Evaluation of Warfarin versus

Aspirin on the Incidence of

Thromboembolic Complications in Patients with Nonvalvular
Atrial Fibrillation
Final Paper
Pharmaceutical Care Project- Outcomes Evaluation
Charlotte Y. James, RPh.
Pharm.D. Candidate
WPPD Program University of Florida
Evaluation of Warfarin versus Aspirin
on the incidence of Thromboembolic
Complications in patients with
Nonvalvular Atrial Fibrillation.
Introduction
Atrial fibrillation (AF) is
an arrhythmia character
ized by an electrical and
mechanical abnormality that predisposes to
blood stasis and subsequent thrombi
formation. Approximately 2 million people in the United States have AF.
1
Its incidence
increases with age and is seen in < 1% of
people aged 40-65 years,
2-5% of people aged
65-74 years, and > 5% of people aged greater than 75 years.
2
Embolic stroke is the most
devastating complication arising
from atrial fibrillation. The us
e of warfarin or aspirin as
antithrombotic agents are recommended for the prevention of thromboembolism.
1
Warfarin is an anticoagulant which inhib
its enzymes responsible for synthesis of
factors II, VII, IX and X. Thereby preventi
ng clot formation. Warf
arin requires routine
monitoring and is associated w
ith bleeding. Aspirin is an an
tiplatelet agent which blocks
prostaglandin synthetase action, resulting in
decreased formation of the platelet-
aggregating substance thromboxane A2. Aspi
rin is associated w
ith bleeding, however
does not require ro
utine monitoring.
According to 2004 Chest guidelines
8
on antithrombotic therapy in atrial
fibrillation, the following is recommended:
All vitamin K antagonist recommendations
have a target international
normalized ratio [INR] of 2.5;
range, 2.0 to 3.0, in patients
with persistent or paroxysmal
AF at high risk of stroke (i
.e., those with prior ischemic
stroke, transient ischemic attack, or system
ic embolism, age >75 years, moderately or
severely impaired left ventri
cular systolic function and/or congestive heart failure, history
of hypertension, or diabetes mellitus), anticoagul
ation with an oral vitamin K antagonist
is recommended. In patients with persistent
AF, age 65 to 75 years, in the absence of
other risk factors, antithrombotic therapy with either an oral vitamin K antagonist or
aspirin, 325mg/d is recommended. In patients wi
th persistent AF < 65 years and with no
other risk factors, aspiri
n 325mg/d is recommended.
The purpose of this paper is to review
five studies (Table 1) which compare the
effects of warfarin versus aspirin on the in
cidence of thromboembolic complications in
patients with nonvalvular atrial fibrillation.
Evaluation of the studies
The AFASAK study was a randomized, placebo-controlled study. A total of 1007
patients with chronic atrial fibr
illation were to be treated fo
r duration of 2 years. Patients
were recruited from two outpatient electroca
rdiography laboratories to which they had
been referred by their general practitioners.
After diagnosis of at
rial fibrillation was
made, the general practitioner was informed a
bout the study and if he
or she agreed, the
patient was invited to take part in the st
udy. The mean age was 74 years. Patients were
randomized to either warfarin (INR 2.8-4.2)
open label, aspirin 75mg once daily or
placebo in a double-blind fashion. The incidences
of thromboembolic complications were
estimated by Kaplan-Meier life-table met
hods. Treatment comparisons of both primary
and secondary endpoints were based on log-ra
nk test. Comparability between groups at
randomization was assessed by chi-square and Kruskal-Wallis test. The goal of this study
was to compare the efficacy of warfarin versus low dose aspirin therapy.
The SPAF I study was a randomized, double-blind, placebo-controlled,
multicenter study. A total of 1330 patients with c
onstant or intermittent atrial fibrillation
were treated for duration 1.3years. Patients we
re identified as inpa
tients or outpatients
from public, private, and Veterans Administra
tion health-care facilities by review of
electrocardiographic logs, by
direct referral from participating and nonparticipating
physicians and by self-referral. During most of
the enrollment period, age greater than 75
years was ineligible to receive
warfarin because fear of he
morrhage. The mean age was
67 years. Patients in group 1 (anticoagulati
on candidates) were ra
ndomized to receive
either open label warfarin (INR 2.0-4.5), as
pirin (325mg) in double- blind fashion, or
matched placebo in a double blind fashion.
Patients in group 2 (non-anticoagulation
candidates) were randomized to either aspi
rin (325mg) or placebo.
In this study warfarin
would be compared with placebo in warfar
in-eligible patients
only, and all patients
receiving aspirin would be compared with
all patients receiving pl
acebo. Primary and
secondary events were repor
ted by neurologist. Verificat
ion was done by the Events
Committee which was unaware of treatment a
llocation. Analyses were based on intention
to treat. Baseline comparisons performed by
chi-square and t test, Comparisons of
treatments for both primary a
nd secondary events used th
e log-rank test. Event rates
computed using Kaplan-Meier. Ninety-five per
cent confidence intervals calculated on the
basis of relative risk. The goal of this st
udy was to determine whether aspirin was of
benefit in all eligible patients and whether
warfarin was of benef
it in the subset of
patients who could and
would take warfarin.
The SPAF II study was a direct extension of the SPAF I study. The SPAF II a
cohort study was a randomized, multicenter study wh
ich consisted of two parallel clinical
trials involving 1100 patients. The study partic
ipants included all of the anticoagulation-
eligible patients randomized to aspirin or
warfarin in the SPAF-1 study. Additionally, 265
SPAF I study participants (most previously as
signed to placebo) were rerandomized in
the SPAF II study. The study duration was 5 years.
Patients were assigned to aspirin
(325mg) or warfarin (INR 2.0 4.5) in tw
o groups < 75 years or > 75 years. Both
patients and investigators were
aware of therapy. All suspec
ted neurologic events were
evaluated by an on-site study neurologist and
verified by an events committee, which had
no knowledge of therapy assignment. The 95%
confidence interval
for the absolute
difference in primary event rates was calculate
d on the basis of observed rates, the log-
rank statistic was used for analyses of prim
ary and secondary events comparing time to
event with warfarin versus aspirin. The goal
of this study was to see whether warfarin
would reduce the risk of primary events compar
ed with aspirin by an
absolute rate of 2%
or more per year in younger patients (< 75y
ears ) and by 4% or more in older patients
(>75years).
The PATAF trial was a randomized contro
l trial. A total of 729 patients were
assigned to treatment. The study duration wa
s 2.7 years. The mean age was 75 years.
Patients eligible for standard anticoagulat
ion (stratum 1) were randomly assigned to
aspirin (150mg/d), low anticoagulation (warfarin INR 1.1-1.6) or standard
anticoagulation (warfarin INR 2.5-3.5). Patients
ineligible for standard anticoagulation
(stratum 2) were randomized to between
aspirin (150mg) and low anticoagulation
(warfarin INR 1.1-1.6). Patients were singl
e blinded for the two intensities of
anticoagulant, but end point ascertainments were blinded for treatment. Analysis was
based on intention to treat appr
oach with a log rank test a
nd Cox regression analysis. The
goal of this study was to compare the effectiv
eness of aspirin and warfarin in preventing
thromboembolsm in atrial fibrillation.
The EAFT study was a randomized, placebo-controlled, multicenter study. A total
Of 1007 patients with non-rheumatic atrial
fibrillation and a
recent TIA or minor
ischemic stroke. This study focused on s
econdary prevention. The study duration was 2.3
years. Patients were assigned to two gr
oups. Group 1 (eligible for anticoagulants)
randomized to receive either open-label warf
arin (INR 2.5- 4.0) or
double-blind treatment
with aspirin (300mg) or placebo). Patients
ineligible were entered in group 2 and
randomized to double-blind treatment with aspirin (300mg) or matching placebo. All
outcome events were independently classifi
ed by at least 3 members of the auditing
Committee for Outcome Events, reviewers were
unaware of the allocated treatment.
Differences of opinion were discussed with
in the Executive committee, which was also
blinded. An independent Data Monitoring Committee monitored the study results.
Baseline comparisons between groups were don
e by chi-square and t-test, the occurrence
of primary outcome events was compared in te
rms of the hazard rati
o. All analyses were
based on an intention to treat premise.
The goal of this study was to compare the
effectiveness of aspirin and warfarin in
the secondary prevention of thromboembolic
events in patients with a r
ecent transient ischemic attack or minor ischemic stroke.
Critique/Analysis
In each of the five studies patients were given warfarin treatment in an openly
fashion. This was done for safety reasons
. However, giving warfarin open-label can
increase the likelihood of bias.
In two of the five studies,
both the AFASAK and SPAF II
studies, warfarin was given openly and both pa
tients and investigators were aware of
therapy assignment. This could increase chan
ce of both patient and
investigator biases.
This problem was addressed by using outside evaluators unaware of
the treatments to
analyze the data. According to the SPAF
I study randomized patients had a mean age 67
years. This trial had an age limit and did not en
roll patients older than 75 years because of
fear of excess risk of hemorrhage. The mean
age in the SPAF I study was lower than the
other four studies. This could cause concern knowing that
the incidence of stroke
increases with age.
1
The PATAF study enrolled patients
with less severe disease than
the other studies which could cause concern. Lo
oking at statistical analyses all studies
were based on intention-to treat premise except when specified. This analysis
incorporates all enrolled patie
nts regardless of whether they
completed the study or had a
complete data file.
The INR target goal for each study was hi
gher than that which is recommended
by Chest guidelines (INR of 2-3, target of 2.5).
8
Four of the five studies, the AFASAK,
SPAF I, SPAF II and EAFT are all older st
udies which used prothrombin time ratios
which was converted to current usage of
INR. The INR target goal for each study was
not appropriate for this patient group.
The SPAF II study predicted to show warfarin
superior to aspirin. Three analyses
were planned. Primary analysis compared
warfarin with aspirin for prevention of
ischemic stroke and systemic embolism (prima
ry events) on an intention to treat basis.
Secondary analyses, specified in advance, incl
uded the effect of therapies on all strokes
with residual functional deficit and primary ev
ents plus vascular death. A non- inferiority
analysis was planned. A safety committee
not involved in the conduct of the trial
monitored for either of two outcomes an unexpected large benefit of
warfarin over aspirin
or sufficient evidence that the trial could not
show advantage for warfarin. Due to low
event rate one of the three planned analys
es was conducted. For the primary hypotheses,
the 95% confidence interval (the adjusted
p-value is 0.0425) for absolute difference in
primary event rates. The PATAF study predicte
d to show a non-inferiority analysis, that
both treatments were equivalent
, and aspirin would be treatm
ent of choice because it does
not require routine monitoring. A one side
d test was performed in this study.
Interim analyses was planned after
31,62,and 93 primary events in the low
anticoagulation and aspirin gr
oups combined with signifi
cance levels of 0.001, 0.008 and
0.017 as boundaries for the one sided P value fr
om the stratified log rank test. The trial
would be stopped when there was at least a 90% probability that the final analyses would
result in a significant difference if the
trial was continued. Values of 0.71, 0.34 and 0.16
were used as boundaries, when there is at leas
t an 80% probability th
at the final analysis
result in non-significant difference.
Summary of findings
The five randomized studies detailed in
Table 1 provide valuable information on
the use of warfarin and aspirin
in patients with nonvalvular at
rial fibrillation. The trials
demonstrate that both warfarin and aspi
rin reduce the risk of thromboembolic
complications in patients with non- rheumatic
atrial fibrillation. Patients in the younger
age group (< 75 years) in the SPAF II study had
a low risk of stroke
on aspirin. Patients
in the PATAF study had less severe disease
and had low overall event rate for stroke.
These two trials demonstrate that younger pa
tients without risk factors would benefit
little from warfarin. The AFASAK, SPAF II,
and SPAF I (indirectly) demonstrated a
greater reduction of primary events in pati
ents receiving warfarin compared to aspirin.
The EAFT study evaluated secondary prevention
in patients with non-rheumatic atrial
fibrillation. This study demonstrated warfarin to be more effec
tive than aspirin in
preventing recurrent stroke.