UK NICE Quality Standard Replaces Aspirin With New Anticoagulants for VTE and Stroke Prevention in AF Patients

July 9, 2015—The United Kingdom’s National Institute for Health and Care Excellence (NICE) issued a quality standard advising that adults with atrial fibrillation (AF) should be prescribed newer anticoagulant medications instead of aspirin for the prevention of venous thromboembolism (VTE) and stroke. According to NICE, the risks of taking aspirin—which can cause stomach bleeding—now outweigh the benefits of taking the drug, which has been used for years to help protect patients from stroke.

NICE’s QS3 quality standard for VTE prevention, which sets out advice on the treatment and management of AF, recommends that people with AF who have a CHA2DS2-VASC stroke risk score ≥ 2 are offered newer anticoagulants, such as apixaban, dabigatran etexilate, rivaroxaban, or a vitamin K antagonist like warfarin.

The NICE announcement stated that it is important to note that many adults with AF may already be taking aspirin for other conditions. If so, this may result in the patient taking aspirin in addition anticoagulants. If a patient chooses not to take anticoagulants, this decision and the reason for it should be documented by his or her doctor.

The quality standard, which is based on NICE’s CG180 guideline on AF, also recommends that patients with AF who are prescribed anticoagulants discuss their options with their doctor at least once a year in order to improve adherence to treatment.

Patients should have their anticoagulation regimen reassessed if they are taking a vitamin K antagonist and have poor anticoagulation control. A referral to specialist management within 4 weeks should be made for those symptoms that have not been controlled by anticoagulation, advised NICE.

In the NICE announcement, Matthew Fay, MD, a specialist member of the committee that developed the standard, commented, “The ineffectiveness of aspirin and the need to remove it from the AF patient pathway receives a much needed, and rare, negative statement. This should provide the impetus to those who still speculate on the value of aspirin from historic practice to have the discussion with their patients about the benefits of anticoagulation hopefully before, and not after, a devastating stroke event.”

Also commenting in the announcement, Prof. Gillian Leng, MD, Deputy Chief Executive and Director of Health and Social Care at NICE, stated,  “AF can be a distressing condition, and people with it have an increased risk of having a stroke. Therefore, it’s important that people with AF have their condition managed effectively in order to eliminate the significant risk of stroke and prevent deterioration in their quality of life.”

Prof. Beverley Hunt, MD, who is Medical Director of Thrombosis UK and specialist member of the committee that developed the standard, added, “The NICE AF quality standard provides a minimum standard of care expected within National Health Services England. It demands that patients at high risk of stroke without a bleeding risk are offered blood thinners—either warfarin or the newer oral anticoagulants—but not aspirin.”

Prof. Hunt continued, “Every patient needs to decide with their health care professional which is most suitable for them, and they should be reviewed annually. Those who self-monitor their warfarin with a home coagulometer should be supported. Lastly, if treatment fails to control symptoms, then patients should be referred for specialist management within 4 weeks. These quality standards are important because without adequate blood thinners, many patients would have a preventable stroke, and stroke can have a devastating impact on lives causing loss of movement, independent living, and even death.”