From the Guidelines
Patients with atrial fibrillation should not be on aspirin and Lovenox (enoxaparin) together for stroke prevention, as this combination has not shown a clear benefit and may increase the risk of bleeding. According to the 2024 ESC guidelines for the management of atrial fibrillation 1, antiplatelet drugs, such as aspirin, are not an alternative to oral anticoagulants (OAC) and should not be used for stroke prevention. The guidelines also state that combining antiplatelet drugs with anticoagulants should only occur in selected patients with acute vascular disease, and not for stroke prevention in atrial fibrillation patients.
The AVERROES trial demonstrated a lower rate of stroke or systemic embolism with apixaban compared with aspirin, with no significant difference in major bleeding 1. Additionally, the combination of OAC with antiplatelet agents, including aspirin, has been shown to increase the risk of bleeding events without a clear benefit in terms of stroke or death prevention 1.
In general, the use of aspirin and Lovenox together should be limited to specific clinical scenarios, such as acute coronary syndromes or percutaneous coronary intervention, and should be carefully considered due to the increased risk of bleeding. Patients on this combination should be monitored for signs of bleeding, and therapy duration should be limited to the period of highest thrombotic risk unless specifically indicated for long-term use.
Key points to consider:
- Aspirin is not an alternative to OAC for stroke prevention in atrial fibrillation patients
- Combining antiplatelet drugs with anticoagulants increases the risk of bleeding events
- The AVERROES trial demonstrated a lower rate of stroke or systemic embolism with apixaban compared with aspirin
- The use of aspirin and Lovenox together should be limited to specific clinical scenarios and carefully considered due to the increased risk of bleeding.
From the Research
Antithrombotic Therapy
The use of aspirin and enoxaparin in patients with acute coronary syndromes has been studied in several clinical trials.
- Aspirin is a standard antiplatelet agent used in the treatment of arterial thrombosis 2.
- Enoxaparin, a low molecular weight heparin, has been shown to be effective in reducing the risk of ischemic events in patients with acute coronary syndromes 3, 4.
Combination Therapy
The combination of aspirin, clopidogrel, and enoxaparin has been studied in patients with non-ST segment elevation acute coronary syndromes.
- This combination therapy has been shown to be associated with a reduction in the combined endpoint of death and non-fatal reinfarctions compared to standard therapy with aspirin and unfractionated heparin 5.
- However, the use of antithrombotic therapies is not without risks, and physician concerns over bleeding risks and complicated monitoring procedures have been reported as barriers to their use in patients 6.
Efficacy and Safety
The efficacy and safety of enoxaparin in acute coronary syndromes have been demonstrated in several clinical trials.
- Enoxaparin has been shown to be superior to unfractionated heparin in reducing the risk of death, myocardial infarction, and recurrent angina or urgent revascularization 3.
- The use of enoxaparin in combination with aspirin has been shown to be effective in reducing the risk of ischemic events in patients with acute coronary syndromes, with a putative odds ratio of 0.53 (95% CI, 0.31 to 0.92; P = .023) compared to placebo or untreated control 4.