Prevention of atrial fibrillation stroke, limited aspirin

September 28, 2014 Source: China Medical News

Lao Dong is an old patient with atrial fibrillation for many years. The doctor has given him oral warfarin and told him that this is to prevent atrial fibrillation from causing a stroke (stroke). Who knows that the trouble of eating warfarin is coming. Lao Dong is not only going to run a hospital every other day, but he still doesn't dare to eat anything. Otherwise, he will continue to take blood tests and constantly adjust the dose. What is even more frightening is that if the medicine is eaten more, it may cause bleeding. Later, Lao Dong simply did not eat warfarin and changed to oral low-dose aspirin (AP). He has heard that aspirin also has the effect of preventing blood clotting. Many patients with coronary heart disease eat it. The dose is fixed without monitoring, and it is not as easy to cause bleeding as warfarin.

However, Lao Dong recently went to a hospital. The cardiologists told him that aspirin has no preventive effect on the thrombus caused by atrial fibrillation, and its bleeding risk is no less than warfarin, so don’t stop now. Eat this medicine. After eating so many years of aspirin, how can it be ineffective? What has actually happened? Let us ask the experts to start with the clinical symptoms of atrial fibrillation.

Atrial fibrillation treatment must pay attention to anticoagulation

Atrial fibrillation (abbreviated as atrial fibrillation) is one of the most common persistent arrhythmias in the clinic. It is an abnormal discharge of abnormal atrial lining, which causes abnormal heart rate. Epidemiological research data suggest that the total prevalence of atrial fibrillation in China is 0.77%, and it is estimated that there are more than 8 million patients with atrial fibrillation in China. Professor Ma Changsheng, director of the Cardiac Internal Medicine Center of Beijing Anzhen Hospital affiliated to Capital Medical University, pointed out that this figure may still underestimate the actual number of patients with atrial fibrillation in China. As the population ages, the number of patients with atrial fibrillation in China will remain in the future. Will continue to grow rapidly.

Professor Lin Junli from the Department of Cardiology, affiliated hospital of Taiwan University School of Medicine, said that the prevalence of atrial fibrillation in Taiwan is 1%. Its greatest harm is caused by cerebral arterial thrombosis and lead to stroke. This is because in the atrial of the tremor, the blood is easily stagnated to form a blood clot. After the thrombus falls off, it can enter the cerebral circulation with blood flow, blocking the cerebral blood vessels and causing ischemic brain damage. , which leads to a stroke.

Professor Lin Junli emphasized that about one-third of patients with atrial fibrillation will have a stroke, and the risk of stroke is five times higher than that of people without atrial fibrillation, and the risk of death is twice as high. At the same time, among stroke patients, about one in every six patients is associated with atrial fibrillation; one in every five hours in Taiwan, China, causes a stroke due to atrial fibrillation.

Atrial fibrillation is so dangerous that the treatment of stroke prevention in patients with atrial fibrillation should be given high priority. The most important thing to prevent atrial fibrillation is anticoagulant therapy . The representative drug is the traditional oral anticoagulant warfarin. The data show that warfarin can reduce the risk of stroke in patients with non-valvular atrial fibrillation by 62%.

Professor Lin Junli pointed out that, unfortunately, due to various reasons such as “risk of bleeding fear”, “monitoring trouble”, “no one said that anticoagulation is needed”, most patients with atrial fibrillation in real life did not score according to stroke risk and followed the treatment guidelines. Come to medication.

Aspirin has less benefit in preventing stroke

In addition to the lack of anticoagulant therapy, many patients in the clinic rely on long-term use of aspirin to prevent stroke. Aspirin is not an anticoagulant, but an antiplatelet agent that works by inhibiting platelet aggregation. For a long time, cardiologists have prescribed aspirin to prevent stroke in patients with atrial fibrillation as required by textbooks.

However, Professor Ma Changsheng pointed out that more and more research evidence now shows that the role of aspirin in preventing atrial fibrillation stroke is limited, only reducing the risk of stroke by more than 20%. At the same time, in elderly patients, the risk of hemorrhage in atrial fibrillation was much greater than that in the prevention of stroke, and the incidence of major bleeding in aspirin antithrombotic therapy was not significantly different from warfarin. Therefore, for most patients with atrial fibrillation, the use of aspirin is ineffective or has little effect and the risk is greater than the benefit.

Professor Ma Changsheng emphasized that whether patients with atrial fibrillation need anticoagulant therapy and how to use it should be based on the risk stratification of stroke. The current risk stratification tools commonly used in the clinic include the CHADS2 scoring system and the CHA2DS2-VASc scoring system, in Europe and the United States. Clinical guidelines are now used to assess stroke risk in patients with atrial fibrillation.

In the CHA2DS2-VASc scoring system, it includes five traditional risk factors for congestive heart failure, hypertension, diabetes, age ≥75 years, previous stroke or transient ischemic attack (TIA), and increased vascular disease. There are 3 risk factors for age 65~74 years old and gender (female). The higher the CHA2DS2-VASc score, the greater the risk of future ischemic stroke in patients with a maximum of 9 points.

In March of this year, the American Heart Association, the American College of Cardiology, and the American Heart Rhythm Society, in conjunction with the American College of Thoracic Surgery, jointly published the "2014 Guidelines for the Management of Patients with Atrial Fibrillation." New guide recommended:

For patients with previous stroke, transient ischemic attack (TIA) or CHA2DS2-VASc score ≥ 2, oral anticoagulants, including warfarin and new oral anticoagulants (dabigatran, rivaroxa) are recommended. Class and apixaban);

For patients with a CHA2DS2-VASc score of 0, no antithrombotic therapy is recommended;

For patients with a score of 1 point, the new guidelines suggest that no anti-thrombosis, oral anticoagulant antithrombotic or oral aspirin can be selected.

Aspirin is not recommended for patients with atrial fibrillation in China

In addition to the United States, Europe also published guidelines for atrial fibrillation in 2012. Among them, the opinion on the application of aspirin to prevent atrial fibrillation is not completely consistent with the US guidelines.

So, for patients with atrial fibrillation in China, do you use aspirin? Ma Changsheng’s answer is “No”. He explained that for patients with a CHA2DS2-VASc score of 0, both European and American guidelines consistently suggest that anticoagulant therapy is not required and that no aspirin is required; for the CHA2DS2-VASc score of 2 or more Patients, the two guidelines are also consistent - the recommended use of oral anticoagulants, but not recommended antithrombotic aspirin.

The only controversy between the two guidelines was that in the treatment of patients with atrial fibrillation with a score of 1 point, the survey showed that this group of people accounted for 15% of all patients with atrial fibrillation. The US guidelines have adopted a more conservative recommendation, which means that patients with atrial fibrillation scored 1 point may or may not use aspirin; the European guidelines give more specific recommendations. Ma Changsheng said: "The 2012 European Guide recommends that in the assessment of patients bleeding risk and patient willingness, one-point patients may consider oral anticoagulant drugs, but do not require oral aspirin."

Since a large number of clinical studies have confirmed that the risk of fatal hemorrhage of aspirin is not less than that of anticoagulants, and the role of preventing stroke is limited, Professor Ma Changsheng believes that for most patients with atrial fibrillation in China, aspirin is not taken. Necessary. If the patient needs anticoagulant therapy, take warfarin or take a new oral anticoagulant if economic conditions permit.

Professor Lin Junli also suggested that many patients with atrial fibrillation are because they are too troublesome to take warfarin, but they also need to take blood monitoring. When they are affected by food and medicine, they will switch to aspirin. It seems that eating a small piece every day is good. But in fact, aspirin is useless, and there is also a risk of bleeding, the advantages of which far outweigh the risk of bleeding.

In Taiwan, many people also like to eat aspirin to maintain health, saying that it can play a role in preventing coronary heart disease, stroke and many diseases. "In fact, these lack of clinical research evidence. Excessive use of aspirin, but it is easy to cause gastrointestinal adverse reactions ." Professor Lin Junli said.

However, both experts have emphasized that if patients with atrial fibrillation have coronary heart disease, it is another matter. Aspirin is still an irreplaceable drug for secondary prevention of coronary heart disease.

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