Hi Betty,
I had AVR surgery 3 years ago, and I have been on a Coumadin and Enteric,(coated), aspirin routine since surgery. There are many doctors that recommend the combination of Coumadin and Aspirin routine. I take my Coumadin and a 325 mg Aspirin daily, and have not had any problems.
You should consult your doctor about this, and also do some seaches on the Web for Coumadin and Aspirin.
Hope I have helped in some way,
Rob
For Example;
Can low dose anticoagulation with warfarin and/or aspirin be effective in
the primary prevention of ischemic heart disease in men at high risk?
Appraised by: Deb Bynum, MD
Date: Feb 11, 1998
Clinical Bottom Lines:
1) Low dose anticoagulation with warfarin (with a mean INR of 1.47) reduced
all ischemic heart disease events (fatal and nonfatal) from 12.4% in
patients not on warfarin (on aspirin alone or placebo) to 9.8% in patients
on warfarin for a RRR of 21% (p=.02). This effect was primarily due to a
39% RRR in fatal events (4.8% of patients not on warfarin had a fatal IHD
event compared to 2.9% patients on warfarin). This also accounted for an
overall decrease in all cause mortality from 13.9% in patients not on
warfarin to 11.6% -- a RRR of 17%. The effect of warfarin on nonfatal IHD
events was not significant.
2) The use of aspirin (with or without warfarin) was associated with a 20%
decrease in all IHD events (p=.04) from 11.8% in patients not on aspirin to
9.5% in those on aspirin. However, in contrast to warfarin, there was no
difference in the rate of fatal IHD events (3.7% on aspirin vs 3.3% not on
Aspirin). Nonfatal IHD events however were decreased from 8.5% to 5.8% with
the use of aspirin (RRR 32%). There was no difference in all cause
mortality between patients taking aspirin and those not on aspirin.
3) Warfarin and aspirin increased the risk of hemorrhagic and fatal
strokes. Patients on warfarin had a slight increase in the rate of strokes
from any cause (2.7% to 3.1%) and a small increase in hemorrhagic strokes
from 0.2% to 0.5%. Aspirin was associated with a slight increase in
hemorrhagic strokes from 0.1% to 0.6%, but a decrease in thrombotic strokes
from 2.0% to 1.3% -- therefore there was no difference in the rate of
strokes from any cause with aspirin (2.9% vs 3.0%).
4) There was an increased risk of ruptured aortic or dissecting aneurysm in
patients on warfarin (15 patients) vs those not on warfarin (3 patients), p
=.01.
5) There was a small but significant increased risk of major and minor
bleeding episodes in patients on warfarin, however the risk was not
significantly different than the rates seen with aspirin alone.
The Evidence: Randomised, blinded trial comparing patients on low dose
warfarin, low dose aspirin, warfarin plus aspirin, or placebo alone with a
primary endpoint of ischemic heart disease events (deaths from coronary
causes or MI); Stroke and overall mortality were secondary endpoints. The
patient population consisted of men at increased risk for heart disease,
but no prior history of MI or strokes.
warfarin + warfarin aspirin placebo
aspirin
IHD (n=1277) (n=1268) (n=1268) (n=1272)
All 71 (8.7%) 83 83 107
(10.3%) (10.2%) (13.3%)
Fatal 24 (3.0%) 19 36 (4.4%) 34 (4.2%)
(2.4%)
Nonfatal 47 (5.8%) 64 47 (5.8 73 (9.0%)
(8.0%) %)
Stroke
All cause 29 (3.6%) 22 18 (2.2%) 26 (3.2%)
(2.7%)
Thrombotic 11 (1.4%) 15 10 (1.2%) 18 (2.2%)
(1.9%)
Hemorrhagic 7 (0.9%) 1 (0.1%) 2 (0.2%) 0
Fatal 12 (1.5%) 5(0.6%) 2 (0.2%) 1 (0.1%)
Total 103 (12.4%) 95 113 110
Mortality (11.4%) (13.6%) (13.1%)
Comments:
1) Potential limitations to applying this to clinical practice include
difficulty and cost of following patients on warfarin and issues of
compliance. The authors point out that the process may be easier and safer
with having the goal INR of 1.5.
2) Caution needed in patients with poorly controlled hypertension who seem
to be at increased risk for strokes. The increased risk of aneurysms on
warfarin raises concerns for need for screening prior to starting treatment
which could be costly.
3) BIG POINT: need to weigh costs and benefits. The results are mainly
given as relative risk reduction-- overall 5 IHD events could be avoided by
treating 1000 men with warfarin and aspirin for one year ( or 3 events with
warfarin alone, 3 with aspirin alone). In other words, the NNT with
warfarin and aspirin to prevent on IHD event is 21. But, the all cause
mortality in the placebo group was 13.1% compared to 12.4% in the warfarin
plus aspirin group for an ARR of 0.7% -- The NNT for all cause mortality is
therefore 143 ! -- Is this worth the cost and risk??
4) Although aspirin alone decreased the risk for nonfatal IHD events, there
was still no difference in fatal IHD events and no difference in overall
mortality -- these results are in agreement with prior studies
demonstrating no overall benefit for the use of aspirin in primary
prevention of IHD.
5) Other potential problems with the study -- large rate of withdrawal,
loss of blinding due to minor bleeding events, limited patient population
(men only), an overall incidence of IHD that was less than anticipated, and
the potential bias of self selection in the initial process.
Reference: Thrombosis prevention trial: randomised trial of low-intensity
oral anticoagulation with warfarin and low-dose aspirin in the primary
prevention of ischemic heart disease in men at increased risk. Lancet 1998:
351: 233-41.
