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A comparison of anticoagulation, antiplatelet, and placebo treatment for patients with heart failure reduced ejection fraction in sinus rhythm: a systematic review and meta-analysis

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Abstract

Previous meta-analyses have not recommended routine warfarin use in heart failure (HF) patients but included limited data on contemporary anticoagulants and practices. We conducted an updated meta-analysis in light of newer literature evaluating rivaroxaban in this patient population. The aim of this meta-analysis was to assess if anticoagulation is associated with a decrease in all-cause mortality, myocardial infarction (MI), stroke, and hospitalization for HF exacerbation without an increased risk of major bleeding. A systematic search was conducted for randomized controlled trials to evaluate the use of antithrombotic therapy in patients with HF in sinus rhythm. Outcomes evaluated included all-cause mortality (ACM), non-fatal stroke, MI, hospitalization for HF exacerbation, and major bleeding. Five trials met criteria with a total of 9390 patients included. Four of the five trials evaluated warfarin use and one trial evaluated rivaroxaban. When anticoagulation was compared to control (antiplatelet and placebo groups), a significant reduction in ischemic stroke was found (OR 0.57; 95% CI, 0.42 to 0.78; P = 0.0005, I2 = 6.9%) and no significant difference was found in the risk of ACM, MI, or HF hospitalization. A significant increase in major bleeding was observed in the anticoagulation group when compared to the control group (OR 2.00; 95% CI, 1.45 to 2.75; P = < 0.0001, I2 = 25.79%). Anticoagulation in HF patients in normal sinus rhythm does not appear to reduce mortality rate, prevent MI, or decrease HF hospitalizations. Use reduces risk of ischemic stroke but is counterbalanced with an increase in major bleeding.

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Authors and Affiliations

  1. Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, 4849 Calhoun Road – Health 2, Room 3044, Houston, TX, 77204-5039, USA

    Elisabeth M. Sulaica & Matthew A. Wanat

  2. Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, 789 S. Limestone Street, TODD 232, Lexington, KY, 40536, USA

    Tracy E. Macaulay

  3. University Libraries, University of Houston, 4849 Calhoun Rd Health 2, Houston, TX, 77204-5039, USA

    Rachel R. Helbing

  4. Gill Heart & Vascular Institute, University of Kentucky, 741 S. Limestone, BBSRB B343, Lexington, KY, 40536-0509, USA

    Mohamed Abo-Aly & Ahmed Abdel-Latif

  5. The Lexington VA Medical Center, 1101 Veterans Drive, Lexington, KY, 40502, USA

    Ahmed Abdel-Latif

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  1. Elisabeth M. Sulaica
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Correspondence to Elisabeth M. Sulaica.

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Relationships with Industry and Other Entities: Dr. Abdel-Latif is supported by the University of Kentucky COBRE Early Career Program (P20 GM103527) and the NIH Grant R01 HL124266. Drs. Tracy E. Macaulay, Mathew A. Wanat, Mohammed Abo-Aly, Elisabeth M. Sulaica, and Ms. Rachel Helbing have no conflicts of interest or financial ties to disclose.

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Search terms included domains of heart failure, anticoagulation, outcomes, and specifications regarding trial type. The PubMed and Embase search strategies are both represented (PDF 33 kb)

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One-study-removal Results – The one-study-removal method was used to assess if removal of any one of the five trials affected overall findings (PNG 412 kb)

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Funnel Plots by Outcome (PNG 194 kb)

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Sulaica, E.M., Macaulay, T.E., Helbing, R.R. et al. A comparison of anticoagulation, antiplatelet, and placebo treatment for patients with heart failure reduced ejection fraction in sinus rhythm: a systematic review and meta-analysis. Heart Fail Rev 25, 207–216 (2020). https://doi.org/10.1007/s10741-019-09818-w

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