Congestive heart failure anticoagulants

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Chronic heart failure is a hyper coagulable state secondary to increased blood viscosity and stasis, endothelial dysfunction and increased levels of biomarkers such as D-dimer, fibrinopeptide A and von-Willebrand factor. This places them at higher risk for development of thromboembolic disorders than the general population. Atrial fibrillation is present in 10-30% of the patients with heart failure. This chapter will discuss the role of anti-coagulation in heart failure patients with atrial fibrillation and those in sinus rhythm, respectively.

Patients with heart failure and atrial fibrillation

A patient with congestive heart failure and atrial fibrillation should be anticoagulated with:

1. Warfarin or dabigatran if the CHADS2 Score is > 2. 2. Aspirin if the CHADS2 Score is 0 or 1.

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.

ACC/AHA Guidelines- Anticoagulant Recommendation

“

Class I 1. It is reasonable to treat patients with atrial fibrillation and heart failure with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone. (Level of Evidence: A)

”

Vote on and Suggest Revisions to the Current Guidelines

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

• 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation

References

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