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Implications of Adding Aspirin to DOAC Without Clear Indication
Quick Takes
- Concomitant use of aspirin and a DOAC is common among patients without an indication for DAPT.
- Aspirin and DOAC are associated with higher rates of bleeding and hospitalization compared to DOAC alone.
- No difference in thrombosis rates was observed for patients using aspirin plus a DOAC compared to a DOAC alone.
Study Questions:
Among patients taking a direct oral anticoagulant (DOAC) for atrial fibrillation (AF) and/or venous thromboembolism (VTE), what are the outcomes following concurrent aspirin use?
Methods:
Data from the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) were used for the present analysis. Four anticoagulation clinics in Michigan provided data from January 2015 to December 2019 on eligible adults undergoing treatment with a DOAC for AF or VTE, without a recent myocardial infarction (MI), history of heart valve replacement, and with ≥3 months of follow-up. Aspirin use was defined based on medications assessed at the time of DOAC initiation. The primary outcomes of interest were bleeding rates (any, nonmajor, major), rates of thrombosis (stroke, VTE, MI), emergency department visits, hospitalizations, and death.
Results:
A total of 3,290 patients (1,673 [51.0%] men; mean [SD] age 68.2 [13.3] years) were included in the present analysis, of which 1,107 (33.8%) were without a clear indication for aspirin and were being treated with DOACs and aspirin. Patients were followed up for a mean of 20.9 (SD, 19.0) months. After propensity matching, patients taking a DOAC and aspirin experienced more bleeding events compared with DOAC monotherapy. Patients taking combination therapy had significantly higher rates of nonmajor bleeding (26.1 bleeds vs. 21.7 bleeds per 100 patient-years, p = 0.02) compared with DOAC monotherapy. However, major bleeding rates were similar between those taking both DOAC and aspirin versus DOAC only. Thrombotic event rates were also similar between the cohorts (2.5 events vs. 2.3 events per 100 patient-years for patients treated with DOAC and aspirin compared with DOAC monotherapy, p = 0.80). Patients were more often hospitalized while undergoing combination therapy (9.1 vs. 6.5 admissions per 100 patient-years, p = 0.02).
Conclusions:
The investigators concluded that nearly one-third of patients with AF and/or VTE treated with a DOAC received aspirin without a clear indication. Compared with DOAC monotherapy, concurrent DOAC and aspirin use was associated with increased bleeding and hospitalizations but similar observed thrombosis rates. Future research should identify and de-prescribe aspirin for patients when the risk exceeds the anticipated benefit.
Perspective:
These findings support the need for education and guidance to providers who care for cardiovascular patients. The implications of reducing unnecessary aspirin use are significant for patients and health care systems.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Anticoagulation Management and Venothromboembolism, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Aspirin, Atrial Fibrillation, Delivery of Health Care, Emergency Service, Hospital, Heart Valve Diseases, Hemorrhage, Myocardial Infarction, Quality Improvement, Secondary Prevention, Stroke, Thrombosis, Vascular Diseases, Venous Thromboembolism
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