Aspirin and prophylaxis of thromboembolic complications in patients with substitute heart valves

Altman, Raúl; Boullón, Fernando; Rouvier, Jorge; Raca, Raul; Fuente, Luis de la; Favaloro, René G.

doi:10.1016/s0022-5223(19)40105-0

Cited by 161 publications

(49 citation statements)

References 9 publications

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“…Major bleeding typically included episodes that led to a drop in hemoglobin of >2 g/dL, required hospitalization or transfusion of blood products, or resulted in death. Again shown in Table 3, major bleeding events were increased or equivalent with warfarin plus aspirin in all three of the single-intervention trials reporting this outcome 13,15,16 (pooled RR, 1.58; 95% CI, 1.02 to 2.44; ARR, −5%; NNH, 20). Conversely, the double-intervention trial 18 found fewer bleeding events in the combination therapy group.…”

Section: Mechanical Heart Valvesmentioning

confidence: 91%

“…Transient ischemic attacks were included in four of the five trials. 12,13,15,18 As shown in Table 3, thromboembolic event rates were lower in the combination therapy groups in all four of the single-intervention trials 12 Major Bleeding. Major bleeding typically included episodes that led to a drop in hemoglobin of >2 g/dL, required hospitalization or transfusion of blood products, or resulted in death.…”

Section: Mechanical Heart Valvesmentioning

confidence: 91%

“…Manual reference review led to the identification of one additional randomized trial. 13 Ultimately, the searches resulted in a collection of nine qualifying trials, 12,13,15 -22 which together addressed three warfarin indications ( Table 1).…”

Section: Study Selectionmentioning

confidence: 99%

“…Because the test of heterogeneity was significant for the combined group (P = .07), we pooled the single-intervention all-cause mortality findings both before and after excluding the Laffort results (the only trial finding increased mortality with combination therapy). 15 Using the data from all four trials 12,13,15,16…”

Section: Mechanical Heart Valvesmentioning

confidence: 99%

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Should aspirin be continued in patients started on warfarin?

Larson

Fisher

2004

J Gen Intern Med

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Section: Mechanical Heart Valvesmentioning

confidence: 91%

Section: Mechanical Heart Valvesmentioning

confidence: 91%

Section: Study Selectionmentioning

confidence: 99%

Section: Mechanical Heart Valvesmentioning

confidence: 99%

See 2 more Smart Citations

Should aspirin be continued in patients started on warfarin?

Larson

Fisher

2004

J Gen Intern Med

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“…may cause some bleeding [17, 181. Conceivably, the combined use of OAC and aspirin should have an additive effect by suppressing both the plasma coagulation cascade and the platelet function. Clinical experience with the combination is limited, however, and reports on bleeding complications are both sparse and conflicting [2,9,10,12,131. The optimal intensity of anticoagulation in combined warfarin and antiplatelet therapy has not yet been established, and routine use of this treatment modality has to our knowledge not previously been reported.…”

Section: Introductionmentioning

confidence: 99%

Comparison of bleeding complications of warfarin and warfarin plus acetylsalicylic acid: a study in 3166 outpatients

Hurlen

Erikssen

Smith

et al. 1994

Journal of Internal Medicine

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Combined Aspirin–Oral Anticoagulant Therapy Compared With Oral Anticoagulant Therapy Alone Among Patients at Risk for Cardiovascular Disease

Dentali

Douketis²,

Lim³

et al. 2007

Arch Intern Med

188

112

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Background: For patients receiving oral anticoagulant (OAC) therapy, deciding whether to add aspirin to their treatment is a common clinical scenario with no clear guidelines to aid practice. We performed a systematic review and meta-analysis of randomized controlled trials comparing these 2 treatment strategies (combined aspirin-OAC therapy vs OAC therapy alone) to assess the therapeutic benefits and risks. Data Sources: Randomized controlled trials published up to June 2005 in MEDLINE, EMBASE, and Cochrane Library databases.Study Selection: Randomized controlled trials with at least 3 months of follow-up that compared aspirin-OAC therapy with OAC therapy alone, in which OAC was administered to achieve the same target international normalized ratio or was given at the same fixed dose in both treatment arms.Data Extraction: Two reviewers independently extracted data on study characteristics and outcomes. Pooled odds ratios (ORs) and associated 95% confidence intervals (CIs) were calculated for study outcomes in patients receiving aspirin-OAC therapy and OAC therapy alone.Data Synthesis: Ten studies were included, totaling 4180 patients. The risk for arterial thromboembolism was lower in patients receiving combined aspirin-OAC therapy compared with OAC therapy alone (OR, 0.66; 95% CI, 0.52-0.84). However, these benefits were limited to patients with a mechanical heart valve (OR, 0.27; 95% CI, 0.15-0.49). There was no difference in the risk for arterial thromboembolism with these treatments in patients with atrial fibrillation (OR, 0.99; 95% CI, 0.47-2.07) or coronary artery disease (OR, 0.69; 95% CI, 0.35-1.36). There was no difference in all-cause mortality with either treatment (OR, 0.98; 95% CI, 0.77-1.25). The risk for major bleeding was higher in patients receiving aspirin-OAC therapy compared with OAC therapy alone (OR, 1.43; 95% CI, 1.00-2.02). Conclusion:Our findings question the current practice of using combined aspirin-OAC therapy except in patients with a mechanical heart valve, given the questionable benefits in reducing thromboembolic events and the increased risk of major bleeding.

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Aspirin and prophylaxis of thromboembolic complications in patients with substitute heart valves

Cited by 161 publications

References 9 publications

Should aspirin be continued in patients started on warfarin?

Should aspirin be continued in patients started on warfarin?

Comparison of bleeding complications of warfarin and warfarin plus acetylsalicylic acid: a study in 3166 outpatients

Combined Aspirin–Oral Anticoagulant Therapy Compared With Oral Anticoagulant Therapy Alone Among Patients at Risk for Cardiovascular Disease

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