There is not enough evidence yet to determine if anticoagulants safely prevent blood clots in patients with chronic heart failure in normal heart rhythm.

Lip GYH, Chung I

Published Online:

March 16, 2011

Blood clots (thromboembolism) in the lungs, legs and brain (ischaemic stroke) contribute to disability and death of patients with heart failure. Although anticoagulants such as warfarin are of proven benefit in patients in certain subgroups of patients with heart failure there is little evidence that it works well on the wider heart failure population. Also there may be serious side effects such as bleeding (ulcers and haemorrhagic stroke). At present there are no data to recommend its routine use to prevent thromboembolism in patients with heart failure who are in normal heart rhythm.

Abstract (click to read)

Background:

Patients with chronic heart failure (heart failure) are at risk of thromboembolic events, including stroke, pulmonary embolism and peripheral arterial embolism, whilst coronary ischaemic events also contribute to the progression of heart failure. Long-term oral anticoagulation is established in certain groups, including patients with heart failure and atrial fibrillation but there is wide variation in the indications and use of oral anticoagulation in the broader heart failure population.

Objectives:

To determine whether long-term oral anticoagulation reduces total deaths and/or major thromboembolic events in patients with heart failure.

Search strategy:

We searched CENTRAL on The Cochrane Library (Issue 2 2005), MEDLINE (2000 to June 2005) and EMBASE (1998 to June 2005). Reference lists of papers and abstracts from national and international cardiovascular meetings were studied to identify unpublished studies. Relevant authors were contacted to obtain further data. No language restrictions were applied.

Selection criteria:

Randomised controlled trials (RCTs) comparing oral anticoagulants with control or placebo in adults with heart failure, and with treatment duration at least one month. Non-randomised studies were also included for assessing side-effects. Inclusion decisions were duplicated, disagreement resolved by discussion or a third party.

Data collection and analysis:

Data were collected by two reviewers independently and where appropriate data from RCTs were meta-analysed.

Main results:

One recent pilot RCT comparing warfarin, aspirin and no antithrombotic therapy was identified, and one large RCT comparing warfarin and antiplatelet therapy (aspirin, clopidogrel) is awaiting evaluation. Three small prospective controlled studies of warfarin in heart failure were also identified, but were over 50 years old with methods not considered reliable by modern standards. Anticoagulation was more efficacious than control for the reduction of all cause death (odds ratio 0.64 95% CI 0.45 to 0.90) and the reduction of cardiovascular events (0.26 95% CI 0.16 to 0.43). Four retrospective non-randomised cohort analyses and four observational studies of oral anticoagulation in heart failure included differing populations of heart failure patients and reported contradictory results.

Authors' conclusions:

Evidence from the RCTs and observational studies found a reduction in mortality and cardiovascular events with anticoagulants compared to control. This evidence needs to be interpreted with caution. Although oral anticoagulation is indicated in certain groups of patients with heart failure (e.g. atrial fibrillation), the data available does not support its routine use in heart failure patients who remain in sinus rhythm. Large randomised trials of warfarin in heart failure patients in sinus rhythm are completed or currently in progress and data from these will be useful addition to this topic.

This record should be cited as:

Lip GYH, Chung I. Anticoagulation for heart failure in sinus rhythm. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD003336. DOI: 10.1002/14651858.CD003336

Assessed as up to date:

December 1, 2005

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Primary Review Group:

Heart Group

Health topics:

Heart & circulation > Heart failure > Drugs

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

There is not enough evidence yet to determine if anticoagulants safely prevent blood clots in patients with chronic heart failure in normal heart rhythm.

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