Stroke and Anticoagulation in Heart Failure Without Atrial Fibrillation

The association between heart failure and stroke risk has been described for >3 decades.1 Hypercoagulability and left ventricular blood stasis are thought to contribute to stroke risk in patients with heart failure,2 in addition to common risk factors such as hypertension and atrial fibrillation. Regardless of the mechanism, however, for the majority of patients with heart failure who do not have atrial fibrillation, this elevated stroke risk is appreciated but not managed.Article see p 1486The current 2013 American College of Cardiology Foundation/American Heart Association Guideline on Management of Heart Failure states that “anticoagulation is not recommended in patients with chronic heart failure with reduced ejection fraction without atrial fibrillation, a prior thromboembolic event, or a cardioembolic source.”3 The 2012 European Society of Cardiology Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure similarly acknowledge the elevated stroke risk, but recommend against treatment with anticoagulation.4 The recommendations are based on the results of previous randomized, controlled trials that assessed anticoagulation with warfarin in patients with heart failure but without atrial fibrillation. These include the Warfarin/Aspirin Study in Heart Failure (WASH), Heart Failure Long-Term Antithrombotic Study (HELAS), and Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trials, as well as the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial that was the largest and was conducted with patients receiving contemporary heart failure therapy.5–8 Consistently, these trials failed to show …