• 
• 

Three Part Question

In [warfarinised ACS patients] is [aspirin] warranted to [decrease morbidity and mortality]

Clinical Scenario

A 70 year old man on warfarin, presents to Emergency Department , having ischaemic sounding chest pain, i wander if Aspirin, would give the patient more benefit in reducing morbidity and mortality

Search Strategy

Medline 1950 to April Week 2, 2010 using the OVID interface.

[exp Angina Pectoris/ or exp Coronary Disease/ or exp Coronary Thrombosis/ or exp Acute Coronary Syndrome/ or exp Angina, Unstable/ or exp Coronary Vessels/ or exp Myocardial Infarction] OR [Acute coronary syndrome$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] AND [exp Warfarin OR Warfarin$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] AND [exp Aspirin/ OR aspirin$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] AND [exp Hospital Mortality/ or exp Mortality/ OR mortality$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] AND [exp Morbidity/ OR morbidity$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] Limit to human and English language

1. exp Angina Pectoris/ or exp Coronary Disease/ or exp Coronary Thrombosis/ or exp Acute Coronary Syndrome/ or exp Angina, Unstable/ or exp Coronary Vessels/ or exp Myocardial Infarction/
2. Acute coronary syndrome$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier]
3. 1 or 2
4. exp Warfarin/
5. Warfarin$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier]
6. 4 or 5
7. exp Aspirin/
8. aspirin$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier]
9. 7 or 8
10. exp Hospital Mortality/ or exp Mortality/
11. mortality$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier]
12. 10 or 11
13. exp Morbidity/
14. morbidity$.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier]
15. 13 or 14
16. 3 and 6 and 9 and 12 and 15

Search Outcome

16 papers of which three were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Williams MJ et el 1997 New Zealand	Fifty-seven patients presenting with unstable angina or MI	Randomised control trial	In patients with an acute coronary syndrome, combined therapy with aspirin and warfarin with a target INR of 2.0 to 2.5 for 10 weeks reduces the risk of progression or reocclusion of the culprit coronary lesion	In subjects randomized to receive warfarin, the culprit lesion was less likely to progress (1 [4%] vs. 8 [33%]) and more likely to regress (5[19%] vs. 2[9%]) than in subjects receiving placebo (p = 0.02). Recurrent MI or a new occlusion at angiography occurred in 2 (7%) of 29 patients receiving warfarin versus 11 (39%) of 28 patients receiving placebo (p = 0.005).	Small number of patients. Does not address the 3 parts question directly
Forman R. Aronow WS 1996 USA	Elderly patients postmyocardial infarction	Review	Aspirin and warfarin sodium (Coumadin) have been shown to benefit patients of all age groups.		Does not address the question directly
Yedinak KC. Sproat TT 1993 USA	Acute myocardial infarction patients	Review	Some patients may benefit from the combination of aspirin and warfarin		Did not specify who are those patients who benifit from the combination

Comment(s)

No research was found to address already warfarinised patients, presenting to emergency department with ACS, but the available papers found that the combination of aspirin and warfarin helps to reduce mortality and morbidity. Bearing in mind the increased risk of bleeding. Giving aspirin to ACS patient on warfarin, theoretically would give patients more anticoagulant & anti platelet effect, as every medication has different mechanism of action

Clinical Bottom Line

Combination of aspirin and warfarin given to ACS patients helps to reduce mortality and morbidity, There is increased risk of bleeding, Local protocols should be followed

References

1. Williams MJ et el Progression of the culprit lesion in unstable coronary artery disease with warfarin and aspirin versus aspirin alone Journal of the American College of Cardiology 30(2):364-9, 1997 Aug
2. Forman R. Aronow WS Management of postmyocardial infarction in the elderly patient Clinics in Geriatric Medicine 12(1):169-80, 1996 Feb
3. Yedinak KC. Sproat TT Heparin and warfarin therapy after acute myocardial infarction Clinical Pharmacy 12(3):197-215, 1993 Mar