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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“Discussion In spite of evidence to support use of oral anticoagulants to prevent stroke and systemic embolism in patients with AF [8-10] and the high prevalence of AF of >5% in over 70 year olds and >10% in over 85 year olds, many patients do not get optimal”
Background
Anticoagulant use in older persons at risk for falls: therapeutic dilemmas—a clinical review
Mitchell, A., Elmasry, Y. E. T., van Poelgeest, E. P., & Welsh, T. J. (2023) · European Geriatric Medicine · doi:10.1007/s41999-023-00811-z · Cited by 41
“Aspirin is sometimes prescribed as an alternative to anticoagulation as prescribers feel it is safer [59]; however, antiplatelet agents are no longer recommended for stroke prevention in AF as they are substantially less effective for stroke than anticoagulation, whilst being associated with a similar risk of major bl…”
Background
Anticoagulation Strategies for the Management of Postoperative Atrial Fibrillation
Anderson, E. J., Dyke, C., & Levy, J. H. (2014) · Clinics in Laboratory Medicine · doi:10.1016/j.cll.2014.06.012 · Cited by 35
Cardiovascular outcomes during treatment with dabigatran: comprehensive analysis of individual subject data by treatment
Clemens, Fraessdorf, M., & Friedman, J. (2013) · Vascular Health and Risk Management · doi:10.2147/vhrm.s49830 · Cited by 35
Temporal Trends in Medication Use and Outcomes in Atrial Fibrillation
Pilote, L., Eisenberg, M. J., Essebag, V., Tu, J. V., Humphries, K. H., Yinko, S. S. L. L., Behlouli, H., Guo, H., & Jackevicius, C. A. (2013) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2012.09.021 · Cited by 34
Clinical profile of direct oral anticoagulants versus vitamin K anticoagulants in octogenarians with atrial fibrillation: a multicentre propensity score matched real-world cohort study
Russo, V., Attena, E., Maio, M. D., Mazzone, C., Carbone, A., Parisi, V., Rago, A., D’Onofrio, A., Golino, P., & Nigro, G. (2019) · Journal of Thrombosis and Thrombolysis · doi:10.1007/s11239-019-01923-9 · Cited by 36
Recent Developments in Understanding Epidemiology and Risk Determinants of Atrial Fibrillation as a Cause of Stroke
Ahmad, Y., Lip, G. Y. H., & Lane, D. A. (2013) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2013.03.009 · Cited by 33
“Treatment with VKAs compared with placebo reduce the risk of stroke by 64% and the risk of death by 26% and consistently outperforms antiplatelet therapy.(13,14) Despite their proven efficacy, VKAs are encumbered by numerous practical inconveniences such as regular international normalized ratio (INR) monitoring, dose…”
Background
Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation?
Dalleur, O., Wouters, D., Spinewine, A., Boland, B. B., Maes, F., Scavée, C., & Henrard, S. (2014) · Clinical Interventions in Aging · doi:10.2147/cia.s62597 · Cited by 34
Oral Anticoagulation in Elderly Adults with Atrial Fibrillation: Integrating New Options with Old Concepts
Zarraga, I. G. E., & Kron, J. (2012) · Journal of the American Geriatrics Society · doi:10.1111/jgs.12042 · Cited by 32
“A recent clinical trial (Birmingham Atrial Fibrillation Treatment of the Aged) has corroborated these findings in individuals with AF aged 75 and older.(6) Table 1.”
Result
Efficacy and safety of novel anticoagulants in the elderly.
Karamichalakis, N., Georgopoulos, S., Vlachos, K. G., Liatakis, I., Efremidis, M., Sideris, A., & Letsas, Κ. P. (2016) · Europe PMC (PubMed Central) · doi:10.11909/j.issn.1671-5411.2016.08.011 · Cited by 33
Real-life use of Rivaroxaban in the Netherlands: data from the Xarelto for Prevention of Stroke in Patients with Atrial Fibrillation (XANTUS) registry
Pisters, R., van Vugt, S. P. G., Brouwer, M. A., Elvan, A., ten Holt, W. L., Zwart, P. A. G., Kirchhof, P. F., Crijns, H. J. G. M., & Hemels, M. E. W. (2017) · Netherlands Heart Journal · doi:10.1007/s12471-017-1009-9 · Cited by 33
Underuse of Vitamin K Antagonist and Direct Oral Anticoagulants for Stroke Prevention in Patients With Atrial Fibrillation: A Contemporary Review
Hsu, J. C., & Freeman, J. V. (2018) · Clinical Pharmacology & Therapeutics · doi:10.1002/cpt.1024 · Cited by 32
“years of age may benefit the most from OAC use due to their heightened stroke risk.(18) Despite physician reticence in treating”
Background
Atrial fibrillation in the elderly population: Challenges and management considerations
Salih, M., Abdel-Hafez, O., Ibrahim, R., & Nair, R. C. (2021) · Journal of Arrhythmia · doi:10.1002/joa3.12580 · Cited by 34
A Propensity Score Matched Comparison of Clinical Outcomes in Atrial Fibrillation Patients Taking Vitamin K Antagonists: Comparing the “Real-World” vs Clinical Trials
Rivera‐Caravaca, J. M., Esteve‐Pastor, M. A., Marín, F. R., Valdés, M., Vicente, V., Roldán, V., & Lip, G. Y. H. (2018) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2018.01.028 · Cited by 33
Gastrointestinal bleeding in patients receiving oral anticoagulation: Current treatment and pharmacological perspectives
Minno, A. D., Spadarella, G., Spadarella, E., Tremoli, E., & Minno, G. D. (2015) · Thrombosis Research · doi:10.1016/j.thromres.2015.10.016 · Cited by 32
Higher baseline international normalized ratio value correlates with higher mortality in intracerebral hemorrhage during warfarin use
Curtze, S., Strbian, D., Meretoja, A., Jukka Putaala, A., Eriksson, H., Haapaniemi, E., Mustanoja, S. M., Sairanen, T., Satopää, J., Silvennoinen, H. M., et al. (2014) · European Journal of Neurology · doi:10.1111/ene.12352 · Cited by 32
Management of atrial fibrillation
Lafuente‐Lafuente, C., Mahé, I., & Extramiana, F. (2009) · BMJ · doi:10.1136/bmj.b5216 · Cited by 32
Characterization of the Proportion of Untreated and Antiplatelet Therapy Treated Patients With Atrial Fibrillation
Ogilvie, I. M., Welner, S. A., Cowell, W., & Lip, G. Y. H. (2011) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2011.02.353 · Cited by 32
A cross-sectional study of quality of life in an elderly population (75 years and over) with atrial fibrillation: secondary analysis of data from the Birmingham Atrial Fibrillation Treatment of the Aged study
Roalfe, A. K., Bryant, T. L., Davies, M. H., Hackett, T. G., Saba, S., Fletcher, K., Lip, G. Y. H., Hobbs, R. F., Mant, J., & on behalf of the BAFTA investigators (2012) · EP Europace · doi:10.1093/europace/eus102 · Cited by 32
Clinical outcome in Japanese elderly patients with non-valvular atrial fibrillation taking warfarin: A single-center observational study
Naganuma, M., Shiga, T., Sato, K., Murasaki, K., Hashiguchi, M., Mochizuki, M., & Hagiwara, N. (2011) · Thrombosis Research · doi:10.1016/j.thromres.2011.11.005 · Cited by 32
“1%/year in the same age group [13].”
Risk of Myocardial Infarction in Patients with Long-Term Non-Vitamin K Antagonist Oral Anticoagulant Treatment
Tornyos, A., Kehl, D., D’Ascenzo, F., & Komócsi, A. (2015) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2015.12.001 · Cited by 33
The effect of dabigatran and rivaroxaban on platelet reactivity and inflammatory markers
Zemer‐Wassercug, N., Haim, M., Leshem‐Lev, D., Orvin, K., Vaduganathan, M., Gutstein, A., Kadmon, E., Mager, A., Kornowski, R., & Lev, E. (2015) · Journal of Thrombosis and Thrombolysis · doi:10.1007/s11239-015-1245-z · Cited by 32
“Vitamin K antagonists have been the mainstay of therapy for primary and secondary prevention of ischemic stroke in patients with AF [10–16].”
Real‐World Clinical Characteristics and Treatment Patterns of Individuals Aged 80 and Older with Nonvalvular Atrial Fibrillation: Results from the ReAl‐life Multicenter Survey Evaluating Stroke Study
Biteker, M., Başaran, Ö., Doğan, V., Altun, İ., Karadeniz, F. Ö., Tekkeşin, A. İ., Çakıllı, Y., Türkkan, C., Hamidi, M., Demir, V., et al. (2017) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14855 · Cited by 32
Effectiveness of CHA2DS2-VASc based decision support on stroke prevention in atrial fibrillation: A cluster randomised trial in general practice
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Atrial Fibrillation and Stroke. A Review on the Use of Vitamin K Antagonists and Novel Oral Anticoagulants
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Secondary Prevention of Stroke in the Elderly: A Review of the Evidence
Alhusban, A., & Fagan, S. C. (2011) · The American Journal of Geriatric Pharmacotherapy · doi:10.1016/j.amjopharm.2011.04.002 · Cited by 32
Anticoagulation for Patients with Atrial Fibrillation in Ambulatory Care Settings
Niska, R. W., & Han, B. (2009) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2009.03.080218 · Cited by 32
Leitlinien zum Management von Patienten mit akutem Hirninfarkt oder TIA der Europäischen Schlaganfallorganisation 2008
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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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