A recent report that states the choice between warfarin and aspirin in patients with heart failure and sinus rhythm should be individualized is the most definitive word to date on the topic, says a hospitalist focused on anticoagulation therapies.
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The report, “Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm,” focused on patients in sinus rhythm who had reduced left ventricular ejection fraction (LVEF). The authors concluded that the reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage.
“The new thing about this study is it’s really the definitive, well-designed, large trial that provides guidance to us as to what is right,” says Margaret Fang, MD, MPH, an associate professor of medicine at the University of California at San Francisco (UCSF) and medical director of the UCSF Anticoagulation Clinic. “Is warfarin really the right decision?”
Dr. Fang notes that the report, known more commonly as the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial, did find that, over time, warfarin began to show improvement over aspirin. But the improvements, which favored warfarin by the fourth year of the six-year trial, were deemed only marginally significant (P=.046).
An editorial accompanying the study noted that while warfarin is often a go-to therapy, the WARCEF trial corroborates other, smaller trials that did not associate it with a reduction in mortality among heart failure patients.
“The WARCEF trial provides clear evidence that anticoagulant therapy prevents stroke, probably embolic stroke, in patients with heart failure who have severe systolic dysfunction, but the rates of stroke are too low to justify the routine clinical use of warfarin in most patients with heart failure, in light of the increase in the risk of bleeding,” the editorial reads.