Abstract
Patients with heart failure (HF) in sinus rhythm (SR) experience an increased incidence
of thromboembolic events including stroke. Among patients with HF, high-quality evidence
supports the use of oral anticoagulation when atrial fibrillation is present, but
the benefit of anticoagulation in SR in the absence of other known indications for
anticoagulation is unclear. In four randomized controlled trials (RCTs), warfarin
did not improve a composite of clinical outcomes compared with aspirin or placebo
in patients with HF with reduced ejection fraction (HFrEF) and SR. A recent RCT assessed
the efficacy of the direct oral anticoagulant rivaroxaban versus placebo in patients
with HFrEF (including mildly reduced ejection fraction), SR, and coronary artery disease.
While rivaroxaban had a neutral effect on the primary composite outcome of myocardial
infarction, stroke, or all-cause mortality, exploratory analyses revealed a significant
reduction in strokes. It is thus possible that a subgroup of patients with HFrEF who
are at high risk of stroke may benefit from anticoagulation. The challenge is to adequately
identify this subgroup and to balance the potential benefit of anticoagulation with
the risk of major bleeding. There is also an unmet need for evidence around anticoagulation
in HF with preserved ejection fraction and SR. This review explores the current evidence
around anticoagulation in patients with HF and SR, identifies challenges regarding
outcome definitions and patient selection, and offers suggestions for future research.
Keywords
anticoagulants - heart failure - ischemic stroke - sinus rhythm - thromboembolism
