Warfarin may reduce risk of ischemic stroke by preventing atrial fibrillation for patients with heart failure and sinus rhythm

Abstract

As compared with the general population, patients with reduced ejection fraction who are in sinus rhythm are observed with a higher risk for ischemic stroke. This relationship is caused by left ventricular stasis, a systemic hypercoagulable state, and endocardial dysfunction in a situation of impaired left ventricular systolic function [ 1 Eikelboom J.W. Connolly S.J. Warfarin in heart failure. N Engl J Med. 2012; 366: 1936-1938 Crossref PubMed Scopus (11) Google Scholar , 2 Freudenberger R.S. Schumaecker M.M. Homma S. What is the appropriate approach to prevention of thromboembolism in heart failure?. Thromb Haemost. 2010; 103: 489-495 Crossref PubMed Scopus (23) Google Scholar ]. Therefore, the issue whether antithrombotic agents especially aspirin or warfarin could successfully prevent stroke for patients with heart failure and sinus rhythm has been tested in a series of clinical trials. The former two trials (the Warfarin/Aspirin Study in Heart Failure (WASH) trial in 2004 and the Heart Failure Long-Term Antithrombotic Study (HELAS) trial in 2006) had too small sample size to detect a significant difference in ischemic stroke rate between patients receiving warfarin and those receiving aspirin [ 3 Cleland J.G. Findlay I. Jafri S. et al. The Warfarin/Aspirin Study in Heart failure (WASH): a randomized trial comparing antithrombotic strategies for patients with heart failure. Am Heart J. 2004; 148: 157-164 Abstract Full Text Full Text PDF PubMed Scopus (354) Google Scholar , 4 Cokkinos D.V. Haralabopoulos G.C. Kostis J.B. Toutouzas P.K. Efficacy of antithrombotic therapy in chronic heart failure: the HELAS study. Eur J Heart Fail. 2006; 8: 428-432 Crossref PubMed Scopus (175) Google Scholar ]. Until recently, the following two largest trials, the Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trial in 2009 and the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) in 2012 demonstrated that warfarin could reduce risk of ischemic stroke among heart failure patients in sinus rhythm [ 5 Massie B.M. Collins J.F. Ammon S.E. et al. Randomized trial of warfarin, aspirin, and clopidogrel in patients with chronic heart failure: the Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trial. Circulation. 2009; 119: 1616-1624 Crossref PubMed Scopus (327) Google Scholar , 6 Homma S. Thompson J.L.P. Pullicino P.M. et al. Warfarin and aspirin in patients with heart failure and sinus rhythm. N Engl J Med. 2012; 366: 1859-1869 Crossref PubMed Scopus (412) Google Scholar ].