Antithrombotic Therapy in Heart Failure

Clarity regarding the role of antithrombotic treatments in patients with heart failure in the absence of atrial fibrillation remains elusive. In an era of an intensified search for personalized medicine, it is instructive to look back at the earliest evidence for a protective effect of anticoagulation, when little else had any promise to reduce morbidity and mortality in heart failure.1–3 It is now evident that those benefits were predominantly driven by effects in subsets of patients with atrial fibrillation and valvular disease. Sixty years later, the role of antithrombotic treatments in the remaining population remains uncertain. The Warfarin and Antiplatelet Therapy in Chronic Heart Failure Trial (WATCH), the results of which are published in the present issue,4 held the promise of providing clear support for one therapeutic approach above the others in reducing the incidence of adverse cardiovascular events. However, the primary WATCH findings provide no clear winner among warfarin, clopidogrel, and aspirin, with the limited statistical power preventing any clear conclusion. WATCH results do suggest that aspirin treatment increases the likelihood of heart failure hospitalization compared with the other approaches.Article p 1616 Evidence exists indicating that heart failure is often accompanied by a hypercoagulable state.5–7 Patients with reduced cardiac output may be predisposed to venous thrombosis and pulmonary embolus. In the sizable percentage of heart failure patients with ischemic heart disease, antiplatelet therapy is expected to decrease the incidence of recurrent coronary ischemic events, as it has been shown to do in the broader ischemic heart disease population.8–12 Among patients without known ischemic heart disease, there is suspicion that many adverse events, including worsening heart failure and sudden cardiac death, may be provoked by myocardial ischemia,13 raising the possibility that antithrombotic treatment may impact natural history in this population as well. On the …