In Reply: B-type natriuretic peptide level and postdischarge thrombotic events in older patients hospitalized with heart failure: Insights from the ADHERE registry

Abstract

We agree with Dr Lin and colleagues that recently published data from randomized clinical trials do not support routine use of warfarin in patients with heart failure, reduced systolic dysfunction, and normal sinus rhythm. We also agree that the overall rate of thromboembolic events in our study population was relatively low, though it was consistent with previous reports. As Lin et al point out, B-type natriuretic peptide (BNP) level was associated with mortality in our study—a finding reported by our group and others—but we did not find an association between BNP level and thromboembolic events. The finding of an association between BNP level and risk of myocardial infarction is novel and suggests that myocardial infarction, in addition to pump failure and ventricular arrhythmia, may also contribute to excess mortality risk in patients with severe heart failure. We disagree with the assertion by Lin et al that we found comparable thromboembolism risk across “patients with or without a severely impaired left ventricular systolic function simply reflected by BNP levels and ejection fraction.” Our study examined BNP level only, not the degree of left ventricular systolic dysfunction or left ventricular ejection fraction. Lin and colleagues also note that sicker patients with the highest BNP levels had greater mortality and, therefore, less time at risk for thromboembolism. We acknowledge that this finding may partially explain the lack of an observed association between BNP level and thromboembolic events. Finally, Lin et al suggest that aspirin or clopidogrel may be superior choices for antithrombotic therapy, reasoning that antiplatelet agents may reduce the risk of death from myocardial infarction or thromboembolism. We have not seen evidence from randomized trials to suggest that this benefit exists. Indeed, in the recently published Warfarin Versus Aspirin in Reduced Cardiac Ejection Fraction trial, warfarin reduced the risk of ischemic stroke by almost 50% in patients with heart failure compared with aspirin, yet the overall mortality rate was the same. The potential benefit of aspirin or clopidogrel in patients with heart failure without known coronary artery disease remains to be studied.