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Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial
Abstract
Background Anticoagulants are more effective than antiplatelet agents at reducing stroke risk in patients with atrial fibrillation, but whether this benefit outweighs the increased risk of bleeding in elderly patients is unknown. We assessed whether warfarin reduced risk of major stroke, arterial embolism, or other intracranial haemorrhage compared with aspirin in elderly patients.Methods 973 patients aged 75 years or over (mean age 81.5 years, SD 4.2) with atrial fibrillation were recruited from primary care and randomly assigned to warfarin (target international normalised ratio 2-3) or aspirin (75 mg per day). Follow-up was for a mean of 2.7 years (SD 1.2). The primary endpoint was fatal or disabling stroke (ischaemic or haemorrhagic), intracranial haemorrhage, or clinically significant arterial embolism. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN89345269.Findings There were 24 primary events (21 strokes, two other intracranial haemorrhages, and one systemic embolus) in people assigned to warfarin and 48 primary events (44 strokes, one other intracranial haemorrhage, and three systemic emboli) in people assigned to aspirin (yearly risk 1.8%vs 3.8%, relative risk 0.48, 95% CI 0.28-0.80, p=0.003; absolute yearly risk reduction 2%, 95% CI 0.7-3.2). Yearly risk of extracranial haemorrhage was 1.4% (warfarin) versus 1.6% (aspirin) (relative risk 0.87, 0.43-1.73; absolute risk reduction 0.2%, -0.7 to 1.2).Interpretation These data support the use of anticoagulation therapy for people aged over 75 who have atrial fibrillation, unless there are contraindications or the patient decides that the benefits are not worth the inconvenience.
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“Antiplatelet therapy increases bleeding risk, especially dual antiplatelet therapy (2.0% vs. 1.3% with antiplatelet monotherapy; P < 0.001), 433 with bleeding rates that are similar to those on OAC.354,362,431,434”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [362]
In the citing paper
“Good data are available to support the use of anticoagulants in older patients from BAFTA (Birmingham Atrial Fibrillation Treatment of the Aged Study), 362 the NOAC trials, 39 and from analyses in elderly Americans (Medicare).396”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [362]
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Lafuente‐Lafuente, C., Emery, C., Laurendeau, C., Fagnani, F., & Bergmann, J. (2010) · International Journal of Cardiology · doi:10.1016/j.ijcard.2010.10.130 · Cited by 4
“Only recently, a large randomised controlled trial studying anticoagulation in patients aged 75 years and more has been published [12].”
BackgroundNew advances in the treatment of atrial fibrillation: focus on stroke prevention
Lau, Y. C., & Lip, G. Y. H. (2014) · Expert Opinion on Pharmacotherapy · doi:10.1517/14656566.2014.948418 · Cited by 4
“Equally important, similar bleeding profile (relating to major hemorrhage and intracranial bleed) is demonstrated in both warfarin and aspirin groups [20].”
BackgroundTrombosis y fármacos antitrombóticos en el anciano
Páramo, J. A., Varea, S., & Lecumberri, R. (2011) · Medicina Clínica · doi:10.1016/j.medcli.2011.05.004 · Cited by 4
Liu, F.-D., Zhao, R., Wang, X., Wang, S., Shen, X., Tao, X., Zheng, B., Peng, J., Zhang, H., Mo, R., et al. (2015) · Chronic Diseases and Translational Medicine · doi:10.1016/j.cdtm.2015.11.005 · Cited by 4
Nye internasjonale retningslinjer for antitrombotisk behandling ved atrieflimmer
Tveit, A. (2009) · Tidsskrift for Den norske legeforening · doi:10.4045/tidsskr.08.0448 · Cited by 4
Time is brain: Balancing risk in the treatment of presumed cardioembolic stroke
Nucera, A., Azarpazhooh, M. R., Alsubaie, R., Riccio, P. M., & Hachinski, V. (2017) · Journal of the Neurological Sciences · doi:10.1016/j.jns.2017.07.022 · Cited by 4
Anticoagulation therapy in the elderly with non-valvular atrial fibrillation: a double-edged sword
Vetta, F., Locorotondo, G., & Vetta, G. (2017) · Geriatric Care · doi:10.4081/gc.2017.6371 · Cited by 4
Induruwa, I., Amis, E., Hannon, N., & Khadjooi, K. (2017) · The Journal of the Royal College of Physicians of Edinburgh · doi:10.4997/jrcpe.2017.405 · Cited by 4
Accidente cerebrovascular en el paciente anciano
Puy, L., & Jouvent, É. (2020) · EMC - Tratado de Medicina · doi:10.1016/s1636-5410(20)43329-x · Cited by 5
Lekander, I., von Euler, M., & Sunnerhagen, K. S. (2020) · BMJ Open · doi:10.1136/bmjopen-2019-036159 · Cited by 4
Atrial fibrillation: trends in prevalence and antithrombotic prescriptions in the community
Joosten, L. P. T., de Boer, A. R., van Eerde, E. J. B., van Doorn, S., Hoes, A. W., Bots, M. L., Rutten, F. H., & Geersing, G. (2022) · Netherlands Heart Journal · doi:10.1007/s12471-022-01667-x · Cited by 4
Management of atrial fibrillation and anticoagulant therapies
O'Neill, M. D., Whitaker, J., Birns, J., & Wright, M. J. (2017) · doi:10.1093/med/9780198701590.003.0103 · Cited by 4
Primary and secondary prevention of stroke
Manning, L., Lam, M. Y., & Robinson, T. G. (2017) · Oxford University Press eBooks · doi:10.1093/med/9780198701590.003.0118 · Cited by 4
Hayek, A., MacDonald, B. J., Marquis‐Gravel, G., Bainey, K. R., Mansour, S., Ackman, M. L., Cantor, W. J., & Turgeon, R. D. (2024) · CJC Open · doi:10.1016/j.cjco.2024.01.001 · Cited by 6
Mearns, E. S., Hawthorne, J., Song, J.-S., & Coleman, C. I. (2014) · BMJ Open · doi:10.1136/bmjopen-2014-005379 · Cited by 4
Wertheimer, G., & Bereznicki, L. (2018) · Journal of Cardiovascular Pharmacology and Therapeutics · doi:10.1177/1074248418786264 · Cited by 4
“The bleeding risk associated with aspirin is not different to the bleeding risk on warfarin(20) or DOAC therapy(14); however, warfarin and DOACs effectively prevent strokes in patients with AF while aspirin does not.(11,14,20) There is currently limited data available regarding the characteristics, clinical management…”
BackgroundWilson, D., Ambler, G., Shakeshaft, C., Banerjee, G., Charidimou, A., Seiffge, D. J., White, M. J., Cohen, H., Yousry, T. A., Rustam, A.-S. S., et al. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-028387 · Cited by 4
“18 Our study has strengths; CROMIS-2 AF was a prospective multicentre observational study with a richly pheno-typed patient population, allowing us to explore multiple demographic and clinical variables.”
MethodNecessity of Antiaggregation and Anticoagulation and Its Prognostic Impact: A Cardiologist’s View
Hink, U., & Voigtländer, T. (2020) · Visceral Medicine · doi:10.1159/000509896 · Cited by 5
Terapia anticoagulante en fibrilación auricular
Prieto, S., Young, P., Ceresetto, J. M., & Bullorsky, E. O. (2011) · Medicina-buenos Aires · Cited by 4
Kleinig, T. J., Kimber, T. E., & Thompson, P. D. (2009) · The Medical Journal of Australia · doi:10.5694/j.1326-5377.2009.tb02635.x · Cited by 4
Metadata
- Authors
- Mant, J., Hobbs, F. R., Fletcher, K., Roalfe, A., Fitzmaurice, D., Lip, G. Y., & Murray, E.
- Affiliations
- University of Birmingham (GB)
- Birmingham City Hospital (GB)
- Corresponding author
- Mant, Jonathan
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2007-08
- Volume
- 370
- Issue
- 9586
- Pages
- 493-503
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- OpenAlex
- W2159730165
- Cited by
- 1,556
- References
- 50
- Citations by year
- 2026: 14 · 2025: 15 · 2024: 25 · 2023: 43 · 2022: 35 · 2021: 51 · 2020: 60 · 2019: 53 · 2018: 73 · 2017: 94 · 2016: 124 · 2015: 116 · 2014: 120 · 2013: 142 · 2012: 158
- FWCI
- 72.56
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
- Keywords
- warfarin, aspirin, atrial fibrillation, stroke prevention, elderly patients, anticoagulation, antiplatelet therapy, intracranial hemorrhage, arterial embolism, bleeding risk, ischemic stroke, primary care
- MeSH terms
- Aged, Aged, 80 and over, Anti-Inflammatory Agents, Non-Steroidal, Aspirin, Atrial Fibrillation, Female, Follow-Up Studies, Humans, Male, Platelet Aggregation Inhibitors, Severity of Illness Index, Warfarin, International Normalized Ratio, Stroke
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