Congestive heart failure anticoagulants
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]
Overview
Chronic heart failure is a hyper coagulable state secondary to increased blood viscosity and stasis, endothelial dysfunction and increased levels of biomarkers such as D-dimer, fibrinopeptide A and von-Willebrand factor. This places them at higher risk for development of thromboembolic disorders than the general population. Atrial fibrillation is present in 10-30% of the patients with heart failure.[1] This chapter will discuss the role of anti-coagulation in heart failure patients with atrial fibrillation and those in sinus rhythm, respectively.
Patients with heart failure and atrial fibrillation
A patient with congestive heart failure and atrial fibrillation should be anticoagulated with:
1. Warfarin or dabigatran if the CHADS2 Score is > 2. 2. Aspirin if the CHADS2 Score is 0 or 1.
Background
- Although aspirin provides some protection from stroke in atrial fibrillation, warfarin provides significantly more protection, albeit with a higher risk of bleeding.[2]
- The higher the risk for stroke in atrial fibrillation, the greater the absolute benefit from warfarin (target INR 2.0-3.0) compared to aspirin (325 mg daily) therapy.
- In the RELY[3] Trial dabigatran at a dose 150mg BID was shown to be superior to warfarin in stroke prevention and can be used for patient in whom the INR is difficult to monitor, however it is currently brand-name only so discussion of cost should be undertaken with the patient.
- The annual incidence of systemic and pulmonary embolism in patients with heart failure is 2-5%. This is not that dissimilar from the risk of severe bleeding among patients to its anticoagulants which is 0.8-2.5% per year.
- As a result anticoagulation is not routinely recommended in the current guidelines for the treatment of heart failure. However among those patients with a atrial fibrillation, a history of emboli, or multiple intracardiac thrombi, or akinesis or dyskinesis detected on echo should be anticoagulated.
- While hospitalized, patients with CHF should receive DVT prophylaxis
Indications for Aspirin
A patient with congestive heart failure should be anticoagulated if:
1. Atrial fibrillation is present
and
2. The CHADS2 Score is 0 or 1
and
3. Patient is not on warfarin or dabigatran
Background
- In patients at relatively low risk for stroke (CHADS2 score 0 or 1), aspirin is a reasonable alternative to warfarin, given its more benign side effect profile and relative convenience to use, although warfarin or dabigatran reduce stroke risk more than does aspirin at all CHADS2 scores.
- The higher the risk for stroke in atrial fibrillation, the greater the absolute benefit from warfarin (target INR 2.0-3.0) compared to aspirin (325 mg daily) therapy.
ACC/AHA Guidelines- Anticoagulant Recommendation [4][5]
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Class I1. It is reasonable to treat patients with atrial fibrillation and heart failure with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone.[6][7][8][9][10] (Level of Evidence: A) |
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Vote on and Suggest Revisions to the Current Guidelines
Guidelines Resources
- The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [4]
- 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation [5]
References
- ↑ Stevenson WG, Stevenson LW (1999). "Atrial fibrillation in heart failure". N. Engl. J. Med. 341 (12): 910–1. doi:10.1056/NEJM199909163411209. PMID 10486424. Unknown parameter
|month=ignored (help) - ↑ "Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study". Lancet. 343 (8899): 687–91. 1994. PMID 7907677. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L (2009). "Dabigatran versus warfarin in patients with atrial fibrillation". The New England Journal of Medicine. 361 (12): 1139–51. doi:10.1056/NEJMoa0905561. PMID 19717844. Retrieved 2012-04-03. Unknown parameter
|month=ignored (help) - ↑ 4.0 4.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
- ↑ 5.0 5.1 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
- ↑ Stevenson WG, Tedrow U (2007). "Management of atrial fibrillation in patients with heart failure". Heart Rhythm : the Official Journal of the Heart Rhythm Society. 4 (3 Suppl): S28–30. doi:10.1016/j.hrthm.2006.12.003. PMID 17336880. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Heist EK, Ruskin JN (2006). "Atrial fibrillation and congestive heart failure: risk factors, mechanisms, and treatment". Progress in Cardiovascular Diseases. 48 (4): 256–69. doi:10.1016/j.pcad.2005.09.001. PMID 16517247. Retrieved 2012-04-05.
- ↑ Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold JM, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey JY, O'Hara G, Pedersen OD, Rouleau JL, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL (2008). "Rhythm control versus rate control for atrial fibrillation and heart failure". The New England Journal of Medicine. 358 (25): 2667–77. doi:10.1056/NEJMoa0708789. PMID 18565859. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD (2002). "A comparison of rate control and rhythm control in patients with atrial fibrillation". The New England Journal of Medicine. 347 (23): 1825–33. doi:10.1056/NEJMoa021328. PMID 12466506. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help) - ↑ Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG, Crijns HJ (2002). "A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation". The New England Journal of Medicine. 347 (23): 1834–40. doi:10.1056/NEJMoa021375. PMID 12466507. Retrieved 2012-04-05. Unknown parameter
|month=ignored (help)