Robin J Larson1, Elliott S Fisher. 1. VA Outcomes Group, Department of Veteran Affairs Medical Center, White River Junction, VT, USA. robin.j.larson@hitchcock.org
Abstract
BACKGROUND AND OBJECTIVE: Clinicians frequently face the decision of whether to continue aspirin when starting patients on warfarin. We performed a meta-analysis to characterize the tradeoffs involved in this common clinical dilemma. DATA SOURCES: Multiple computerized databases (1966 to 2003), reference lists of relevant articles, conference proceedings, and queries of primary authors. STUDY SELECTION: Randomized trials comparing warfarin plus aspirin versus warfarin alone. Studies with target international normalized ratios (INRs) <2 were excluded. DATA EXTRACTION: Two reviewers independently extracted baseline data and major outcomes: rates of thromboembolism, hemorrhage, and all-cause mortality. DATA SYNTHESIS: Nine studies met the inclusion criteria. Of the five that enrolled patients with mechanical heart valves, four used the same target INR in both groups, while one used a reduced target INR for the warfarin plus aspirin group. Pooling the results of the first four studies demonstrated that combination of warfarin plus aspirin significantly decreased thromboembolic events (relative risk [RR], 0.33; 95% confidence interval [CI], 0.19 to 0.58), increased major bleeding (RR, 1.58; 95% CI, 1.02 to 2.44), and decreased all-cause mortality (RR, 0.43; 95% CI, 0.23 to 0.81) compared to warfarin alone. The one valve trial using a reduced INR in the warfarin plus aspirin group reported no difference in thromboembolic outcomes but found decreased major bleeding and a significant mortality benefit with combination therapy. Of the remaining trials, three evaluated a warfarin indication not routinely used in the United States (post-myocardial infarction), and the only trial that considered atrial fibrillation was terminated early due to inadequate enrollment. CONCLUSIONS: For mechanical heart valve patients, the benefits of continuing aspirin when starting warfarin therapy are clear. For other routine warfarin indications, there are not adequate data to guide this common clinical decision.
BACKGROUND AND OBJECTIVE: Clinicians frequently face the decision of whether to continue aspirin when starting patients on warfarin. We performed a meta-analysis to characterize the tradeoffs involved in this common clinical dilemma. DATA SOURCES: Multiple computerized databases (1966 to 2003), reference lists of relevant articles, conference proceedings, and queries of primary authors. STUDY SELECTION: Randomized trials comparing warfarin plus aspirin versus warfarin alone. Studies with target international normalized ratios (INRs) <2 were excluded. DATA EXTRACTION: Two reviewers independently extracted baseline data and major outcomes: rates of thromboembolism, hemorrhage, and all-cause mortality. DATA SYNTHESIS: Nine studies met the inclusion criteria. Of the five that enrolled patients with mechanical heart valves, four used the same target INR in both groups, while one used a reduced target INR for the warfarin plus aspirin group. Pooling the results of the first four studies demonstrated that combination of warfarin plus aspirin significantly decreased thromboembolic events (relative risk [RR], 0.33; 95% confidence interval [CI], 0.19 to 0.58), increased major bleeding (RR, 1.58; 95% CI, 1.02 to 2.44), and decreased all-cause mortality (RR, 0.43; 95% CI, 0.23 to 0.81) compared to warfarin alone. The one valve trial using a reduced INR in the warfarin plus aspirin group reported no difference in thromboembolic outcomes but found decreased major bleeding and a significant mortality benefit with combination therapy. Of the remaining trials, three evaluated a warfarin indication not routinely used in the United States (post-myocardial infarction), and the only trial that considered atrial fibrillation was terminated early due to inadequate enrollment. CONCLUSIONS: For mechanical heart valvepatients, the benefits of continuing aspirin when starting warfarin therapy are clear. For other routine warfarin indications, there are not adequate data to guide this common clinical decision.
Authors: J B Segal; R L McNamara; M R Miller; N Kim; S N Goodman; N R Powe; K A Robinson; E B Bass Journal: J Gen Intern Med Date: 2000-01 Impact factor: 5.128
Authors: Carl van Walraven; Robert G Hart; Daniel E Singer; Andreas Laupacis; Stuart Connolly; Palle Petersen; Peter J Koudstaal; Yuchiao Chang; Beppie Hellemons Journal: JAMA Date: 2002-11-20 Impact factor: 56.272
Authors: C M O'Connor; W A Gattis; A S Hellkamp; A Langer; R L Larsen; R A Harrington; S D Berkowitz; P T O'Gara; S L Kopecky; M Gheorghiade; R Daly; R M Califf; V Fuster Journal: Am J Cardiol Date: 2001-09-01 Impact factor: 2.778
Authors: M Heras; J H Chesebro; V Fuster; W J Penny; D E Grill; K R Bailey; G K Danielson; T A Orszulak; J R Pluth; F J Puga Journal: J Am Coll Cardiol Date: 1995-04 Impact factor: 24.094
Authors: Tiago L L Leiria; Renato D Lopes; Judson B Williams; Jason N Katz; Renato A K Kalil; John H Alexander Journal: J Thromb Thrombolysis Date: 2011-05 Impact factor: 2.300
Authors: Natalie Oake; Alison Jennings; Alan J Forster; Dean Fergusson; Steve Doucette; Carl van Walraven Journal: CMAJ Date: 2008-07-29 Impact factor: 8.262