From the Guidelines
For atrial fibrillation, anticoagulants rather than antiplatelets are the treatment of choice, and antiplatelet therapy alone is not recommended for stroke prevention. The most recent and highest quality study, the 2024 ESC guidelines for the management of atrial fibrillation 1, emphasizes that antiplatelet drugs, such as aspirin and clopidogrel, are not an alternative to oral anticoagulation (OAC) and should not be used for stroke prevention. This is further supported by the AVERROES trial, which demonstrated a lower rate of stroke or systemic embolism with apixaban compared with aspirin 1.
Key Points
- Antiplatelet therapy alone is not recommended for stroke prevention in atrial fibrillation
- Anticoagulants, such as direct oral anticoagulants (DOACs), are preferred over warfarin for most patients
- The decision to anticoagulate should be based on stroke risk assessment using the CHA₂DS₂-VASc score
- Combining antiplatelet drugs with anticoagulants should only occur in selected patients with acute vascular disease
The 2024 ESC guidelines also highlight that combining OAC with antiplatelet agents without an adequate indication occurs frequently in clinical practice, but bleeding events are more common when antithrombotic agents are combined, and no clear benefit has been observed in terms of prevention of stroke or death 1. Therefore, aspirin or other antiplatelet agents should not be used as a substitute for anticoagulation in patients with atrial fibrillation, unless there are specific contraindications to anticoagulation, in which case aspirin 81-325mg daily may be considered, but it provides significantly less stroke protection. The CHA₂DS₂-VASc score should be used to assess stroke risk, with anticoagulation generally recommended for scores of 2 or higher in men and 3 or higher in women 1.
From the Research
Antiplatelet Therapy in Atrial Fibrillation
The choice of antiplatelet therapy in patients with atrial fibrillation (AF) depends on various factors, including the presence of other conditions such as heart failure or coronary artery disease.
- Aspirin is often used, but its effectiveness in preventing stroke is limited compared to oral anticoagulants like warfarin or non-vitamin K antagonist oral anticoagulants (NOACs) 2, 3.
- In patients with AF undergoing percutaneous coronary intervention (PCI), dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is recommended, along with a non-vitamin K antagonist oral anticoagulant 4, 5.
- The use of triple antithrombotic therapy (aspirin, P2Y12 inhibitor, and oral anticoagulant) may be necessary in certain situations, but it increases the risk of bleeding 4, 5, 6.
Specific Antiplatelet Agents
- Clopidogrel is a commonly used P2Y12 inhibitor in patients with AF, and it is often preferred over aspirin alone in patients who have refused oral anticoagulation 6.
- Apixaban, a NOAC, has been shown to have a favorable effectiveness and safety profile compared to warfarin, and it may be used in combination with a P2Y12 inhibitor in patients with AF undergoing PCI 3, 5.
Bleeding Risks
- The risk of bleeding is a major concern in patients with AF receiving antiplatelet therapy, and the use of triple antithrombotic therapy increases this risk 4, 5, 6.
- The choice of antiplatelet agent and oral anticoagulant should be individualized based on the patient's risk of bleeding and thromboembolic events 2, 3.