Concomitant use of direct oral anticoagulants and aspirin versus direct oral anticoagulants alone in atrial fibrillation and flutter: a retrospective cohort

Abstract

Background: The benefit of combining aspirin and direct oral anticoagulants on the reduction of cardiovascular events in atrial fibrillation or flutter is not well studied. We aimed to assess whether concurrent aspirin and direct oral anticoagulant therapy for atrial fibrillation or flutter will result in less coronary, cerebrovascular and systemic ischemic events compared to direct oral anticoagulant therapy alone. Methods: Retrospective study of adult patients between 18 and 100 years old who have nonvalvular atrial fibrillation or flutter and were started on a direct oral anticoagulant (apixaban, rivaroxaban, or dabigatran), between January 1, 2010 and September 1, 2015 within the Beaumont Health System. Exclusions were history of venous thromboembolic disease and use of other antiplatelet therapies such as P2Y12 inhibitors. Patients were classified into two groups based on concurrent aspirin use and observed for a minimum of 2 years. Primary outcome was major adverse cardiac events, defined as acute coronary syndromes, ischemic strokes, and embolic events. Secondary outcomes were bleeding and death. Results: Six thousand four patients were in the final analysis, 57% males and 80% Caucasians, median age 71, interquartile range (63-80). The group exposed to aspirin contained 2908 subjects, and the group unexposed to aspirin contained 3096 subjects. After using propensity scores to balance the baseline characteristics in both groups, the analysis revealed higher rate of major adverse cardiac events in the exposed group compared to the unexposed group, (HR 2.11, 95% CI (1.74-2.56)) with a number needed to harm of 11 (95% CI [9-11]). The rate of bleeding was also higher in the exposed group, (HR 1.30, 95% CI (1.11-1.52)). The rate of death was not statistically different between the groups, (HR 0.87, 95% CI (0.61-1.25)).

Pharmacogenetics of Bleeding and Thromboembolic Events in Direct Oral Anticoagulant Users

“…Antiplatelets are in many cases used in parallel with a DOAC to increase protection towards thromboembolic events. As shown in this study and others, concomitant use of antiplatelets and a DOAC increases the risk of bleeding 43–45 . One strength of the present study is that we were able to access information on acetylsalicylic acid usage via the data obtained from patient records 33 .…”

“…As shown in this study and others, concomitant use of antiplatelets and a DOAC increases the risk of bleeding. [43][44][45] One strength of the present study is that we were…”

Fatal Adverse Events of Dabigatran Combined With Aspirin in Elderly Patients: An Analysis Using Data From VigiBase

“…Hence, we have selected and analyzed the well-documented reports. In addition, the risk of particularly devastating consequences deriving from concomitant antithrombotic drugs used post-marketing could be higher than reported in controlled clinical trial as underlined in several previous studies ( Gulati et al, 2018 ; Menditto and Antonicelli, 2020 ; Said et al, 2020 ). However, the magnitude of this risk cannot be determined in this study due to the nature of spontaneous reporting.…”

Efficacy and safety of direct oral anticoagulants with and without Aspirin: A systematic review and Meta-analysis

“…More recently, randomized control trials and cohort studies compared an alternative therapy- monotherapy with DOAC alone vs dual therapy with DOAC + Aspirin (ASA) to identify the safest treatment option for patients with atrial fibrillation (AF). [3] , [5] , [6] Evidence shows that patients exposed to dual therapy have a higher risk of bleeding and major adverse cardiac events. [3] Nevertheless, there are limited meta -analyses and systematic reviews that investigate the safety and efficacy of dual therapy (DOAC + ASA) vs mono therapy (DOAC alone) among patients with NVAF and VTE (Venous thromboembolism).…”