Antithrombotics

There are many reasons to consider treating patients with heart failure with antithrombotic agents, including atrial fibrillation, coronary artery disease (CAD), intracardiac thrombus, prevention and treatment of deep vein thrombosis, and to reduce thrombotic complications of left ventricular assist devices or mechanical valves. Current clinical practice is based largely on clinical opinion or extrapolation from trials that did not focus primarily on heart failure. There is good evidence that anticoagulants, compared to aspirin, reduce the risk of stroke in patients who have heart failure, whether or not they have atrial fibrillation, but it is uncertain whether this translates into a reduction in disability or death. The increased risk of bleeding should be weighed against the benefits of stroke reduction. For patients with heart failure and CAD, new evidence suggests that adding low-dose (2.5 mg bd) rivaroxaban to aspirin reduces vascular events and mortality, but perhaps only if left ventricular ejection fraction is >40%. There is no evidence that aspirin alone or any other antiplatelet agent improves outcome in patients with heart failure with or without CAD, regardless of left ventricular ejection fraction. Patients with heart failure were included in many of the clinical trials showing that prophylactic use of heparin or anticoagulants reduces the risk of deep vein thrombosis and pulmonary embolism among acute medical admissions. Extending anticoagulation for 6 weeks after discharge may further reduce the risk of deep vein thrombosis but it is not clear that this reduces the risk of pulmonary embolism or mortality.