The True Story of the Safety of Aspirin

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The MD Magazine Peer Exchange “Novel Anticoagulation Options: Target-Specific Oral Agents and Their Antidotes” features leading physician specialists discussing key topics in anticoagulation therapy, including the clinical characteristics of current and emerging agents and criteria for use in specific patient populations.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Scott Kaatz, DO, MSc, Chief Quality Officer at Hurley Medical Center in Flint, Michigan, and clinical associate professor at Michigan State University
• Seth Bilazarian, MD, clinical and interventional cardiologist at Pentucket Medical and instructor of medicine at Harvard Medical School
• Gerald Naccarelli, MD, Bernard Trabin Chair in Cardiology, professor of medicine and chief of the Division of Cardiology at Penn State University School of Medicine, and associate clinical director at Penn State Heart and Vascular Institute in Hershey, Pennsylvania
• Christian T. Ruff, MD, associate physician in the cardiovascular medicine division at Brigham and Women’s Hospital, and assistant professor of medicine at Harvard Medical School in Boston

“The most important decision in a patient who has atrial fibrillation is actually not which drug you use but whether you’re anticoagulated,” said Ruff. Therefore, warfarin is a lot better than nothing. Half of the patients in this country who should be on a therapeutic anticoagulant are not, said Naccarelli, so getting them on a real blood thinner, any real blood thinner, has to be a priority to save them from being unprotected.

One of the examples of something that is used frequently but is not a “real” blood thinner is aspirin. Naccarelli said that aspirin is used sometimes when the patient refuses to use warfarin but the doctor feels obligated to do something. The panel revealed that, statistically speaking, there were just as many intracranial bleeds with aspirin as there were with apixaban in the AVERROES trial, which was a small trial that was stopped early, but this was still an important finding.

So, in the case of atrial fibrillation, aspirin does not work. However, it can help patients with drug-eluting stents, carotid disease, vascular disease, and coronary disease, for example, said Naccarelli. It is important to check a new patient’s list of medications, because, Ruff said, the aspirin should be stopped for patients with atrial fibrillation, in part because they may stop their therapy if the aspirin gives them a gastrointestinal bleed, and they may never reinitiate therapy again.