Oral anticoagulants compared to antiplatelet or placebo in adult patients with chronic heart failure in sinus rhythm and reduced ejection fraction: a systematic review

Abstract

ABSTRACT Background: There was a long-standing hypothesis that heart failure (HF) is a prothrombotic state. This hypothesis was a contributory factor to the development of a long-standing assumption that thrombosis can lead to undesirable events in HF patients with reduced ejection fraction even when in normal sinus rhythm (NSR). This risk of thrombosis requires the administration of antithrombotic therapy. Objectives: This systematic review aims to define if oral anticoagulation has a better risk/benefit profile compared to antiplatelet or placebo in adult patients with chronic heart failure and reduced ejection fraction who are in sinus rhythm. Methods Updated comprehensive literature searches were conducted using (Embase Classic and Embase) and Medline search engine (via Ovid platform), Cochrane central register for randomised controlled trials (RCT), and ClinicalTrials.gov from their inception to June 2019. Only published randomised controlled trials evaluating the effect of antithrombotic medications in heart failure patients were included. Risk of bias was assessed using the guidelines in the Cochrane Handbook for assessment of risk of bias (RoB). Key findings Five studies were included in the qualitative synthesis; all trials that compared warfarin to antiplatelets or placebo showed no significant difference in the primary composite outcomes specified by each trial. A reduction in ischemic stroke was seen by warfarin in two trials but was counterbalanced by the increased risk of major haemorrhage. Only one study compared rivaroxaban to placebo and demonstrated a significantly higher risk of major bleeding in rivaroxaban treated group compared with those on placebo. On the other hand, no difference in the composite outcome of death from any cause, myocardial infarction or stroke was seen between the two groups. Conclusions Summary from overall evidence did not identify an advantage of anticoagulation use in comparison to antiplatelets or placebo in adult patients with heart failure, reduced ejection fraction and normal sinus rhythm.