Letter by de Boer and van Veldhuisen Regarding Article, “Risk of Thromboembolism in Heart Failure: An Analysis from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT)”

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HomeCirculationVol. 117, No. 1Letter by de Boer and van Veldhuisen Regarding Article, “Risk of Thromboembolism in Heart Failure: An Analysis from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT)” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by de Boer and van Veldhuisen Regarding Article, “Risk of Thromboembolism in Heart Failure: An Analysis from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT)” Rudolf A. de Boer and Dirk J. van Veldhuisen Rudolf A. de BoerRudolf A. de Boer University Medical Center Groningen, Thoraxcenter, Department of Cardiology, Groningen, The Netherlands Search for more papers by this author and Dirk J. van VeldhuisenDirk J. van Veldhuisen University Medical Center Groningen, Thoraxcenter, Department of Cardiology, Groningen, The Netherlands Search for more papers by this author Originally published1 Jan 2008https://doi.org/10.1161/CIRCULATIONAHA.107.725440Circulation. 2008;117:e7To the Editor:We read with interest the recent article from Freudenberger et al.1 The major observation in this article is the incidence of thromboembolism in patients receiving contemporary heart failure management. The increased risk for thromboembolism in heart failure has been appreciated for quite some time, but whether preventive treatment with antiplatelet or anticoagulant agents is indicated in heart failure remains a controversial issue. Current American Heart Association/American College of Cardiology guidelines for the treatment of heart failure do not recommend standard treatment with antiplatelet or anticoagulant agents, except in patients with additional diseases such as coronary artery disease, atrial fibrillation, or ventricular thrombus, or with prosthetic valves.Much to our surprise, treatment with anticoagulant agents (warfarin) was not associated with a lower rate of thromboembolic events in the analysis of Freudenberger et al.1 From the data presented, it remains somewhat unclear which patients are struck by thromboembolism, as the authors do not present data on what percentage of the patients using either antiplatelet or anticoagulant or no antithrombotic therapy developed a thromboembolic event. The authors speculate that the number of embolic events, mainly consisting of ischemic stroke, may have primarily been driven by hypertension and atherosclerosis rather than by cardiogenic embolism. Such a mechanism may have been predominant, because the current analysis excluded patients with prior atrial fibrillation or atrial flutter. Nevertheless, from a pathophysiological perspective, oral anticoagulants should theoretically reduce the occurrence of thromboembolism.These data are important because they add to the currently scarce database on anticoagulant therapy in heart failure. Several (retrospective) analyses from heart failure cohorts2–4 have suggested that anticoagulant agents may reduce heart failure–associated mortality. Thus, next to amiodarone and an implantable cardioverter-defibrillator, available observational evidence suggests that treatment with anticoagulants may reduce morbidity and mortality in heart failure. A large prospective randomized trial testing the efficacy of antiplatelet and anticoagulant therapy in heart failure5 is eagerly awaited.DisclosuresNone. References 1 Freudenberger RS, Hellkamp AS, Halperin JL, Poole J, Anderson J, Johnson G, Mark DB, Lee KL, Bardy GH; SCD-HeFT Investigators. Risk of thromboembolism in heart failure: an analysis from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). Circulation. 2007; 115: 2637–2641.LinkGoogle Scholar2 Loh E, Sutton MS, Wun CC, Rouleau JL, Flaker GC, Gottlieb SS, Lamas GA, Moyé LA, Goldhaber SZ, Pfeffer MA. Ventricular dysfunction and the risk of stroke after myocardial infarction. N Engl J Med. 1997; 336: 251–257.CrossrefMedlineGoogle Scholar3 Al-Khadra AS, Salem DN, Rand WM, Udelson JE, Smith JJ, Konstam MA. Warfarin anticoagulation and survival: a cohort analysis from the Studies of Left Ventricular Dysfunction. J Am Coll Cardiol. 1998; 31: 749–753.CrossrefMedlineGoogle Scholar4 de Boer RA, Hillege HL, Tjeerdsma G, Verheugt FW, van Veldhuisen DJ. Both antiplatelet and anticoagulant therapy may favorably affect outcome in patients with advanced heart failure. A retrospective analysis of the PRIME-II trial. Thromb Res. 2005; 116: 279–285.CrossrefMedlineGoogle Scholar5 Pullicino P, Thompson JL, Barton B, Levin B, Graham S, Freudenberger RS; on behalf of the WARCEF Investigators. Warfarin versus aspirin in patients with reduced cardiac ejection fraction (WARCEF): rationale, objectives, and design. J Card Fail. 2006; 12: 39–46.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails January 1, 2008Vol 117, Issue 1 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.725440PMID: 18172042 Originally publishedJanuary 1, 2008 PDF download Advertisement SubjectsAnticoagulantsCerebrovascular Disease/StrokeCongenital Heart Disease