The Role for Anticoagulation with Warfarin in Patients with Systolic Heart Failure and Normal Sinus Rhythm

Abstract

Objective: To evaluate the role of anticoagulation with warfarin in patients with systolic heart failure (HF) and normal sinus rhythm (NSR). Data Sources: Literature was accessed through MEDLINE (1950–December 2007) and the American College of Cardiology Annual Scientific Session (2004) using the terms heart failure, warfarin, and anticoagulation. Study Selection and Data Extraction: All articles in English identified via the searches were evaluated. We excluded trials that evaluated the use of anticoagulation in patients with atrial fibrillation (AF) or valvular disorders. Data Synthesis: Patients with systolic HF are considered to be in a prothrombotic state. Studies have demonstrated a decreased incidence of thromboembolic events with anticoagulation therapy in patients with HF and concomitant AF, valvular dysfunction, or hypercoagulable disorders, but there are limited data supporting the role of anticoagulation in patients with HF and NSR. There are 3 prospective clinical trials and 1 ongoing trial designed to assess the efficacy of warfarin in patients with HF and NSR. These trials compare warfarin with antiplatelet therapy or no antithrombotic therapy. Warfarin did not show a benefit in the primary clinical composite outcome of death, myocardial infarction, or stroke, but was associated with more adverse events. However, these trials were underpowered to detect a difference between treatment arms. Conclusions: There is no objective evidence to support the need for anticoagulation with warfarin in patients with systolic HF and NSR. Additional large randomized, controlled trials need to be completed to determine the efficacy and safety of anticoagulation with warfarin in such patients.