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(Circulation. 2008;117:e7.)
© 2008 American Heart Association, Inc.

Correspondence

Letter by de Boer and van Veldhuisen Regarding Article, "Risk of Thromboembolism in Heart Failure: An Analysis from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT)"

Rudolf A. de Boer, MD; Dirk J. van Veldhuisen, MD

University Medical Center Groningen, Thoraxcenter, Department of Cardiology, Groningen, The Netherlands

To the Editor:

We read with interest the recent article from Freudenberger et al.¹ The major observation in this article is the incidence of thromboembolism in patients receiving contemporary heart failure management. The increased risk for thromboembolism in heart failure has been appreciated for quite some time, but whether preventive treatment with antiplatelet or anticoagulant agents is indicated in heart failure remains a controversial issue. Current American Heart Association/American College of Cardiology guidelines for the treatment of heart failure do not recommend standard treatment with antiplatelet or anticoagulant agents, except in patients with additional diseases such as coronary artery disease, atrial fibrillation, or ventricular thrombus, or with prosthetic valves.

Much to our surprise, treatment with anticoagulant agents (warfarin) was not associated with a lower rate of thromboembolic events in the analysis of Freudenberger et al.¹ From the data presented, it remains somewhat unclear which patients are struck by thromboembolism, as the authors do not present data on what percentage of the patients using either antiplatelet or anticoagulant or no antithrombotic therapy developed a thromboembolic event. The authors speculate that the number of embolic events, mainly consisting of ischemic stroke, may have primarily been driven by hypertension and atherosclerosis rather than by cardiogenic embolism. Such a mechanism may have been predominant, because the current analysis excluded patients with prior atrial fibrillation or atrial flutter. Nevertheless, from a pathophysiological perspective, oral anticoagulants should theoretically reduce the occurrence of thromboembolism.

These data are important because they add to the currently scarce database on anticoagulant therapy in heart failure. Several (retrospective) analyses from heart failure cohorts^2–4 have suggested that anticoagulant agents may reduce heart failure–associated mortality. Thus, next to amiodarone and an implantable cardioverter-defibrillator, available observational evidence suggests that treatment with anticoagulants may reduce morbidity and mortality in heart failure. A large prospective randomized trial testing the efficacy of antiplatelet and anticoagulant therapy in heart failure⁵ is eagerly awaited.

	Acknowledgments

 
Disclosures

None.

	References

Top References

 
1. Freudenberger RS, Hellkamp AS, Halperin JL, Poole J, Anderson J, Johnson G, Mark DB, Lee KL, Bardy GH; SCD-HeFT Investigators. Risk of thromboembolism in heart failure: an analysis from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). Circulation. 2007; 115: 2637–2641.[Abstract/Free Full Text]

2. Loh E, Sutton MS, Wun CC, Rouleau JL, Flaker GC, Gottlieb SS, Lamas GA, Moyé LA, Goldhaber SZ, Pfeffer MA. Ventricular dysfunction and the risk of stroke after myocardial infarction. N Engl J Med. 1997; 336: 251–257.[Abstract/Free Full Text]

3. Al-Khadra AS, Salem DN, Rand WM, Udelson JE, Smith JJ, Konstam MA. Warfarin anticoagulation and survival: a cohort analysis from the Studies of Left Ventricular Dysfunction. J Am Coll Cardiol. 1998; 31: 749–753.[Abstract/Free Full Text]

4. de Boer RA, Hillege HL, Tjeerdsma G, Verheugt FW, van Veldhuisen DJ. Both antiplatelet and anticoagulant therapy may favorably affect outcome in patients with advanced heart failure. A retrospective analysis of the PRIME-II trial. Thromb Res. 2005; 116: 279–285.[CrossRef][Medline] [Order article via Infotrieve]

5. Pullicino P, Thompson JL, Barton B, Levin B, Graham S, Freudenberger RS; on behalf of the WARCEF Investigators. Warfarin versus aspirin in patients with reduced cardiac ejection fraction (WARCEF): rationale, objectives, and design. J Card Fail. 2006; 12: 39–46.[CrossRef][Medline] [Order article via Infotrieve]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by de Boer, R. A. Articles by van Veldhuisen, D. J. Search for Related Content PubMed PubMed Citation Articles by de Boer, R. A. Articles by van Veldhuisen, D. J. Pubmed/NCBI databases Medline Plus Health Information Heart Failure Related Collections Congestive Anticoagulant mechanisms Coumarins Embolic stroke