Congestive heart failure anticoagulants

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Indications for Warfarin or Dabigatran

A patient with congestive heart failure should be anticoagulated if:

1. Atrial fibrillation is present

and

2. The CHADS2 Score is > 2

Background

• Although aspirin provides some protection from stroke in atrial fibrillation, warfarin provides significantly more protection, albeit with a higher risk of bleeding.
• The higher the risk for stroke in atrial fibrillation, the greater the absolute benefit from warfarin (target INR 2.0-3.0) compared to aspirin (325 mg daily) therapy.
• In the RELY Trial dabigatran at a dose 150mg BID was shown to be superior to warfarin in stroke prevention and can be used for patient in whom the INR is difficult to monitor, however it is currently brand-name only so discussion of cost should be undertaken with the patient.
• The annual incidence of systemic and pulmonary embolism in patients with heart failure is 2-5%. This is not that dissimilar from the risk of severe bleeding among patients to its anticoagulants which is 0.8-2.5% per year.
• As a result anticoagulation is not routinely recommended in the current guidelines for the treatment of heart failure. However among those patients with a atrial fibrillation, a history of emboli, or multiple intracardiac thrombi, or akinesis or dyskinesis detected on echo should be anticoagulated.
• While hospitalized, patients with CHF should receive DVT prophylaxis

Indications for Aspirin

A patient with congestive heart failure should be anticoagulated if:

1. Atrial fibrillation is present

and

2. The CHADS2 Score is 0 or 1

and

3. Patient is not on warfarin or dabigatran

Background

• In patients at relatively low risk for stroke (CHADS2 score 0 or 1), aspirin is a reasonable alternative to warfarin, given its more benign side effect profile and relative convenience to use, although warfarin or dabigatran reduce stroke risk more than does aspirin at all CHADS2 scores.

• The higher the risk for stroke in atrial fibrillation, the greater the absolute benefit from warfarin (target INR 2.0-3.0) compared to aspirin (325 mg daily) therapy.

References

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