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Results of the second Warfarin-Aspirin Re-Infarction Study (WARIS II) suggest that the combination of warfarin and aspirin is superior to either agent alone in reducing death and recurrent events after MI.
WARIS II was a long-term secondary prevention study. The results of the 20 Norwegian hospitals participating in the trial were presented at the XXIII Congress of the European Society of Cardiology in Stockholm, Sweden, by Principal Investigator Harald Arnesen, MD, PhD, of Ullevaal University Hospital in Oslo, Norway.
The trial aimed to investigate whether there was a benefit in addressing both the activated platelets and fibrin that make up coronary thrombus in patients who had already had an MI, Arnesen said. "In the WARIS II trial, the combined treatment of warfarin with a mean INR of 2.2, together with aspirin in a dose of 75 mg a day, was significantly more efficient in reducing the combined endpoint of death, nonfatal MI and stroke than aspirin alone," Arnesen concluded. Warfarin also was more effective than aspirin but to a lesser degree than the combination.
Arnesen indicated that he believed these findings — along with the rationale of what is known about how coronary thrombus is constituted of platelets and fibrin — are sufficient to change practice in this large population of patients. He pointed out that the level of anticoagulation in this study was 2.0-2.5, the same as is now recommended for warfarin treatment as stroke prophylaxis in patients with atrial fibrillation.
Cost also will be an important factor, Arnesen said. In this study, INRs were managed on an outpatient basis according to the standard practice of the hospitals involved. But that may be changing, too. "The tradition of anticoagulation may be changed because today, it’s more and more common that patients monitor their own INR, as the diabetics do with their blood sugar. It shouldn’t be too dramatic to make that change."
Physicians, however, might not be so quick to change their practice because of this trial, preferring instead to continue using long-term clopidogrel.