Intervention Reduces Aspirin Use in Patients with AF, VTE Taking Warfarin, Improves Outcomes

A multicenter aspirin deprescribing intervention substantially lowered excessive aspirin use among patients addressed with warfarin for atrial fibrillation (AF) and/or venous thromboembolism (VTE) who experienced no apparent sign for concomitant antithrombotic therapy.

The “deimplementation” plan was affiliated with a just about 50% lower in in general aspirin use across 6 anticoagulation clinics which in convert was connected to appreciably much less bleeding activities and a lower in overall health care use, with out an boost in thrombotic outcomes.

Study authors, led by Geoffrey D. Barnes, MD, MSc, assistant professor, cardiovascular medication and vascular medication, University of Michigan Wellbeing Procedure, compose that aspirin is correctly merged with warfarin for some individuals with AF or VTE immediately after acute coronary syndromes or percutaneous coronary interventions, and also for some clients with mechanical heart valves.

For most other clients, having said that, the evidence indicates larger damage than superior from the mix which improves the hazard for bleeding situations devoid of a apparent reduction in thrombotic outcomes, the authors add. Clinical guidelines advocate from the observe, but the investigators note that “many sufferers surface to be obtaining aspirin even when the possible threat exceeds the gain.”

For most other people, even so, the proof implies better damage than excellent from the mix of aspirin and warfarin which increases the possibility for bleeding gatherings without the need of a clear reduction in thrombotic outcomes.

Barnes et al utilised patient populations attending 6 clinical web sites in the Michigan Anticoagulation High quality Improvement Initiative (MAQI) for the pre-publish observational top quality advancement analyze, assessing the pre- and postintervention proportion of sufferers whose aspirin use appeared unclear as properly as the affect of the intervention on clinical outcomes.

Each of the 6 MAQI clinics employed a site-particular screening process to detect people receiving aspirin without the need of a distinct indicator, collecting information among January 2010 and December 2019. The high-quality enhancement interventions took put in between Oct 2017 and June 2018, according to the examine.

For individuals people whose sign for aspirin was unclear or appeared inappropriate, session with the patient’s most important care clinician or specialist could bring about discontinuation.

The indications for aspirin use were being assessed at enrollment for the pre-intervention cohort and assessed at enrollment or the to start with adhere to-up soon after implementation of the intervention for the post-intervention cohort.

The MAQI followed 6738 clients recognized as remaining taken care of with warfarin without having an sign for aspirin (necessarily mean age, 62.8 years 46.9% men) for a median of 6.7 months. Additional than fifty percent (55.1%) ended up obtaining anticoagulation for VTE.

Overall, there was a approximately 50% reduction in excess aspirin use immediately after the deprescribing intervention, from a 29.4% to 15.7%.

Specially, information documented by Barnes and colleagues show a slight reduce in use of aspirin across MAQI web pages from a baseline imply of 29.4% (95% CI, 28.9% – 29.9%) to 27.1% (95% CI, 26.1% – 28.%) for the duration of the 24-month preintervention time period (P < .001 for slope before and after 24 months before the intervention).

Following the intervention, the decrease in aspirin use accelerated significantly to a mean of 15.7% (95% CI, 14.8% – 16.5%), a trajectory the authors point out was steeper than that seen during the preintervention period (P = .001 for slope before and after intervention).

Overall, there was a nearly 50% reduction in excess aspirin use after the deprescribing intervention, from 29.4% to 15.7%.

Results of primary analysis demonstrated a significant decrease in major bleeding events per month (preintervention, 0.31% 95% CI, 0.27%-0.34% postintervention, 0.21% 95% CI, 0.14%-0.28% P = .03 for difference in slope before and after intervention). Notably, there was no significant change from before to after the intervention in mean percentage of patients with a thrombotic event (0.21% vs 0.24% P = .34 for difference in slope).

In the secondary analysis, the research team found that reduced use of aspirin (starting 24 months prior to deprescribing intervention) was associated with decreases in mean percentage of patients:

  • having any bleeding event (2.3% vs 1.5% P = .02 for change in slope before and after 24 months before the intervention)
  • having a major bleeding event (0.31% vs 0.25% P = .001 for change in slope before and after 24 months before the intervention)
  • with an emergency department visit for bleeding (0.99% vs 0.67% P = .04 for change in slope before and after 24 months before the intervention)

“Our findings highlight the need for greater aspirin stewardship among patients receiving warfarin for anticoagulation,” wrote Barnes and colleagues, adding that the “successful intervention across multiple health systems, with different patient populations and clinical structures, could serve as a national model for reducing excess aspirin use.”

“Given that aspirin is not a prescription medication, it could be postulated that clinicians may not always be aware that patients are taking aspirin, which is a barrier to aspirin-deprescribing efforts,” they add.

They call for additional research to determine whether deprescribing aspirin for patients receiving newer direct oral anticoagulants is similarly effective as well as to confirm the current findings, “ideally with a control group.”

Reference: Schaefer JK, Errickson J, Gu X, et al. Assessment of an intervention to reduce aspirin prescribing for patients receiving warfarin for anticoagulation. JAMA Netw Open. 20225(9):e2231973. doi:10.1001/jamanetworkopen.2022.31973

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