European Heart Journal Advance Access originally published online on September 5, 2005
European Heart Journal 2006 27(5):519-526; doi:10.1093/eurheartj/ehi485
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Aspirin plus warfarin compared to aspirin alone after acute coronary syndromes: an updated and comprehensive meta-analysis of 25 307 patients
Institute of Cardiology, Catholic University, Largo F. Vito, 00168, Rome, Italy
Received 16 June 2005; revised 4 August 2005; accepted 11 August 2005; online publish-ahead-of-print 5 September 2005.
* Corresponding author. Tel: +39 0 6 30154187; fax: +39 0 6 3055535. E-mail address: felicita.andreotti{at}iol.it
Aims In patients recovering from acute coronary syndromes (ACS) the role of oral anticoagulation (and its intensity) in addition to aspirin remains controversial. We conducted a specific meta-analysis of randomized trials comparing aspirin plus warfarin (A+W) with aspirin alone in such patients.
Methods and results MEDLINE and Cochrane databases yielded 14 (of 148 potentially relevant) articles enrolling 25 307 patients. Follow-up ranged from 3 months to 5 years. Irrespective of International normalized ratio (INR), A+W did not significantly affect the risk of major adverse events (MAE: all cause death, non-fatal myocardial infarction, and non-fatal thrombo-embolic stroke) when compared with aspirin alone [OR 0.96 (0.90–1.03), P=0.30], but increased the risk of major bleeds (MB): OR 1.77 (1.47–2.13), P<0.00001. However, in studies with INR of 2–3, A+W was associated with a significant reduction of MAE [OR 0.73 (0.63–0.84), P<0.0001, number needed to treat to avoid one MAE=33], albeit at an increased risk of MB [OR 2.32 (1.63–3.29), P<0.00001; number needed to harm by causing one MB=100]. In both analyses, intracranial bleeding was not significantly increased by A+W when compared with aspirin alone.
Conclusion For patients recovering from ACS, a combined strategy of A+W at INR values of 2–3 doubles the risk of MB, but is nonetheless superior to aspirin alone in preventing MAE. Whether this combined regimen is also superior to a ‘double’ anti-platelet strategy or to newer evolving treatments warrants further investigation.
Key Words: Aspirin • Warfarin • Acute coronary syndromes • Meta-analysis • Outcome • Risk/benefit ratio
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  APPRAISE Steering Committee and Investigators Apixaban, an Oral, Direct, Selective Factor Xa Inhibitor, in Combination With Antiplatelet Therapy After Acute Coronary Syndrome: Results of the Apixaban for Prevention of Acute Ischemic and Safety Events (APPRAISE) Trial Circulation, June 9, 2009; 119(22): 2877 - 2885. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. S. Berger, M. J. Krantz, J. M. Kittelson, and W. R. Hiatt Aspirin for the Prevention of Cardiovascular Events in Patients With Peripheral Artery Disease: A Meta-analysis of Randomized Trials JAMA, May 13, 2009; 301(18): 1909 - 1919. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Sourgounis, J. Lipiecki, T. S. Lo, and M. Hamon Coronary Stents and Chronic Anticoagulation Circulation, March 31, 2009; 119(12): 1682 - 1688. [Full Text] [PDF]
|
|
|
|
 |
|
 F. Crea, P. G. Camici, R. De Caterina, and G. A. Lanza CHAPTER 17 Chronic Ischaemic Heart Disease ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Authors/Task Force Members, F. Van de Werf, J. Bax, A. Betriu, C. Blomstrom-Lundqvist, F. Crea, V. Falk, G. Filippatos, K. Fox, K. Huber, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology: Eur. Heart J., December 1, 2008; 29(23): 2909 - 2945. [Full Text] [PDF]
|
|
|
|
|
|
M. Y. Chan, F. Andreotti, and R. C. Becker Hypercoagulable States in Cardiovascular Disease Circulation, November 25, 2008; 118(22): 2286 - 2297. [Full Text] [PDF]
|
|
|
|
 |
|
 S. Husted Benefits and risks with antiplatelet therapy: how great a problem is bleeding? Eur. Heart J. Suppl., November 1, 2008; 10(suppl_I): I19 - I24. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. L. Bhatt, J. Scheiman, N. S. Abraham, E. M. Antman, F. K.L. Chan, C. D. Furberg, D. A. Johnson, K. W. Mahaffey, E. M. Quigley, R. A. Harrington, et al. ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents J. Am. Coll. Cardiol., October 28, 2008; 52(18): 1502 - 1517. [Full Text] [PDF]
|
|
|
|
|
|
Writing Committee Members, D. L. Bhatt, J. Scheiman, N. S. Abraham, E. M. Antman, F. K.L. Chan, C. D. Furberg, D. A. Johnson, K. W. Mahaffey, and E. M. Quigley ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents Circulation, October 28, 2008; 118(18): 1894 - 1909. [Full Text] [PDF]
|
|
|
|
 |
|
 G. Y H Lip Managing the anticoagulated patient with atrial fibrillation at high risk of stroke who needs coronary intervention BMJ, September 12, 2008; 337(sep12_1): a840 - a840. [Full Text]
|
|
|
|
 |
|
 J. Ansell, J. Hirsh, E. Hylek, A. Jacobson, M. Crowther, and G. Palareti Pharmacology and Management of the Vitamin K Antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 160S - 198S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Schulman, R. J. Beyth, C. Kearon, and M. N. Levine Hemorrhagic Complications of Anticoagulant and Thrombolytic Treatment: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 257S - 298S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Y H Lip Don't add aspirin for associated stable vascular disease in a patient with atrial fibrillation receiving anticoagulation BMJ, March 15, 2008; 336(7644): 614 - 615. [Full Text] [PDF]
|
|
|
|
 |
|
 The Warfarin Antiplatelet Vascular Evaluation Tria Oral Anticoagulant and Antiplatelet Therapy and Peripheral Arterial Disease N. Engl. J. Med., July 19, 2007; 357(3): 217 - 227. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. C. Nguyen, Y. L. Lim, A. Walton, J. Lefkovits, G. Agnelli, S. G. Goodman, A. Budaj, D. C. Gulba, J. Allegrone, D. Brieger, et al. Combining warfarin and antiplatelet therapy after coronary stenting in the Global Registry of Acute Coronary Events: is it safe and effective to use just one antiplatelet agent? Eur. Heart J., July 2, 2007; 28(14): 1717 - 1722. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Authors/Task Force Members, J.-P. Bassand, C. W. Hamm, D. Ardissino, E. Boersma, A. Budaj, F. Fernandez-Aviles, K. A.A. Fox, D. Hasdai, E. M. Ohman, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology Eur. Heart J., July 1, 2007; 28(13): 1598 - 1660. [Full Text] [PDF]
|
|
|
|
|
|
R. De Caterina, S. Husted, L. Wallentin, G. Agnelli, F. Bachmann, C. Baigent, J. Jespersen, S. D. Kristensen, G. Montalescot, A. Siegbahn, et al. Anticoagulants in heart disease: current status and perspectives Eur. Heart J., April 10, 2007; (2007) ehl492v1. [Full Text] [PDF]
|
|
|
|
|
|
G. Y. H. Lip and M. Karpha Anticoagulant and Antiplatelet Therapy Use in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: The Need for Consensus and a Management Guideline Chest, December 1, 2006; 130(6): 1823 - 1827. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. G.L. Biondi-Zoccai, M. Lotrionte, P. Agostoni, A. Abbate, M. Fusaro, F. Burzotta, L. Testa, I. Sheiban, and G. Sangiorgi A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50 279 patients at risk for coronary artery disease Eur. Heart J., November 2, 2006; 27(22): 2667 - 2674. [Abstract] [Full Text] [PDF]
|
|