Anticoagulants for stroke prevention in heart failure with reduced ejection fraction

Area of Science:

• Cardiology
• Neurology
• Pharmacology

Background:

• Impaired left-ventricular ejection-fraction (LV-EF) is a significant risk factor for ischemic stroke in heart failure (HF) patients, even without atrial fibrillation.
• Traditional anticoagulation with Vitamin-K antagonists (VKA) has shown limited benefit due to increased bleeding risk in HF patients with sinus rhythm.
• Non-Vitamin K oral anticoagulants (NOACs) are effective for stroke prevention in atrial fibrillation and may offer a better risk-benefit profile in HF.

Purpose of the Study:

• To review NOAC efficacy in HF patients with atrial fibrillation.
• To explore the rationale and evidence for stroke prevention with NOACs in HF patients with sinus rhythm.
• To identify HF patients who may benefit from individualized stroke risk reduction strategies.

Main Methods:

• Review of existing evidence for NOACs in HF patients with atrial fibrillation.
• Analysis of rationale for stroke prevention in HF patients with sinus rhythm.
• Summary of data from anticoagulation trials (COMPASS, COMMANDER-HF) in HF with sinus rhythm.
• Discussion of subgroup data and potential for individualized treatment.

Main Results:

• NOACs are established for stroke prevention in atrial fibrillation.
• Trials in HF with sinus rhythm (COMPASS, COMMANDER-HF) have shown mixed results, with COMMANDER-HF neutral on overall ischemic benefit but suggesting potential subgroup benefits.
• Recent subgroup analyses indicate possible benefits of rivaroxaban for stroke prevention in specific HF patient populations.

Conclusions:

• NOACs represent a potential therapeutic option for stroke prevention in HF patients, including those with sinus rhythm.
• Individualized treatment strategies are crucial for optimizing stroke risk reduction in HF patients.
• Further research may clarify the role of NOACs in specific HF subpopulations with high embolic risk.