Anticoagulation in heart failure: current status and future direction.

Abstract

Despite therapeutic advances, patients with worsening heart failure (HF) requiring hospitalization have unacceptably high post-discharge mortality and re-admission rates soon after discharge. Evidence suggests a hypercoagulable state is present in patients with HF. Although thromboembolism as a direct consequence of HF is not frequently clinically recognized, it may contribute to mortality and morbidity. Additionally, many patients with HF have concomitant disorders conferring additional thrombotic risk, including atrial fibrillation (AF) and coronary artery disease (CAD). Acute coronary syndrome (ACS), a known consequence of coronary thrombosis, is a common precipitating factor for worsening HF. Coronary thrombosis may also cause sudden death in patients with HF and CAD. Because data are largely derived from observational studies or trials of modest size, guideline recommendations on anticoagulation for HF vary between organizations. The recently presented Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial of HF patients in sinus rhythm suggested anticoagulation reduces the risk of stroke, although rates of the combined primary endpoint (death, ischemic stroke, or intracerebral hemorrhage) were similar for acetylsalicylic acid and warfarin. Newer oral anticoagulants dabigatran, apixaban, and rivaroxaban have successfully completed trials for the prevention of stroke in patients with AF and have shown benefits in the subpopulation of patients with concomitant HF. Positive results of the Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Standard Therapy in Subjects with Acute Coronary Syndrome-Thrombolysis in Myocardial Infarction 51 (ATLAS ACS 2-TIMI 51) trial of rivaroxaban in ACS are also encouraging. These data suggest there is a need to assess the potential role for these newer agents in the management of patients hospitalized for HF who continue to have a high post-discharge event rate despite available therapies.

• Authors: Mihai Gheorghiade, Muthiah Vaduganathan, Gregg C Fonarow, Stephen J Greene, Barry H Greenberg, Peter P Liu, Barry M Massie, Mandeep R Mehra, Marco Metra, Faiez Zannad, John G F Cleland, Dirk J van Veldhuisen, Ami N Shah, Javed Butler
• Journal: Heart failure reviews (Heart Fail Rev) Vol. 18 Issue 6 Pg. 797-813 (Nov 2013) ISSN: 1573-7322 [Electronic] United States
• PMID: 22987320 (Publication Type: Journal Article, Research Support, Non-U.S. Gov't, Review)

Chemical References

• Anticoagulants

Topics

• Acute Coronary Syndrome (complications, diagnostic imaging, drug therapy)
• Anticoagulants (administration & dosage)
• Atrial Fibrillation (complications, diagnosis, drug therapy)
• Blood Coagulation Disorders (complications, drug therapy, mortality, physiopathology)
• Coronary Thrombosis (complications, diagnostic imaging, drug therapy)
• Dose-Response Relationship, Drug
• Drug Administration Schedule
• Female
• Forecasting
• Heart Failure (drug therapy, etiology, mortality, physiopathology)
• Humans
• Male
• Myocardial Infarction (complications, diagnostic imaging, drug therapy)
• Practice Guidelines as Topic
• Prognosis
• Radiography
• Randomized Controlled Trials as Topic
• Severity of Illness Index
• Survival Rate
• Treatment Outcome