Commentary| Volume 79, P25-26, September 2020

Is aspirin safer than a direct oral anticoagulant for patients with atrial fibrillation at high risk of bleeding?

Published:August 06, 2020DOI:
      Alexander P. Benz reports a personal research grant from the German Heart Foundation (Deutsche Herzstiftung e.V.). John W. Eikelboom received grants and/or research support from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Inc., Janssen, Pfizer and Portola.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Connolly S.J.
        • Eikelboom J.
        • O'Donnell M.
        • et al.
        Challenges of establishing new antithrombotic therapies in atrial fibrillation.
        Circulation. 2007; 116: 449-455
        • Cowan J.C.
        • Wu J.
        • Hall M.
        • et al.
        A 10 year study of hospitalized atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation.
        Eur Heart J. 2018; 39: 2975-2983
      1. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: pulmonary embolism prevention (PEP) trial.
        Lancet. 2000; 355: 1295-1302
        • Brighton T.A.
        • Eikelboom J.W.
        • Mann K.
        • et al.
        Low-dose aspirin for preventing recurrent venous thromboembolism.
        N Engl J Med. 2012; 367: 1979-1987
        • Hart R.G.
        • Pearce L.A.
        • Aguilar M.I
        Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.
        Ann Intern Med. 2007; 146: 857-867
        • Warkentin A.E.
        • Donadini M.P.
        • Spencer F.A.
        • et al.
        Bleeding risk in randomized controlled trials comparing warfarin and aspirin: a systematic review and meta-analysis.
        J Thromb Haemost. 2012; 10: 512-520
        • Sagris D.
        • Leventis I.
        • Georgiopoulos G.
        • et al.
        Bleeding risk comparison between direct oral anticoagulants at doses approved for atrial fibrillation and aspirin: systematic review, meta-analysis and meta-regression.
        Eur J Intern Med. 2020;
        • Weitz J.I.
        • Lensing A.W.A.
        • Prins M.H.
        • et al.
        Rivaroxaban or aspirin for extended treatment of venous thromboembolism.
        N Engl J Med. 2017; 376: 1211-1222
        • Connolly S.J.
        • Eikelboom J.
        • Joyner C.
        • et al.
        Apixaban in patients with atrial fibrillation.
        N Engl J Med. 2011; 364: 806-817
        • Hart R.G.
        • Sharma M.
        • Mundl H.
        • et al.
        Rivaroxaban for stroke prevention after embolic stroke of undetermined source.
        N Engl J Med. 2018; 378: 2191-2201
        • Diener H.C.
        • Sacco R.L.
        • Easton J.D.
        • et al.
        Dabigatran for prevention of stroke after embolic stroke of undetermined source.
        N Engl J Med. 2019; 380: 1906-1917
        • Ruff C.T.
        • Giugliano R.P.
        • Braunwald E.
        • et al.
        Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.
        Lancet. 2014; 383: 955-962
        • Kirchhof P.
        • Benussi S.
        • Kotecha D.
        • et al.
        ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
        Eur Heart J. 2016; 37 (2016): 2893-2962
        • January C.T.
        • Wann L.S.
        • Calkins H.
        • et al.
        AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        J Am Coll Cardiol. 2019; 74 (2019): 104-132