Thromboembolism in Heart Failure Patients in Sinus Rhythm

Lin, Andrew; Dinatolo, Elisabetta; Metra, Marco; Sbolli, Marco; Dasseni, Nicolò; Butler, Javed; Greenberg, Barry

doi:10.1016/j.jchf.2021.01.009

Cited by 25 publications

(21 citation statements)

References 52 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Nevertheless, stroke continues to be a devastating complication in patients with HF. 1 2 Among patients with HF, it is hypothesized that the combination of endothelial dysfunction, comorbid conditions increasing the hypercoagulability of blood, and stasis of flow from atrial and ventricular dysfunction produces a prothrombotic state and subsequently increases the risk of intracardiac thrombi and stroke 1 3 ( Fig. 1 ).…”

Section: Introductionmentioning

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

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

Section: Introductionmentioning

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

“…Rivaroxaban with ASA reduced the relative risk of stroke (HR 0.48; 95% CI 0.28-0.83) in patients with HF [36]. The effect on stroke reduction appeared interesting, however, the annual mortality rate in this HF cohort ranging about 2-3% is much lower than reported in many HF trials and registries [37,38]. Furthermore, exclusion of advanced HF patients limits the generalisability of the results also indicated by the lower reduction of stroke risk in patients with reduced LV-EF (Table 5).…”

Section: Rivaroxaban In Hf Patients In Compassmentioning

confidence: 77%

Anticoagulants for stroke prevention in heart failure with reduced ejection fraction

2021

View full text Add to dashboard Cite

Impaired left-ventricular ejection-fraction (LV-EF) is a known risk factor for ischemic stroke and systemic embolism in patients with heart failure (HF) even in the absence of atrial fibrillation. While stroke risk is inversely correlated with LV-EF in HF patients with sinus rhythm, strategies using anticoagulation with Vitamin-K antagonists (VKA) were futile as the increase in major bleedings outweighed the potential benefit in stroke reduction. Non-Vitamin K oral anticoagulants (NOACs) proved to be an effective and in general safer approach for stroke prevention in patients with atrial fibrillation and may also have a favourable risk–benefit profile in HF patients. In HF patients with sinus rhythm, the COMPASS trial suggested a potential benefit for rivaroxaban, whereas the more dedicated COMMANDER-HF trial remained neutral on overall ischemic benefit owed to a higher mortality which was not influenced by anticoagulation. More recent data from subgroups in the COMMANDER-HF trial, however, suggest that there might be a benefit of rivaroxaban regarding stroke prevention under certain circumstances. In this article, we review the existing evidence for NOACs in HF patients with atrial fibrillation, elaborate the rationale for stroke prevention in HF patients with sinus rhythm, summarise the available data from anticoagulation trials in HF with sinus rhythm, and describe the patient who might eventually profit from an individualised strategy aiming to reduce stroke risk. Graphic abstract

show abstract

“…It is known that the components of hypertension, older age, heart failure, diabetes and vascular disease history in the CHA2DS2-VASc score contribute to the development of thrombus and therefore cause undesirable events [19][20][21][22][23]. Arterial hypertension causes direct damage to the vascular endothelium due to increased shear stress and thus causes remodeling in endothelial cells.…”

Section: Discussionmentioning

confidence: 99%

“…As a result of this damage, endothelial dysfunction develops and pro-coagulant molecules are released, resulting in a state of hypercoagulability [ 22 ]. In the presence of heart failure, various causes, especially low cardiac output, are added to causes such as increased inflammation, high prothrombotic substances, and endothelial dysfunction; it gives us an idea why the thrombotic complication rate is high in heart failure patients even if they are in sinus rhythm [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

Association of CHA2DS2-VASc score with successful recanalization in acute ischemic stroke patients undergoing endovascular thrombectomy

Nasifov¹,

Özmen²,

Deniz³

et al. 2022

pwki

View full text Add to dashboard Cite

Introduction:The CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease and sex) score is a simple risk stratification algorithm to estimate stroke/thromboembolic risk in patients with non-valvular atrial fibrillation (AF). Higher pre-stroke CHA2DS2-VASc score is known to be associated with greater stroke severity and poorer outcomes. AF patients generally have higher CHA2DS2-VASc scores than non-AF patients. The Modified Thrombolysis in Cerebral Infarction (mTICI) score is the most widely used grading system to assess the result of recanalizing therapies in acute ischemic stroke (AIS). mTICI 2c and mTICI 3 are conventionally accepted as successful recanalization.Aim: We investigated whether pre-stroke CHA2DS2-VASc score is associated with mTICI recanalization score in AIS patients with and without AF undergoing percutaneous thrombectomy.Material and methods: One hundred fifty-nine patients with the diagnosis of AIS who were admitted within 6 h from symptom onset were included in the study (mean age: 65.7 ±12.9). All subjects underwent endovascular treatment. CHA2DS2-VASc scores of the participants were calculated. Subjects were grouped according to mTICI scores achieved after endovascular treatment. mTICI 2c and mTICI 3 were accepted as successful recanalization.Results: Successful reperfusion was observed in 130 (81.8%) of all patients who underwent endovascular treatment (mTICI flow ≥ 2c) and first-pass reperfusion was observed in 107 (67.3%) patients. When the patients with successful (mTICI flow ≥ 2c) and unsuccessful (mTICI flow ≤ 2b) reperfusion were divided into groups, no significant difference was observed between the patients in terms of comorbidities such as AF, hypertension, hyperlipidemia, coronary artery disease and cerebrovascular accident history. Patients with unsuccessful reperfusion were older than patients with successful reperfusion (71.4 ±11.2 vs. 64.5 ±13.01, p = 0.006), with a higher CHA2DS2-VASc score (4.1 ±1.5 vs. 3.04 ±1.6, p = 0.002). In addition, the duration of the procedure was longer in the unsuccessful reperfusion group (92.4 ±27.2 min vs. 65.0 ±25.1 min, p < 0.001). CHA2DS2-VASc score significantly correlated with successful recanalization (correlation coefficient; 0.243, p = 0.002). Multivariate logistic regression analysis revealed that only CHA2DS2-VASc score (OR = 1.43, 95% CI: 1.09-1.87, p = 0.006) and procedure time (OR = 1.03, 95% CI: 1.01-1.05, p < 0.001) were independent predictors of successful reperfusion. The receiver-operating characteristic (ROC) curve was used to determine the cutoff value for the CHA2DS2-VASc score that best predicts successful reperfusion. The optimal threshold was 3.5, with a sensitivity of 58.6% and specificity of 59.2% (area under the curve (AUC): 0.669, p = 0.005).Conclusions: For the first time in the literature, we investigated and demonstrated that pre-stroke CHA2DS2-VASc score was associated with success of recanalization as assessed with mTICI 2c and mTICI 3 in a cohort of AIS patients reg...

show abstract

Thromboembolism in Heart Failure Patients in Sinus Rhythm

Cited by 25 publications

References 52 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?

Anticoagulants for stroke prevention in heart failure with reduced ejection fraction

Association of CHA2DS2-VASc score with successful recanalization in acute ischemic stroke patients undergoing endovascular thrombectomy

Contact Info

Product

Resources

About