Antiplatelet agents versus control or anticoagulation for heart failure in sinus rhythm

Lip GYH, Chung I

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Summary

There is insufficient evidence to determine effect of aspirin versus anticoagulation or placebo for thromboembolism in patients with chronic heart failure in sinus rhythm.

Blood clots (thromboembolism) in the lungs, legs and brain (ischaemic stroke) contribute to disability and death of patients with heart failure. Although aspirin is of proven benefit in patients following myocardial infarction, there is inadequate evidence from long term studies to recommend its routine use in patients with heart failure. There is also no evidence to indicate superior effects from oral anticoagulation, when compared to aspirin, in patients with heart failure, although there may be more hospital admissions in those taking aspirin compared to warfarin. There is no presently available prospective evidence from long term studies, to recommend routine use of aspirin to prevent thromboembolism in patients with heart failure who are in sinus rhythm.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 3, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Lip GYH, Chung I. Antiplatelet agents versus control or anticoagulation for heart failure in sinus rhythm. Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD003333. DOI: 10.1002/14651858.CD003333.

This version first published online: October 23. 2001

Abstract

Background

Morbidity and mortality in patients with symptomatic chronic heart failure is high, it predisposes to stroke and thromboembolism which in turn contribute to high mortality in heart failure.

Objectives

To determine effect of antiplatelet agents when compared to placebo or anticoagulant therapy on death and/or major thromboembolic events in adults with heart failure who are in sinus rhythm.

Search strategy

Systematic search of electronic databases (MEDLINE, EMBASE, DARE). Abstracts from cardiology meetings and reference lists of relevant papers were searched. Authors of studies were contacted for further information.

Selection criteria

Randomised parallel group placebo or controlled trials comparing antiplatelet therapy with control or anticoagulation in adults with chronic heart failure in sinus rhythm.
Treatment for at least 1 month. To assess any adverse effects cohort study & non-randomised controlled studies were assessed. Orally administered antiplatelet agents e.g. non-steroidal anti-inflammatory agents, ticlopidine, clopidogrel, dipyridamole, aspirin compared with anticoagulant agents e.g. coumarins, warfarin or placebo.

Data collection and analysis

Data were extracted by two reviewers independently. No meta-analyses were performed as no data were available from randomised comparisons. The data extracted included data relating to the complexities of the topic area, such as patient characteristics and concomitant treatments, as well as data relating to study eligibility, quality, and outcomes. Non-randomised studies were used to identify side-effects caused by anticoagulants.

Main results

One recent pilot RCT compared warfarin, aspirin and no antithrombotic therapy was identified, and one large RCT comparing warfarin and antiplatelet therapy (aspirin, clopidogrel) is awaiting evaluation as no definitive data have yet been published.
Three retrospective, non-randomised cohort studies from the V-HeFT, SOLVD and SAVE trials examining the role of ACE inhibitors have examined the role of aspirin therapy +/- anticoagulant therapy in patients with heart failure and/or left ventricular systolic dysfunction were reviewed for adverse events. The results from these trials were conflicting.

Authors' conclusions

At present there is no evidence from long term RCTs to recommend use of aspirin to prevent thromboembolism in patients with heart failure in sinus rhythm. A possible interaction with ACE inhibitors may reduce the efficacy of aspirin, although this evidence is mainly from retrospective analyses of trial cohorts and one pilot RCT. There is also limited evidence from one pilot RCT and preliminary results from one large RCT to indicate superior effects from oral anticoagulation, when compared to aspirin, in patients with heart failure in sinus rhythm, in relation to hospitalisations.

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