Anticoagulation in heart failure without atrial fibrillation: gaps and dilemmas in current clinical practice

Siliste, R.; Antohi, Elena‐Laura; Pepoyan, Sergey; Nakou, Eleni; Vardas, Panos

doi:10.1002/ejhf.1153

Cited by 13 publications

(11 citation statements)

References 61 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Remote monitoring with intracardiac and wearable devices can detect atrial tachyarrhythmias and AF, both risk factors for stroke (23)…”

Section: Stroke: Rhythm and Risk Predictionmentioning

confidence: 99%

“…A subanalysis of the COMMANDER-HF trial also suggested that including venous thromboembolism in the thromboembolic endpoints could better identify the subset of patients with HF and SR who may benefit from antithrombotic therapy. 16 The CHA 2 DS 2 -VASc score (congestive HF, hypertension, age !75 years, diabetes mellitus, prior stroke or thromboembolism, vascular disease, age 65 to 75 years, and female sex)-used to stratify the risk of stroke in patients with AF 19,20 -can predict thromboembolic events (ischemic stroke, transient ischemic attack, and peripheral arterial embolism) similarly well in patients in SR, [21][22][23] as it reflects the abovementioned risk factors for thromboembolism in patients with HF and SR. Patients with AF and with two or more CHA 2 DS 2 -VASc risk factors have an almost threefold increased risk of stroke compared with those without any risk factors.…”

Section: Can Risk Stratification Identify Patients Who May Benefit Fr...mentioning

confidence: 99%

See 1 more Smart Citation

Stroke and Thromboembolism in Patients with Heart Failure and Sinus Rhythm: A Matter of Risk Stratification?

et al. 2022

View full text Add to dashboard Cite

Patients with heart failure (HF) in sinus rhythm (SR) experience an increased incidence of thromboembolic events including stroke. Among patients with HF, high-quality evidence supports the use of oral anticoagulation when atrial fibrillation (AF) is present, but the benefit of anticoagulation in SR in absence of other known indications for anticoagulation is unclear. In four randomized controlled trials (RCTs), warfarin did not improve a composite of clinical outcomes compared with aspirin or placebo in patients with HF with reduced ejection fraction (HFrEF) and SR. A recent RCT assessed the efficacy of the direct oral anticoagulant rivaroxaban versus placebo in patients with HFrEF (including mildly reduced ejection fraction), SR and coronary artery disease. While rivaroxaban had a neutral effect on the primary composite outcome of MI, stroke, or all-cause mortality, exploratory analyses revealed a significant reduction in strokes. It is thus possible that a subgroup of patients with HFrEF who are at high risk of stroke may benefit from anticoagulation. The challenge is to adequately identify this subgroup and to balance the potential benefit of anticoagulation with the risk of major bleeding. There is also an unmet need for evidence around anticoagulation in HF with preserved ejection fraction (HFpEF) and SR. This review explores the current evidence around anticoagulation in patients with HF and SR, identifies challenges regarding outcome definitions and patient selection, and offers suggestions for future research.

show abstract

“…Remote monitoring with intracardiac and wearable devices can detect atrial tachyarrhythmias and AF, both risk factors for stroke (23)…”

Section: Stroke: Rhythm and Risk Predictionmentioning

confidence: 99%

Section: Can Risk Stratification Identify Patients Who May Benefit Fr...mentioning

confidence: 99%

Stroke and Thromboembolism in Patients with Heart Failure and Sinus Rhythm: A Matter of Risk Stratification?

et al. 2022

View full text Add to dashboard Cite

show abstract

“…Meanwhile, the top three diseases for which warfarin was prescribed included CHF, CHF-AF, and AF. Warfarin administration to patients with CHF has proved to be able to reduce the risk of both systemic complications and venous thromboembolism (Siliste et al, 2018). The use of warfarin has also proved to be effective in preventing thromboembolism among patients with atrial fibrillation at I-A level of evidence (Katritsis et al, 2015).…”

Section: Resultsmentioning

confidence: 99%

Bleeding Incidence in Patients Administered with Warfarin at Secondary Hospitals in Yogyakarta Province

Ningrum

Sufiyah²,

Widyastuti

et al. 2020

Indonesian J Pharm

View full text Add to dashboard Cite

Warfarin is an oral anticoagulant most-commonly prescribed for prevention and treatment of thromboembolism. It is widely acknowledged that warfarin has both narrow therapeutic index and various drug-food interactions, thus carrying the risk of subtherapeutic or bleeding. Therefore, warfarin is among the priority drugs to be evaluated to improve the quality of care for warfarin use. This study aimed to analyze the indications and dosage as well as the bleeding incidence in warfarin use at secondary hospitals in Yogyakarta. This research employed the retrospective cross-sectional design among outpatients and inpatients who received warfarin for a minimum of three days. Data of patient demographics, indications and doses of warfarin, incidence of bleeding, and other drugs interacting with warfarin were collected from the medical records for two years of research. The bleeding incidence could include conjunctival bleeding, melena, hematemesis, petechiae, purpura, ecchymosis, or hematochezia as was documented in the medical records. The research involved 139 patients with a majority of male patients and age range of >60 years. The three highest indications of warfarin use were CHF (37.41%), CHF-AF (23.74%), and AF (10.79%) with an average dose of 1.83±0.54 mg/day. Despite the administration of low doses of warfarin, four patients (2.90%) experienced bleeding with hematuria as the main clinical manifestation. This study recommends adjusting to a lower warfarin dose, particularly for the elderly who receive a combination with aspirin. In addition to a lower maintenance dose, a lower therapeutic target of INR should be further verified for Indonesian patients who receive warfarin.

show abstract

“…This triad consists of blood stasis, endothelial disruption, and hypercoagulability. [4,5] In looking at HF patients who appear to be in sinus rhythm, they may carry a burden of subclinical atrial fibrillation contributing to thromboembolic events. [7] Thromboembolic risk stratification is important in HF with normal sinus rhythm.…”

Section: Discussionmentioning

confidence: 99%

Acute Systolic Heart Failure as the only Risk Factor for Cardioembolic Cerebrovascular Accident in the Setting of Nonischemic Cardiomyopathy and Normal Sinus Rhythm: A Case Report with Literature Review

Madoukh¹,

Battisha²,

Ukwu³

et al. 2019

AJMCR

View full text Add to dashboard Cite

The association between atrial fibrillation and stroke is well-known by use of the CHA 2 DS 2 VASc risk assessment. However, little is known about the thromboembolic risk in patients who have isolated systolic heart failure (HF) with sinus rhythm. Despite growing literature which shows how HF in the setting of normal sinus rhythm is a risk factor for thromboembolic disease, the recommendation for use of anticoagulation, whether warfarin or direct oral anticoagulation (DOAC) in this setting, is not yet reflected in cardiology guidelines. To reduce the risk of thromboembolism, anticoagulation trials have been done but have not conclusively shown benefit over risk. We present a case of left middle cerebral artery (MCA) stroke after de novo HF in a patient with sinus rhythm, who was previously not on anticoagulation. Case: A 57-year-old male presented to our hospital with worsening shortness of breath for 3 days. He had signs of hypervolemia consistent with an acute heart failure exacerbation. Pertinent physical exam findings included lower extremity edema, rales, and jugular venous distension. He also had fatigue and exertional dyspnea. During his hospital course, he underwent imaging studies that revealed cardiomegaly, absence of pulmonary embolism, and a severely reduced ejection fraction. During his acute heart failure admission, he developed a left MCA stroke suspected to be of cardioembolic etiology and was successfully treated with tissue plasminogen activator (tPA). Conclusion: According to the most recent AHA/ACC cardiovascular disease guidelines, anticoagulation is not indicated in systolic heart failure patients with sinus rhythm. However, our case is rare because the patient had no underlying risk factors for thromboembolism and significant past medical history. He developed new-onset nonischemic cardiomyopathy complicated by a stroke. Therefore, we suggest the need for prophylactic anticoagulation should be assessed on an individual basis, with the assistance of shared decision making, especially when the ejection fraction is acutely and severely reduced.

show abstract

Anticoagulation in heart failure without atrial fibrillation: gaps and dilemmas in current clinical practice

Cited by 13 publications

References 61 publications

Stroke and Thromboembolism in Patients with Heart Failure and Sinus Rhythm: A Matter of Risk Stratification?

Stroke and Thromboembolism in Patients with Heart Failure and Sinus Rhythm: A Matter of Risk Stratification?

Bleeding Incidence in Patients Administered with Warfarin at Secondary Hospitals in Yogyakarta Province

Acute Systolic Heart Failure as the only Risk Factor for Cardioembolic Cerebrovascular Accident in the Setting of Nonischemic Cardiomyopathy and Normal Sinus Rhythm: A Case Report with Literature Review

Contact Info

Product

Resources

About