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Antiplatelet agents versus control or anticoagulation for heart failure in sinus rhythm
1Haemostasis Thrombosis and Vascular Biology Unit, University Department of Medicine, City Hospital, Dudley Road, Birmingham, UK, B18 7QH. g.y.h.lip@bham.ac.uk
Insights
Current research lacks evidence from randomized controlled trials (RCTs) to support aspirin for preventing thromboembolism in heart failure patients. Anticoagulation also shows no superior benefit over aspirin in this population.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Symptomatic chronic heart failure is associated with high morbidity and mortality.
- Heart failure predisposes patients to stroke and thromboembolism, increasing mortality rates.
Purpose of the Study:
- To evaluate the efficacy of antiplatelet agents compared to placebo or anticoagulants.
- To assess the impact on death and/or major thromboembolic events in adults with heart failure in sinus rhythm.
Main Methods:
- Systematic search of electronic databases (MEDLINE, EMBASE, DARE) and conference abstracts.
- Included randomized parallel group placebo or controlled trials comparing antiplatelet therapy with control or anticoagulation.
- Assessed adverse effects using cohort and non-randomized controlled studies.
Main Results:
- One randomized controlled trial (RCT) on warfarin and aspirin versus no antithrombotic therapy yielded no definitive published data.
- Three retrospective, non-randomized cohort studies on ACE inhibitors and aspirin therapy showed conflicting results.
- No meta-analyses were performed due to a lack of data from randomized comparisons.
Conclusions:
- Insufficient evidence from long-term RCTs exists to recommend aspirin for preventing thromboembolism in heart failure patients in sinus rhythm.
- A potential interaction between ACE inhibitors and aspirin may reduce aspirin's efficacy, based on retrospective analyses.
- No evidence supports oral anticoagulation as superior to aspirin for heart failure patients in sinus rhythm.
Background:
Morbidity and mortality in patients with symptomatic chronic heart failure is high, it predisposes to stroke and thromboembolism which in turn contribute to high mortality in heart failure.
Objectives:
To determine effect of antiplatelet agents when compared to placebo or anticoagulant therapy on death and/or major thromboembolic events in adults with heart failure who are in sinus rhythm.
Search Strategy:
Systematic search of electronic databases (MEDLINE, EMBASE, DARE). Abstracts from cardiology meetings and reference lists of relevant papers were searched. Authors of studies were contacted for further information.
Selection Criteria:
Randomised parallel group placebo or controlled trials comparing antiplatelet therapy with control or anticoagulation in adults with chronic heart failure in sinus rhythm. Treatment for at least 1 month. To assess any adverse effects cohort study & non-randomised controlled studies were assessed. Orally administered antiplatelet agents e.g. non-steroidal anti-inflammatory agents, TICLOPIDINE, CLOPIDOGREL, DIPYRIDAMOLE, ASPIRIN compared with anticoagulant agents e.g. COUMARINS, WARFARIN or placebo.
Data Collection And Analysis:
Data were extracted by two reviewers independently. No meta-analyses were performed as no data were available from randomised comparisons. The data extracted included data relating to the complexities of the topic area, such as patient characteristics and concomitant treatments, as well as data relating to study eligibility, quality, and outcomes. Non-randomised studies were used to identify side-effects caused by anticoagulants.
Main Results:
One RCT of warfarin, aspirin versus no antithrombotic therapy was found but no definitive data have yet been published. Three retrospective, non-randomised cohort studies from the V-HeFT, SOLVD and SAVE trials examining the role of ACE inhibitors have examined the role of aspirin therapy +/- anticoagulant therapy in patients with heart failure and/or left ventricular systolic dysfunction. The results from these trials were conflicting.
Reviewer'S Conclusions:
At present there is no evidence from long term RCTs to recommend use of aspirin to prevent thromboembolism in patients with heart failure in sinus rhythm. A possible interaction with ACE inhibitors may reduce the efficacy of aspirin, although this evidence is from retrospective analyses of trial cohorts. There is also no evidence to indicate superior effects from oral anticoagulation, when compared to aspirin, in patients with heart failure in sinus rhythm.
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