Cited by 1,556Atrial Fibrillation Management and OutcomesAcute Ischemic Stroke ManagementVenous Thromboembolism Diagnosis and Management

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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

Mant, Jonathan, Hobbs, FD Richard, Fletcher, Kate, Roalfe, Andrea, Fitzmaurice, David, Lip, Gregory YH, Murray, Ellen·2007·The Lancet

DOI 10.1016/s0140-6736(07)61233-1

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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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MethodInfluential
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Drug adherence in patients taking oral anticoagulation therapy
Ewen, S., Rettig‐Ewen, V., Mahfoud, F., Böhm, M., & Laufs, U. (2013) · Clinical Research in Cardiology · doi:10.1007/s00392-013-0616-8 · Cited by 49
Thromboembolic Prevention in Frail Elderly Patients With Atrial Fibrillation: A Practical Algorithm
Granziera, S., Cohen, A. T., Nante, G., Manzato, E., & Sergi, G. (2015) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2014.12.008 · Cited by 50
Post-acute care and secondary prevention after ischaemic stroke
McArthur, K. S., Quinn, T. J., Higgins, P., & Langhorne, P. (2011) · BMJ · doi:10.1136/bmj.d2083 · Cited by 51
Stroke Prevention in the Very Elderly
Lindley, R. I. (2018) · Stroke · doi:10.1161/strokeaha.117.017952 · Cited by 51
Net clinical benefit of anticoagulant treatments in elderly patients with nonvalvular atrial fibrillation: Experience from the real world
Alnsasra, H., Haim, M., Senderey, A. B., Reges, O., Leventer‐Roberts, M., Arnson, Y., Leibowitz, M., Hoshen, M., & Avgil-Tsadok, M. (2018) · Heart Rhythm · doi:10.1016/j.hrthm.2018.08.016 · Cited by 50
Overview of oral antithrombotic treatment in elderly patients with atrial fibrillation
Kato, E. T., Goto, S., & Giugliano, R. P. (2018) · Ageing Research Reviews · doi:10.1016/j.arr.2018.10.006 · Cited by 51
Impact of prescribed medications on patient safety in older people
Anathhanam, S., Powis, R. A., Cracknell, A. L., & Robson, J. (2012) · Therapeutic Advances in Drug Safety · doi:10.1177/2042098612443848 · Cited by 49
Anticoagulation in Patients Aged ≥75 years with Atrial Fibrillation: Role of Novel Oral Anticoagulants
Ng, K. H., Hart, R. G., & Eikelboom, J. W. (2013) · Cardiology and Therapy · doi:10.1007/s40119-013-0019-y · Cited by 49
The likelihood of decreasing strokes in atrial fibrillation patients by strict application of guidelines
Pisters, R., van Oostenbrugge, R. J., Knottnerus, I. L. H., de Vos, C. B., Boreas, A., Lodder, J., Prins, M. H., Crijns, H. J. G. M., & Tieleman, R. G. (2010) · EP Europace · doi:10.1093/europace/euq080 · Cited by 49
Underprescription of medications in older adults: causes, consequences and solutions—a narrative review
Lombardi, F., Paoletti, L., Carrieri, B., Dell’Aquila, G., Fedecostante, M., Muzio, M. D., Corsonello, A., Lattanzio, F., & Cherubini, A. (2021) · European Geriatric Medicine · doi:10.1007/s41999-021-00471-x · Cited by 50
Influence of sex on risk of bleeding in anticoagulated patients: a systematic review and meta‐analysis
Lapner, S. T., Cohen, N., & Kearon, C. (2014) · Journal of Thrombosis and Haemostasis · doi:10.1111/jth.12529 · Cited by 47
“Patel et al. 2011 [30] Goodman et al. 2011 [31] RCT AF 100 73†† 8601/5663 Rivaroxaban 20 mg od Warfarin INR 2–3 No Median 23.3 ARISTOTLE§ Granger et al. 2011 [32] RCT AF 100 70†† 11 785/6416 Apixaban 5 mg bid Warfarin INR 2–3 No NR AMADEUS¶ Lane et al. 2011 [33] Amadeus inves.”
BackgroundInfluential
Stroke and Bleeding Risk in Atrial Fibrillation
Senoo, K., Lane, D. A., & Lip, G. Y. H. (2014) · Korean Circulation Journal · doi:10.4070/kcj.2014.44.5.281 · Cited by 46
Upper limb arterial thromboembolism: a systematic review on incidence, risk factors, and prognosis, including a meta-analysis of risk-modifying drugs
Andersen, L. V., Lip, G. Y. H., Lindholt, J. S., & Frost, L. (2013) · Journal of Thrombosis and Haemostasis · doi:10.1111/jth.12181 · Cited by 47
The Business Case for Quality Improvement
Rose, A. J., Berlowitz, D. R., Ash, A. S., Ozonoff, A., Hylek, E. M., & Goldhaber‐Fiebert, J. D. (2011) · Circulation Cardiovascular Quality and Outcomes · doi:10.1161/circoutcomes.111.960591 · Cited by 47
Warfarin and atrial fibrillation: from ideal to real the warfarin affaire
Molteni, M., & Cimminiello, C. (2014) · Thrombosis Journal · doi:10.1186/1477-9560-12-5 · Cited by 48
Risk stratification for stroke in atrial fibrillation: a critique
Killu, A. M., Granger, C. B., & Gersh, B. J. (2018) · European Heart Journal · doi:10.1093/eurheartj/ehy731 · Cited by 50
Management of atrial fibrillation: two decades of progress — a scientific statement from the European Cardiac Arrhythmia Society
Lévy, S., Steinbeck, G., Santini, L., Näbauer, M., Penela, D., Kantharia, B. K., Saksena, S. V., & Cappato, R. (2022) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-022-01195-z · Cited by 50
“9% per year [128, 129], with no difference in the risk of major bleeding between the use of vitamin K antagonists and that of aspirin [121, 122].”
Background
Edoxaban vs. warfarin in vitamin K antagonist experienced and naive patients with atrial fibrillation†
O’Donoghue, M. L., Ruff, C. T., Giugliano, R. P., Murphy, S. A., Grip, L. T., Mercuri, M. F., Rutman, H., Shi, M., Kania, G., Čermák, O., et al. (2015) · European Heart Journal · doi:10.1093/eurheartj/ehv014 · Cited by 46
The Effect and Safety of the Antithrombotic Therapies in Patients with Atrial Fibrillation and CHADS2 Score 1
Lee, B. H., Park, J.-S., Park, J. H., PARK, J. S., Kwak, J. J., Hwang, E.-S., Kim, S. K., Choi, D., Kim, Y., & Pak, H. (2009) · Journal of Cardiovascular Electrophysiology · doi:10.1111/j.1540-8167.2009.01661.x · Cited by 46
Valor predictivo de la escala CHA2DS2-VASc en pacientes con fibrilación auricular de alto riesgo embólico en tratamiento anticoagulante
Jover, E., Roldán, V., Gallego, P., Hernández‐Romero, D., Valdés, M., Vicente, V., Lip, G. Y. H., & Marín, F. R. (2012) · Revista Española de Cardiología · doi:10.1016/j.recesp.2012.02.017 · Cited by 46
An Endogenous Vitamin K-Dependent Mechanism Regulates Cell Proliferation in the Brain Subventricular Stem Cell Niche
Gély-Pernot, A., Coronas, V., Harnois, T., Prestoz, L., Mandairon, N., Didier, A., Berjeaud, J., Monvoisin, A., Bourmeyster, N., de Frutos, P. G., et al. (2012) · Stem Cells · doi:10.1002/stem.1045 · Cited by 48
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
Waldo, A. L. (2008) · Yearbook of Cardiology · doi:10.1016/s0145-4145(08)06021-8 · Cited by 46
Unanswered questions and research priorities to optimise stroke prevention in atrial fibrillation with the new oral anticoagulants
Hankey, G. J. (2013) · Thrombosis and Haemostasis · doi:10.1160/th13-09-0741 · Cited by 44
Risks for stroke and bleeding with warfarin or aspirin treatment in patients with atrial fibrillation at different CHA2DS2VASc scores: experience from the Stockholm region
Forslund, T., Wettermark, B., Wändell, P. E., von Euler, M., Hasselström, J., & Hjemdahl, P. (2014) · European Journal of Clinical Pharmacology · doi:10.1007/s00228-014-1739-1 · Cited by 46
MRI Screening for Chronic Anticoagulation in Atrial Fibrillation
Fisher, M. (2013) · Frontiers in Neurology · doi:10.3389/fneur.2013.00137 · Cited by 45
Association between atrial fibrillation, anticoagulation, risk of cerebrovascular events and multimorbidity in general practice: a registry-based study
Vanbeselaere, V., Truyers, C., Elli, S., Buntinx, F., Witte, H. D., Degryse, J., Henrard, S., & Vaes, B. (2016) · BMC Cardiovascular Disorders · doi:10.1186/s12872-016-0235-1 · Cited by 45
Warfarin Treatment and All‐Cause Mortality in Community‐Dwelling Older Adults with Atrial Fibrillation: A Retrospective Observational Study
Pilotto, A., Gallina, P., Copetti, M., Pilotto, A., Marcato, F., Mello, A. M., Simonato, M., Logroscino, G., Padovani, A., Ferrucci, L., et al. (2016) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14221 · Cited by 46
Prevention of Cardioembolic Stroke
Freeman, W. D., & Aguilar, M. I. (2011) · Neurotherapeutics · doi:10.1007/s13311-011-0048-y · Cited by 45
“3 to 1% annually [63–68, 71].”
Method
Lower versus standard intensity oral anticoagulant therapy (OAT) in elderly warfarin-experienced patients with non-valvular atrial fibrillation
Cucchini, U., Denas, G., Davidson, B., Marzot, F., Jose, S. P., Iliceto, S., & Pengo, V. (2010) · Thrombosis and Haemostasis · doi:10.1160/th09-05-0311 · Cited by 44
Bleeding risk in randomized controlled trials comparing warfarin and aspirin: a systematic review and meta‐analysis
WARKENTIN, A. E., Donadini, M. P., Spencer, F. A., Lim, W., & Crowther, M. A. (2012) · Journal of Thrombosis and Haemostasis · doi:10.1111/j.1538-7836.2012.04635.x · Cited by 44
Use of Oral Anticoagulation among Stroke Patients with Atrial Fibrillation in China: The ChinaQUEST (Quality Evaluation of Stroke Care and Treatment) Registry Study
Gao, Q., Fu, X., Wei, J. W., Chen, X., Huang, Y., Wang, J., Anderson, C. S., Wong, K. S., & for the China QUEST Study Investigators (2011) · International Journal of Stroke · doi:10.1111/j.1747-4949.2011.00716.x · Cited by 44
Could Geriatric Characteristics Explain the Under-Prescription of Anticoagulation Therapy for Older Patients Admitted with Atrial Fibrillation?
Breucker, S. D., Herzog, G., & Pepersack, T. (2010) · Drugs & Aging · doi:10.2165/11537900-000000000-00000 · Cited by 44
A rat model of chronic subdural hematoma: Insight into mechanisms of revascularization and inflammation
Quan, W., Zhang, Z., Tian, Q., Wen, X., Yu, P., Wang, D., Cui, W., Zhou, L., Park, E., BAKER, A. J., et al. (2015) · Brain Research · doi:10.1016/j.brainres.2015.08.017 · Cited by 43
“…risk of occurrence in the groups over 65 years of age, cases with a history of traumatic brain injury, or administration of anticoagulants which can exacerbate the incidence from 8.2/100,000/year to 310/100,000/year (Asghar et al., 2002; Hart et al., 2012; Karibe et al., 2011; Mant et al., 2007).”
Influential
Atrial fibrillation in older inpatients: are there any differences in clinical characteristics and pharmacological treatment between the frail and the non‐frail?
Nguyen, T. N., Cumming, R. G., & Hilmer, S. N. (2015) · Internal Medicine Journal · doi:10.1111/imj.12912 · Cited by 43
Evolving landscape of stroke prevention in atrial fibrillation within the UK between 2012 and 2016: a cross-sectional analysis study using CPRD
Lacoin, L., Lumley, M., Ridha, E., Pereira, M. M., McDonald, L., Ramagopalan, S. V., Lefèvre, C., Evans, D., & Halcox, J. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-015363 · Cited by 43

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
ORCID: Mant, Jonathan
Fletcher, Kate
Roalfe, Andrea
Fitzmaurice, David
Lip, Gregory YH
Venue: The Lancet
Publisher: Elsevier BV
Published: 2007-08
Volume: 370
Issue: 9586
Pages: 493-503
ISSN: 0099-5355 (ISSN-L)
0140-6736
DOI: 10.1016/s0140-6736(07)61233-1
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
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
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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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

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