [2 points], diabetes mellitus, prior stroke/transient ischemic attack or thromboembolism [2 points], vascular disease, age 65 to 74 years, and sex category) score of greater than 1, beyond sex. However, the role of antiplatelet therapy, specifically aspirin in low-risk patients or as an alternative to oral anticoagulation, remains controversial. The most recent US guidelines conflict with the European guidelines, which do not recommend antiplatelet monotherapy for stroke prevention irrespective of stroke risk. The aim of this review is to summarize published studies that question the role of aspirin in preventing strokes associated with atrial fibrillation. Overall, aspirin is found to play a limited role in the prevention of stroke in patients with atrial fibrillation and is associated with a similar risk of hemorrhagic events compared with anticoagulants. The benefit of dual antiplatelet therapy as an alternative to oral anticoagulation requires further study.
a Correlation of CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [2 points], diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism [2 points], vascular disease, age 65 to 74 years, sex category) score with annual percent risk of cardioembolic stroke. Score of 0 corresponds to 0.3% risk, score of 1 corresponds to 0.9% risk, score of 2 corresponds to 2.9% risk, score of 3 corresponds to 4.6% risk, score of 4 corresponds to 6.7% risk, score of 5 corresponds to 10% risk, score of 6 corresponds to 13.6% risk, score of 7 corresponds to 15.7% and score of 8 or 9 corresponds to 15.2%.10
b It is recommended that international normalized ratio (INR) range be in the therapeutic range at least equal to or greater than 65% of the time while receiving vitamin K antagonist therapy.
c Class of Evidence: I, strong recommendation for the studied treatment to be performed/administered; IIa, reasonable recommendation for studied treatment to be performed however additional studies with focused objectives are needed; IIb, recommendation for studied treatment may be considered however additional studies with broad objectives are needed and additional registry data would be useful; III, recommendation that treatment is not useful/effective and may be harmful given sufficient evidence from multiple randomized trials or meta-analyses.8
d Level of Evidence: A, data derived from multiple randomized clinical trials and evaluated by multiple populations; B, data derived from a single randomized trial or nonrandomized studies with evaluation of limited populations; C, evidence taken from consensus of expert opinions, case studies and standard of care with evaluation from very limited populations.8
Abbreviation: ACS, acute coronary syndrome; AF, atrial fibrillation; NOAC, novel oral anticoagulants; OAC, oral anticoagulation.
Abbreviations: AF, atrial fibrillation; DAPT, dual antiplatelet therapy; INR, international normalized ratio; TIA, transient ischemic attack.
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