Rational Pharmacotherapy in Cardiology

Advanced search


Full Text:


Current guidelines for the management of atrial fibrillation (AF) recommend using anticoagulants as first-line drugs for stroke prevention, but in real medical practice antiplatelet drugs are often prescribed to elderly patients. Review of clinical and pharmacoepidemiological studies allows us to conclude that  risk associated with acetylsalicylic acid (ASA) use in patients ≥75 years can overweigh its potential benefit. Other antiplatelet drugs are poorly studied in patients with AF. Dual antiplatelet therapy (ASA + clopidogrel) can be prescribed to elderly patients with cardiovascular comorbidity who are deemed unsuitable candidates for anticoagulant therapy for reasons other  than  bleeding risk or those  who refuse to take oral anticoagulants. Combined therapy of antiplatelet drugs with warfarin or new oral anticoagulants results in no reduction in stroke rate compared with anticoagulant monotherapy but is associated with increased risk of bleeding and can’t be recommended.

About the Authors

E. А. Ushkalova
People's Friendship University of Russia
Russian Federation

Elena A. Ushkalova – MD, PhD, Professor, Chair of General and Clinical Pharmacology.

Miklukho-Maklaya ul. 6, Moscow, 117198

S. K. Zyryanov
People's Friendship University of Russia
Russian Federation

Sergei K. Zyryanov – MD, PhD, Professor, Head of Chair of General and Clinical Pharmacology.

Miklukho-Maklaya ul. 6, Moscow, 117198

E. V. Dumchenko
People's Friendship University of Russia
Russian Federation

Ekaterina V. Dumchenko – MD, PhD Student, Chair of General and Clinical Pharmacology.

Miklukho-Maklaya ul. 6, Moscow, 117198


1. Pugh D., Pugh J., Mead G.E. Attitudes of physicians regarding anticoagulation for atrial fibrillation: a systematic review. Age and ageing. 2011;40(6):675-83.

2. Singer D.E., Albers G.W., Dalen J.E., et al. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6Suppl):546S-592S.

3. Lip G.Y., Laroche C., Dan G.A., et al. A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry. Europace. 2014;16(3):308-19.

4. Hsu J.C., Maddox T.M., Kennedy K., et al. Aspirin Instead of Oral Anticoagulant Prescription in Atrial Fibrillation Patients at Risk for Stroke. J Am CollCardiol. 2016 ;67(25):2913-23.

5. Ben Freedman S., Gersh B.J., Lip G.Y. Misperceptions of aspirin efficacy and safety may perpetuate anticoagulant underutilization in atrial fibrillation. Eur Heart J. 2015;36:653-6.

6. Bajorek B., Magin P.J., Hilmer S., Krass I. Utilization of antithrombotic therapy for stroke prevention in atrial fibrillation: a cross-sectional baseline analysis in general practice. J Clin Pharm Ther. 2016;41(4):432-40.

7. Linchak R.M., Kompanietz O.G., Nedbaikin A.M., et al. What are the realities of antithrombotic therapy prescribing and control in out-patient practice? Kardiologiia. 2015;55(6):34-9. (In Russ.) [Линчак Р.М., Компаниец О.Г., Недбайкин А.М. и др. Каковы реалии назначения и контроля антитромботической терапии при фибрилляции предсердий в амбулаторной практике? Кардиология. 2015;55(6):34-9].

8. Antithrombotic Agents for the Prevention of Stroke and Systemic Embolism in Patients With Atrial Fibrillation [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2013 Mar. CADTH Therapeutic Reviews. Available at: Checked by Feb 10, 2017.

9. Hart R.G., Pearce L.A., Aguilar M.I. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Annals of internal medicine. 2007;146(12):857-67.

10. Stroke Prevention in Atrial Fibrillation Investigators. Stroke prevention in atrial fibrillation study. Final results. Circulation. 1991;84(2):527-39.

11. Aguilar M., Hart R., Pearce L.A. Oral anticoagulants versus antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no history of stroke or transient ischemic attacks. Cochrane Database Syst Rev. 2007;(3):CD006186.

12. Cameron C., Coyle D., Richter T., et al. Systematic review and networkmeta-analysis comparing antithrombotic agents for the prevention of stroke andmajor bleeding in patients with atrial fibrillation. BMJ Open. 2014;4(6):e004301.

13. ACTIVE Investigators. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009;360:2066-78.

14. Olesen J.B., Lip G.Y., Lindhardsen J., et al. Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: A net clinical benefit analysis using a ‘real world’ nationwide cohort study. Thrombosis and Haemostasis. 2011;106(4):739-49.

15. Själander S., Själander A., Svensson P.J., Friberg L. Atrial fibrillation patients do not benefit from acetylsalicylic acid. Stroke. 2009;40:1410-6.

16. Sato H., Ishikawa K., Kitabatake A., et al. Low-dose aspirin for prevention of stroke in low-risk patients with atrial fibrillation: Japan Atrial Fibrillation Stroke Trial. Stroke. 2006;37(2):447-51.

17. Segal J.B., McNamara R.L., Miller M.R., et al. Prevention of thromboembolism in atrial fibrillation. A meta-analysis of trials of anticoagulants and antiplatelet drugs. J Gen Intern Med. 2000;15:56-67.

18. Andersen L.V., Vestergaard P., Deichgraeber P., et al. Warfarin for the prevention of systemic embolism in patients with non-valvular atrial fibrillation: a meta-analysis. Heart 2008; 94:1607-13.

19. Zhang J.T., Chen K.P., Zhang S. Efficacy and safety of oral anticoagulants versus aspirin for patients with atrial fibrillation: a meta-analysis. Medicine (Baltimore). 2015;94(4):e409.

20. Vazquez F.J., Gonzalez J.P., LeGal G., et al. Risk of major bleeding in patients receiving vitamin K antagonists or low doses of aspirin. A systematic review and meta-analysis. Thromb Res. 2016;138: 1-6.

21. Warkentin A.E., Donadini M.P., Spencer F.A., et al. Bleeding risk in randomized controlled trials comparing warfarin and aspirin: a systematic review and meta-analysis. J Thromb Haemost. 2012;10(4): 512-20.

22. Tawfik A., Bielecki J.M., Krahn M., et al. Systematic review and network meta-analysis of stroke prevention treatments in patients with atrial fibrillation. Clin Pharmacol. 2016;8:93-107.

23. Connolly S.J., Eikelboom J., Joyner C., et al. Apixaban in patients with atrial fibrillation. N Engl J Med.2011;364(9):806-17.

24. Kirchhof P., Benussi S., Kotecha D., et al. Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893-2962.

25. Hobbs F.R., Taylor C.J., Jan Geersing G., et al. European Primary Care Cardiovascular Society (EPCCS) consensus guidance on stroke prevention in atrial fibrillation (SPAF) in primary care. Eur J PrevCardiol. 2016;23(5):460-73.

26. Flaker G.C., Gruber M., Connolly S.J., et al. Risks and benefits of combining aspirin with anticoagulant therapy in patients with atrial fibrillation: an exploratory analysis of stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) trials. Am Heart J. 2006;152(5):967-73.

27. Dentali F., Riva N., Crowther M., et al. Efficacy and safety of the novel oral anticoagulants in atrial fibrillation: a systematic review and meta-analysis of the literature. Circulation. 2012;126(20): 2381-91.

28. [No authors listed.]. Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet. 1996;348:633.

29. Manning W.J., Singer D.E., Lip G.Y.H. Atrial fibrillation: Anticoagulant therapy to prevent embolization. UpToDate. Available at: Checked by Feb 10, 2017.

30. Kumar S., Danik S.B., Altman R.K., et al. Non-Vitamin K Antagonist Oral Anticoagulants and Antiplatelet Therapy for Stroke Prevention in Patients With Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials. Cardiol Rev. 2016;24(5):218-23.

31. Lane D.A., Raichand S., Moore D., et al. Combined anticoagulation and antiplatelet therapy for highrisk patients with atrial fibrillation: a systematic review. Health Technol Assess. 2013;17(30):1-188.

32. vanWalraven C., Hart R.G., Connolly S., et al. Effect of age on stroke prevention therapy in patients with atrial fibrillation: the atrial fibrillation investigators. Stroke. 2009;40(4):1410-6.

33. Rash A., Downes T., Portner R., et al. A randomised controlled trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation(WASPO). Age Ageing. 2007;36:151-6.

34. Vazquez F.J., Gonzalez J.P., Gándara E. Aspirin compared to low intensity anticoagulation in patients with non-valvularatrial fibrillation. A systematic review and meta-analysis. PLoS One. 2015 12;10(11):e0142222.

35. Eckman M.H., Lip G.Y., Wise R.E., et al. Using an atrial fibrillation decision support tool for thromboprophylaxis in atrial fibrillation: effect of sex and age. J Am Geriatr Soc. 2016;64(5):1054-60.

36. Sarafoff N., Byrne R. A., Sibbing D. Clinical use of clopidogrel. Current Pharmaceutical Design. 2012;18(33):5224-39.

37. Diagnostics and Treatment of Atrial Fibrillation. Russian Guidelines. Moscow: VNOAandACVS; 2012. (In Russ.) Диагностика и лечение фибрилляции предсердий. Национальные рекомендации. М.: ВНОАиАССХ; 2012.

38. Edholm K., Ragle N., Rondina M.T. Antithrombotic management of atrial fibrillation in the elderly. Med Clin North Am. 2015;99(2):417-30.

39. Fernández S.C., Formiga F., Camafort M. Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach. BMC Cardiovascular Disorders 2015;15:143.

40. O'Mahony D., O'Sullivan D., Byrne S., et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(N2):213-8.

For citation:

Ushkalova E.А., Zyryanov S.K., Dumchenko E.V. ANTIPLATELET THERAPY OF ATRIAL FIBRILLATION: FOCUS ON THE ELDERLY. Rational Pharmacotherapy in Cardiology. 2017;13(1):124-128. (In Russ.)

Views: 367

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.

ISSN 1819-6446 (Print)
ISSN 2225-3653 (Online)