Role of Antithrombotic Agents in Heart Failure

Abstract

Despite a vast body of research on antithrombotic therapy for patients with cardiac disease, there are few clinical settings where robust evidence of their benefit exists. Patients with heart failure often have vascular disease and atrial fibrillation contributing to their poor prognosis. For patients with heart failure and atrial fibrillation, anticoagulants are appropriate. For patients with heart failure in sinus rhythm, the weight of evidence suggests that doctors should generally avoid using any antithrombotic agent even if the patient has coronary artery disease. If there is a compulsion to treat, then there is less evidence of harm with clopidogrel or warfarin than with aspirin, although most receive aspirin. More research is required for this "evidence-light" problem. For those with the opportunity, engaging with a randomized trial is clinically and scientifically appropriate. The dilemma for such studies is the comparator. Should it be against or in addition to "standard of care" or both?

Chronic exercise leads to antiaggregant, antioxidant and anti-inflammatory effects in heart failure patients

“…18 Therefore, the use of antiplatelet pharmacological agents in with HF is scientifically sound, but it is still not recommended for HF patients in sinus rhythm. 19 This is mainly due to a possible reduction of angiotensin-converting enzyme inhibitor benefits and other side effects. 20 Therefore, the main advantage of exercise training is to reduce platelet activation without interfering with the benefits of standard medication for HF treatment.…”

Antithrombotics in Heart Failure With Reduced Ejection Fraction and Normal Sinus Rhythm

“…Despite the lack of proven benefit of aspirin over no-antithrombotic therapy, aspirin is the most widely used antithrombotic agent in this population. 3,63…”

Efficacy and safety of Xa inhibitors in patients with heart failure and coronary or peripheral artery disease: a systematic review and meta-analysis of randomized controlled trials

“…However, due to the slow onset of action, the narrow therapeutic concentration window, and interactions with multiple drugs and diet, VKA has many drawbacks in anticoagulation therapy (3). Furthermore, VKA does not perform well in patients with HF (28). Rivaroxaban and apixaban are novel types of OACs and are direct-acting medications for activated factor Xa, which is an integral component of the coagulation cascade.…”