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The general public has been conditioned over many years to accept aspirin as an effective, safe, and inexpensive remedy for heart attacks and for primary and secondary prevention of cardiovascular events. In most countries aspirin was available as an over-the-counter remedy well before its widespread use in cardiovascular disease, which probably contributed to its widespread acceptability. Moreover, many physicians took part in the physicians health study,1 a pivotal study of primary prevention in cardiovascular disease, originally promoted as showing that aspirin reduced non-fatal myocardial infarction, but without emphasis of the increase in intracranial haemorrhage and unchanged mortality in this essentially neutral study.In non-valvular atrial fibrillation (AF), aspirin has for a number of years been recommended as thrombo-prophylaxis for those not considered at high risk (see Table 1 , e.g. CHADS2 score <2).2 Unfortunately, the implied benefit of guideline approbation probably led to widespread use of aspirin as the ‘easy’, or ‘soft’ option in those at higher stroke risk with either real or perceived contra-indications to Vitamin K antagonist (VKA, e.g. warfarin). This could be the result of differences in perception among physicians and patients of the risks of stroke vs. bleeding3,4 and also the misperception that aspirin is somewhat effective in stroke prevention in this setting and has lower bleeding risk. Another possible contributory factor may be an exaggerated estimate of VKA-associated bleeding, feared by physicians who do not see the strokes prevented, but do see the bleeds. Coupled with this is the issue that VKA therapy is hard to manage, and appears to be universally disliked by physicians, patients, the media, and industry. Perhaps the connotation with …

Misperceptions of aspirin efficacy and safety may perpetuate anticoagulant underutilization in atrial fibrillation