Warfarin Anticoagulation and Survival: A Cohort Analysis From the Studies of Left Ventricular Dysfunction 11This study was supported by Grant MO1-RR00054 from the General Clinical Research Center, funded by the Division of Research Resources, National Institutes of Health, Bethesda, Maryland. The Studies of Left Ventricular Dysfunction (SOLVD) were funded by the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, with a contribution from Merck, Sharpe and Dohme Pha

Al‐Khadra, Ayman S.; Salem, Deeb N.; Rand, William; Udelson, James E.; Smith, Jordan; Konstam, Marvin A.

doi:10.1016/s0735-1097(98)00006-0

Cited by 193 publications

(10 citation statements)

References 12 publications

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“…Administration of subcutaneous heparin after thrombolysis for a STEMI [12], or alone in anterior STEMI [41], also did not demonstrate an effect on stroke. In a retrospective analysis [42], warfarin use in patients with heterogeneous causes of chronic left ventricular dysfunction demonstrated improved survival and risk of hospitalization for heart failure, but had no effect on stroke.…”

Section: Discussionmentioning

confidence: 99%

Anticoagulation after Anterior Myocardial Infarction and the Risk of Stroke

et al. 2010

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BackgroundSurvivors of anterior MI are at increased risk for stroke with predilection to form ventricular thrombus. Commonly patients are discharged on dual antiplatelet therapy. Given the frequency of early coronary reperfusion and risk of bleeding, it remains uncertain whether anticoagulation offers additional utility. We examined the effectiveness of anticoagulation therapy for the prevention of stroke after anterior MI.Methods and FindingsWe performed a population-based cohort analysis of 10,383 patients who survived hospitalization for an acute MI in Ontario, Canada from April 1, 1999 to March 31, 2001. The primary outcome was four-year ischemic stroke rates compared between anterior and non-anterior MI patients. Risk factors for stroke were assessed by multivariate Cox proportional-hazards analysis. Warfarin use was determined at discharge and followed for 90 days among a subset of patients aged 66 and older (n = 1483). Among the 10,383 patients studied, 2,942 patients survived hospitalization for an anterior MI and 20% were discharged on anticoagulation therapy. Within 4 years, 169 patients (5.7%) were admitted with an ischemic stroke, half of which occurred within 1-year post-MI. There was no significant difference in stroke rate between anterior and non-anterior MI patients. The use of warfarin up to 90 days was not associated with stroke protection after anterior MI (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.37–1.26). The use of angiotensin-converting-enzyme inhibitors (HR, 0.65; 95% CI, 0.44–0.95) and beta-blockers (HR, 0.60; 95% CI, 0.41–0.87) were associated with a significant decrease in stroke risk. There was no significant difference in bleeding-related hospitalizations in patients who used warfarin for up to 90 days post-MI.ConclusionMany practitioners still consider a large anterior-wall MI as high risk for potential LV thrombus formation and stroke. Among a cohort of elderly patients who survived an anterior MI there was no benefit from the use of warfarin up to 90 days post-MI to prevent ischemic stroke. Our data suggests that routine anticoagulation of patients with anterior-wall MI may not be indicated. Prospective randomized trials are needed to determine the optimal antithrombin strategy for preventing this common and serious adverse outcome.

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Section: Discussionmentioning

confidence: 99%

Anticoagulation after Anterior Myocardial Infarction and the Risk of Stroke

et al. 2010

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“…Retrospective analyses of HF studies have suggested a mortality reduction by anticoagulants in HF [32, 33]. Death and intracerebral hemorrhage were included in the primary WARCEF endpoint as they are major life-altering events that may be influenced by warfarin.…”

Section: Warcef Combined Endpoint Of Ischemic Stroke Intracerebral Hmentioning

confidence: 99%

Oral Anticoagulation in Patients with Cardiomyopathy or Heart Failure in Sinus Rhythm

Pullicino

Thompson²,

Mohr³

et al. 2008

Cerebrovasc Dis

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Background: Despite many prospective randomized studies defining the benefits of anticoagulation in atrial fibrillation (AF), there have been no adequate studies in cardiomyopathy (CM) in sinus rhythm. Methods: We review the current knowledge of the risk of stroke in CM, left ventricular systolic dysfunction and heart failure as well as the indications for antithrombotic agents and compare this with AF. Results: The current knowledge of risk factors for stroke and indications for antithrombotic agents in CM is similar to that of AF prior to the treatment studies of the 1980s–1990s. Conclusion: Prospective randomized trial data are urgently needed to determine the role of antithrombotic drugs in CM.

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“…Up to 28% of HF individuals in sinus rhythm are currently treated with warfarin. (11;12) Many individuals with HF on warfarin may not be benefiting from it or may be suffering needless hemorrhagic complications. The aims of this study were firstly to examine the annual stroke rate in participants of the REGARDS study with HF without AF and also in subgroups of participants with vascular risk factors to determine if a subgroup with a stroke rate high enough to warrant anticoagulation can be identified.…”

Section: Introductionmentioning

confidence: 99%

Identifying a High Stroke Risk Subgroup in Individuals with Heart Failure

Pullicino

McClure

Howard

et al. 2013

Journal of Stroke and Cerebrovascular Diseases

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Heart failure (HF) is associated with an overall stroke rate that is too low to justify anticoagulation in all patients. This study was conducted to determine if vascular risk factors can identify a subgroup of individuals with heart failure with a stroke rate high enough to warrant anticoagulation. The REGARDS study is a population-based cohort of US adults aged ≥45 years. Participants are contacted every six months by telephone for self- or proxy-reported stroke and medical records are retrieved and adjudicated by physicians. Participants were characterized into three groups: HF without atrial fibrillation (AF), AF with or without HF, and neither HF nor AF. Cardiovascular risk factors at baseline were compared between participants with and without incident stroke in HF and AF. Stroke incidence was assessed in risk factor subgroups in HF participants. Of the 30,239 participants, those with missing/anomalous data were excluded. Of the remaining 28,832, 1,360 (5%) had HF without AF, 2,528 (9%) had AF, and 24,944 (86%) had neither. Prior stroke/TIA (p=0.0004), diabetes (DM) (p=0.03) and higher systolic blood pressure (p=0.046), were associated with increased stroke risk in participants with HF without AF. In participants with HF without AF, stroke incidence was highest in those with prior stroke/TIA and DM (2.4 [1.1, 4.0] per hundred personyears). The combination of prior stroke/TIA and DM increases the incidence of stroke in participants with HF without AF. No analyzed subgroup had a stroke rate high enough to make it likely that the benefits of warfarin would outweigh the risks.

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Abstract: In patients with LV systolic dysfunction, warfarin use is associated with improved survival and reduced morbidity. This association is primarily due to a reduction in cardiac events and does not appear to be limited to any particular subgroup.

Cited by 193 publications

References 12 publications

Anticoagulation after Anterior Myocardial Infarction and the Risk of Stroke

Anticoagulation after Anterior Myocardial Infarction and the Risk of Stroke

Oral Anticoagulation in Patients with Cardiomyopathy or Heart Failure in Sinus Rhythm

Identifying a High Stroke Risk Subgroup in Individuals with Heart Failure

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