Thrombo-embolism and antithrombotic therapy for heart failure in sinus rhythm. A joint consensus document from the ESC Heart Failure Association and the ESC Working Group on Thrombosis

Antithrombotics in Heart Failure With Reduced Ejection Fraction and Normal Sinus Rhythm

Objective: To review the thromboembolic risk, pathophysiology associated with the risk, and literature investigating the use of antithrombotics in patients with heart failure with reduced ejection fraction and normal sinus rhythm (HFrEF-NSR). Data Sources: An English language literature search was performed with MEDLINE/PubMed and Embase from January 1950 to October 2013 using the search terms heart failure, HFrEF, systolic heart failure, cardiomyopathy, left ventricular dysfunction, sinus rhythm, thromboembolism, deep vein thrombosis, pulmonary embolism, myocardial infarction, acute coronary syndrome, acute coronary events, coronary artery disease, stroke, and cerebrovascular events to identify relevant articles. References in the retrieved articles were also assessed to identify other important articles. Study Selection and Data Abstraction: All pertinent original studies, reviews, consensus documents, and guidelines were evaluated for inclusion. Data Synthesis: Patients with HFrEF-NSR may be predisposed to developing thromboembolic events. Studies that have examined the role of antithrombotics (warfarin and/or antiplatelet therapy) for reducing thromboembolic risk have been inconclusive. The WASH and HELAS pilot trials—the only studies with a no-antithrombotics or placebo comparator group—did not find a benefit with antithrombotic therapy but found an increased risk of bleeding with warfarin and of hospitalizations with aspirin. Although the clinical outcome studies (WATCH and WARCEF) suggested that warfarin may reduce stroke risk compared with antiplatelet therapy, the lack of a placebo group and lower-than-projected enrollment prevents definitive conclusions from being made. Conclusions: Current evidence does not support the routine use of antithrombotics for preventing thromboembolic events in patients with HFrEF-NSR without compelling indications.

Oral anticoagulation therapy in heart failure patients in sinus rhythm: a systematic review and meta-analysis

BACKGROUND

Heart failure (HF) patients show high morbidity and mortality rate with increased risk of malignant arrhythmia and thromboembolism. Anticoagulation reduces embolic event and death rates in HF patients with atrial fibrillation, but if antithrombotic therapy is beneficial in patients with HF in sinus rhythm is still debated.

METHODOLOGY AND PRINCIPAL FINDINGS

We conducted a systematic review of prospective, randomized controlled trials (RCTs) to assess the efficacy and safety of oral anticoagulant therapies (OATs) compared to antiplatelet treatment in HF patients in sinus rhythm. MEDLINE, Web of Science, CENTRAL and Scopus databases were searched up to May 2012. Four RCTs were identified and a total of 3663 patients were included in the meta-analysis. Patients with both ischemic and non-ischemic HF were included. There was no significant difference in mortality (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.86 to 1.19) between OATs group and antiplatelet drug group. OATs have reduced ischemic stroke risk (OR 0.49, 95% CI 0.32 to 0.74), but have increased major bleeding risk (OR 2.01, 95% CI 1.40 to 2.88) compared to antiplatelet treatment.

CONCLUSION

In HF patients in sinus rhythm OATs do not show a better risk-benefit profile compared to antiplatelet treatment in cardioembolism prevention. Warfarin and aspirin seem to be similar in reducing mortality. Warfarin reduces the incidence of ischemic stroke, but increases major bleedings. Thus, it is possible to speculate that aspirin prescription be indicated in patients with high risk of bleeding, whereas warfarin could be preferred in patients with high thromboembolic risk.

Updated meta-analysis on antithrombotic therapy in patients with heart failure and sinus rhythm

AIM

Heart failure (HF) is a prothrombotic state, but current evidence does not support the routine use of aspirin, antiplatelet agents, or anticoagulation in these patients in sinus rhythm (SR). We conducted an updated meta-analysis comparing these medications on outcomes in HF.

METHODS AND RESULTS

All randomized trials in patients with chronic HF and reduced ejection fraction (HFREF) in sinus rhythm (SR; n >100), in which the effect of aspirin, antiplatelet agents, or anticoagulants was determined, were prospectively evaluated. Four trials met the entry criteria. Intervention time was 28 months. No difference in all-cause mortality was seen when aspirin was compared with warfarin [n = 3701, relative risk (RR) 1.00, 95% confidence interval (CI) 0.88-1.13, P = 0.94]. Compared with aspirin, significantly fewer strokes were seen with warfarin (n = 3701, RR 0.59, 95% CI 0.41-0.85, P = 0.004), and fewer fatal and non-fatal ischaemic strokes (n = 3368, RR 0.48, 95% CI 0.32-0.73, P = 0.0006). Warfarin doubled the risk of major haemorrhage compared with aspirin (n = 3701, RR 2.02, 95% CI 1.45-2.80, P < 0.0001); however, intracranial haemorrhage was rare. There was no significant difference in HF hospitalizations with aspirin vs. warfarin (n = 3701, RR 1.16, 95% CI 0.79-1.71, P = 0.45).

CONCLUSION

With warfarin compared with aspirin in HFREF in SR, significant reductions in stroke risk were observed but no mortality benefit was seen. Major haemorrhage doubled but intracranial haemorrhage was rare. These findings suggest that overall the benefit of warfarin in HFREF in SR outweighs the risk. Aspirin use did not increase HF hospitalization as has been previously suggested.

Thromboembolism and antithrombotic therapy for heart failure in sinus rhythm: an executive summary of a joint consensus document from the ESC Heart Failure Association and the ESC Working Group on Thrombosis

Chronic heart failure (HF) with either reduced or preserved left ventricular (LV) ejection fraction is common and remains an extremely serious disorder with a high mortality and morbidity. Many complications related to heart failure can be related to thrombosis. Epidemiological and pathophysiological data also link HF to an increased risk of thrombosis, leading to the clinical consequences of sudden death, stroke, systemic thromboembolism and/or venous thromboembolism. This executive summary of a joint consensus document of the Heart Failure Association (EHFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Thrombosis reviews the published evidence, summarises 'best practice', and puts forward consensus statements that may help to define evidence gaps and assist management decisions in everyday clinical practice. In HF patients with atrial fibrillation, oral anticoagulation is clearly recommended, and the CHA2DS2-VASc and HAS-BLED scores should be used to determine the likely risk-benefit ratio (thromboembolism prevention versus risk of bleeding) of oral anticoagulation. In HF patients with reduced LV ejection fraction who are in sinus rhythm there is no evidence of an overall benefit of vitamin K antagonists (e.g. warfarin) on mortality, with risk of major bleeding. Whilst there is the potential for a reduction in ischaemic stroke, there is currently no compelling reason to routinely use warfarin for these patients. Risk factors associated with increased risk of thromboembolic events should be identified and decisions regarding use of anticoagulation individualised. Patient values and preferences are important determinants when balancing the risk of thromboembolism against bleeding risk. Novel oral anticoagulants that offer a different risk-benefit profile compared with warfarin may appear as an attractive therapeutic option, but this would need to be confirmed in clinical trials.