BACKGROUND It is unknown whether warfarin or aspirin therapy is superior for patients with heart failure who are in sinus rhythm. METHODS We designed this trial to determine whether warfarin (with a target international normalized ratio of 2.0 to 3.5) or aspirin (at a dose of 325 mg per day) is a better treatment for patients in sinus rhythm who have a reduced left ventricular ejection fraction (LVEF). We followed 2305 patients for up to 6 years (mean [±SD], 3.5±1.8). The primary outcome was the time to the first event in a composite end point of ischemic stroke, intracerebral hemorrhage, or death from any cause. RESULTS The rates of the primary outcome were 7.47 events per 100 patient-years in the warfarin group and 7.93 in the aspirin group (hazard ratio with warfarin, 0.93; 95% confidence interval [CI], 0.79 to 1.10; P = 0.40). Thus, there was no significant overall difference between the two treatments. In a time-varying analysis, the hazard ratio changed over time, slightly favoring warfarin over aspirin by the fourth year of follow-up, but this finding was only marginally significant (P = 0.046). Warfarin, as compared with aspirin, was associated with a significant reduction in the rate of ischemic stroke throughout the follow-up period (0.72 events per 100 patient-years vs. 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33 to 0.82; P = 0.005). The rate of major hemorrhage was 1.78 events per 100 patient-years in the warfarin group as compared with 0.87 in the aspirin group (P<0.001). The rates of intracerebral and intracranial hemorrhage did not differ significantly between the two treatment groups (0.27 events per 100 patient-years with warfarin and 0.22 with aspirin, P = 0.82). CONCLUSIONS Among patients with reduced LVEF who were in sinus rhythm, there was no significant overall difference in the primary outcome between treatment with warfarin and treatment with aspirin. A reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage. The choice between warfarin and aspirin should be individualized.

Digoxin was associated with a significant increase in all-cause mortality in patients with AF after correcting for clinical characteristics and comorbidities, regardless of gender or of the presence or absence of HF. These findings call into question the widespread use of digoxin in patients with AF.

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Peripartum cardiomyopathy is a life-threatening condition of unknown cause that occurs in previously healthy women during the peripartum period. It is characterized by left ventricular dysfunction and symptoms of heart failure that can arise in the last trimester of pregnancy or up to 5 months after delivery. We review its possible causes and how to recognize and manage it.

Summary:Coronary artery ectasia is the abnormal enlargement of the coronary artery. The prognosis, treatment, and etiology of this disease remain an enigma. There is some evidence to suggest that the incidence of ectasia is increasing, and therefore understanding of this entity needs to improve. This article reviews the current literature on coronary artery ectasia and summarizes the findings. A treatment plan that targets each of the suggested clinical complications is provided. Using multiple indirect observations and current understanding of endothelium-derived relaxation factor, a possible etiology that implicates overstimulation of endogenous nitric oxide is provided. Current literature suggests that ectatic coronary arteries, even without the presence of coronary stenosis, are subject to thrombus formation, vasospasm, and spontaneous dissection. Newer subgroups of ectasia are arising with the use of multiple interventional devices to dilate coronary artery stenosis. By design, these destroy the media of the coronary artery, and it is not clear whether these "iatrogenic" ectatic arteries are subject to the same complications as "idiopathic" coronary artery ectasia. Further investigation is necessary to help define the benefit of the proposed treatment regimen, to clarify the prognosis of these newer groups of "iatrogenic" ectasia, and to confirm or disprove the hypothesis targeting nitric oxide as an etiologic factor.This manuscript was published in part as a "signed commentary" in the January 20, 1996 issue of The Lancer. ReviewThe first case report of a coronary artery aneurysm was by Bourgon ( 1 8 12) who described the postmortem finding of a right coronary artery dilatation in a patient who died suddenly.' The first literature review was provided by Packard and Wechsler and included 20 additional case reports and patient profiles? The first use of the term "ectasia" to describe dilated coronary arteries in vivo was provided by B j~r k .~ He included three patients who underwent angiography for cyanosis. At cardiac catheterization, they were found to have tetrology of Fallot and also markedly dilated coronary arteries. Surgical repair of the tetrology was performed without complication. The surgeon dealt with the dilated coronary arteries simply by manually pushing the ectatic vessels aside at the time of surgery. No etiology for the never before described anomaly was offered and no follow-up was provided.Markis et al. provided the first prospective evaluation of the incidence of coronary artery ectasia." They found 30 patients in a study group consisting of 2,500 consecutive cardiac catheterizations. Their work provided insight into the incidence, associated factors, and clinical outcome over a shortterm follow-up of 24 months. Markis et al. found that patients without coronary artery disease, but with ectasia, had a greater prevalence of family histories with coronary artery disease, abnormal electrocardiograms, previous myocardial infarctions, and hypertension than the control group. They also found ...