A comparison of anticoagulation, antiplatelet, and placebo treatment for patients with heart failure reduced ejection fraction in sinus rhythm: a systematic review and meta-analysis

Sulaica, Elisabeth M; Macaulay, Tracy; Helbing, Rachel; Abo-Aly, Mohamed; Abdel‐Latif, Ahmed; Wanat, Matthew A.

doi:10.1007/s10741-019-09818-w

Cited by 15 publications

(14 citation statements)

References 37 publications

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“…Whereas some of the trials are not adequately designed to reliably make inferences, the breadth of evidence suggests that anticoagulation may prevent thromboembolic events among patients with HFrEF and SR, but this benefit may be offset by bleeding. Two recent meta-analyses of WASH, HELAS, WATCH, WARCEF, and COMMANDER-HF showed that anticoagulation consistently reduced stroke risk (12,13). However, there was a significant increase in bleeding, a consistent finding across three of the largest trials regardless of type of OAC.…”

Section: Accepted Manuscriptmentioning

confidence: 95%

Stroke and Thromboembolism in Patients with Heart Failure and Sinus Rhythm: A Matter of Risk Stratification?

et al. 2022

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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.

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Section: Accepted Manuscriptmentioning

confidence: 95%

Stroke and Thromboembolism in Patients with Heart Failure and Sinus Rhythm: A Matter of Risk Stratification?

et al. 2022

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“…Previous reviews of the literature provide no clear evidence that treatment with OAC is beneficial for HF patients in sinus rhythm. [28][29][30] The present systematic review revealed minor heterogeneity between the conducted RCTs; Three studies were double blinded, whereas two were open label. The study populations did not differ markedly with respect to age, gender, follow-up time, and systolic blood pressure.…”

Section: Discussionmentioning

confidence: 76%

Efficacy and Safety of Oral Anticoagulants in Patients with Systolic Heart Failure in Sinus Rhythm: A Systematic Review and Meta-analysis of Randomized Controlled Trials and Cohort Studies

Nygaard

Hvas

Grove

2020

TH Open

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Introduction There is conflicting evidence on the risk–benefit ratio of oral anticoagulants (OAC) in heart failure (HF) patients without atrial fibrillation. We aimed to evaluate the efficacy and safety of OAC in HF patients in sinus rhythm. Methods A systematic literature search was conducted using PubMed and Embase. We included randomized controlled trials (RCT) and cohort studies, comparing OAC with antiplatelet or no treatment/placebo in patients with HF. Outcomes evaluated were stroke, myocardial infarction (MI), all-cause mortality, and major bleeding. Results Five RCTs and three cohort studies were included. OAC was associated with a reduced risk of ischemic stroke when compared with no treatment/placebo (odds ratio [OR] = 0.67, 95% confidence interval [CI]: [0.47, 0.94]) and antiplatelet therapy (OR = 0.55, 95% CI: [0.37, 0.81]). No significant reduction was found in MI, when OAC was compared with no treatment/placebo (OR = 0.82, 95% CI: [0.63, 1.07]) or antiplatelet therapy (OR = 1.04, 95% CI: [0.60, 1.81]). The all-cause mortality analysis showed no significant reduction when comparing OAC with no treatment/placebo (OR = 0.99, 95% CI: [0.87, 1.12]) or antiplatelet therapy (OR = 1.00, 95% CI: [0.86, 1.16]). The nonsignificant effect of OAC on all-cause mortality was supported by a meta-analysis of the three cohort studies (OR = 1.02, 95% CI: [0.75, 1.38]). Patients treated with OAC had a significantly higher risk of major bleeding than patients receiving antiplatelet therapy (OR = 2.16, 95% CI: [1.55, 3.00]) and a numerically higher risk when compared with no treatment/placebo (OR = 2.38, 95% CI: [0.87, 6.49]). Conclusion The present study does not support the routine use of OAC in patients with HF in sinus rhythm.

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“…In view of the increased incidence of strokes and thromboembolic events in patients with CHF, the use of OAC in CHF has been an area of interest and the focus of multiple studies. A meta-analysis including five trials and a total of 9,390 patients concluded a decreased risk of stroke and a higher risk of bleeding with the use of OAC, but no effect on mortality, hospitalizations or the risk of myocardial infarction [36]. While some researchers continue to monitor whether ASA may increase bleeding events when used in patients with HF, this was addressed in very few of the studies included.…”

Section: Asa and Oral Anticoagulation In Hf Patientsmentioning

confidence: 99%

Survival Benefit of Aspirin in Patients With Congestive Heart Failure: A Meta-Analysis

et al. 2021

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Background There is no clear consensus on the use of aspirin (ASA) in patients with congestive heart failure (CHF) due to its reported interaction with other cardio-prudent medications. The aim was to evaluate the effect of ASA on all-cause mortality and the frequency of hospitalization for heart failure in patients with CHF using meta-analysis, as well as to study the potential variables interacting with this effect. Methods Eligible studies were identified via a PubMed search, the “related article” feature and a manual search of references. Studies were included if they had a study population with CHF of any etiology, compared ASA to no ASA or placebo, and reported one or both of the following outcomes: 1) all-cause mortality and 2) the frequency of hospitalization for heart failure. Data were extracted and verified. We used the inverse variance method in a random-effects model to combine effect sizes. Results A total of 14 studies with a combined study population of 64,550 patients were included in the final analysis. All-cause mortality was found to be significantly lower in patients who were taking ASA (P = 0.003). When examining the use of ASA, no significant difference was found in the frequency of hospitalization for heart failure. ASA use was demonstrated to be more beneficial against mortality in studies with a larger percentage of patients on nitrates (P = 0.008) and oral anticoagulants (P = 0.04). A significantly lower rate of hospitalization for heart failure was observed in patients who used oral anticoagulants and ASA concurrently (P = 0.02). Conclusions ASA may have beneficial effects on mortality in patients with heart failure of all etiologies.

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A comparison of anticoagulation, antiplatelet, and placebo treatment for patients with heart failure reduced ejection fraction in sinus rhythm: a systematic review and meta-analysis

Cited by 15 publications

References 37 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?

Efficacy and Safety of Oral Anticoagulants in Patients with Systolic Heart Failure in Sinus Rhythm: A Systematic Review and Meta-analysis of Randomized Controlled Trials and Cohort Studies

Survival Benefit of Aspirin in Patients With Congestive Heart Failure: A Meta-Analysis

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