[Anticoagulant treatment and cardiac insufficiency]

In cardiac failure, should conventional therapy be associated systematically with anticoagulant or antiplatelet therapy? Embolic complications are uncommon (1 to 2.5% per year) and the benefit/risk ratio seems to be marginal. The absence of prospective randomised controlled trials makes it impossible to give a definitive reply to this question. The indications of oral anticoagulants are based on experience, good sense, the recognition of known embolic risk factors: severe cardiac failure, atrial fibrillation, EF < 0.30 and low VO2 max, mitral valve disease or prosthetic valve, detection of intracavitary thrombus or spontaneous contrast on transoesophageal echocardiography. Aspirin does not seem to be mandatory even if it reduces the thromboembolic risk non-significantly. In this elderly population with a high co-morbidity, the risks of haemorrhage cannot be ignored, and, if oral anticoagulants are prescribed, biological surveillance must be intensive.