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.

Indications for anti-coagulation

Patients with congestive heart failure should be anticoagulated if they have a history of:

• Documented paroxysmal, persistent or long-standing Atrial fibrillation.
• Systemic or pulmonary emboli including stroke or transient ischemic attack.
• While hospitalized, patients should receive DVT prophylaxis.

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 1 (Heart failure gives 1 point).

Background

• Recently, the CHA2DS2-VASc score has been shown to better predict the incidence of stroke in patients with atrial fibrillation. European society of cardiology guidelines recommended further risk stratification using this score in those with a CHADS2 score of 1. However, it has still not been adopted in American guidelines.
• 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.
• 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.

Patients with heart failure and sinus rhythm

• Anticoagulation is not recommended for the treatment of heart failure according to current evidence.
• Randomized controlled trials with anticoagulation in this group of patients have failed to show any mortality benefit, however they did report a significantly reduced incidence of ischemic stroke. Following trials have been conducted in chronological order:

WASH (2004)

• Purpose: To investigate the effect of anticoagulation in heart failure patients.
• Study population and design: Randomized open-label controlled trial enrolling a total of 279 patients.
• Results: No significant difference in the primary outcome (composite of death/nonfatal myocardial infarction, and nonfatal stroke) was observed among the 3 groups of aspirin (32%), warfarin (26%) or no anti-thrombotic therapy (26%), respectively. Patients in the aspirin group had the highest risk of all-cause hospitalization. Results were similar after excluding patients with atrial fibrillation (4-7%).
• Conclusions: This trial highlighted the lack of evidence for anticoagulation in heart failure patients and provided the basis for designing future larger trials evaluating the effect of anticoagulation in heart failure.

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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