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From the Department of Neurology (Dr. Pullicino), State University of New York at Buffalo; The Zena and Michael A. Wiener Cardiovascular Institute (Dr. Halperin), Mount Sinai Medical Center, New York, NY; and the Division of Biostatistics (Dr. Thompson), School of Public Health, Columbia University, New York, NY.
Address correspondence and reprint requests to Dr. Patrick Pullicino, Stroke Service, Department of Neurology, Buffalo General Hospital, 100 High Street, Buffalo, NY 14203.
BACKGROUND: Cardiac failure is associated with both stroke of presumed cardioembolic origin and a high mortality rate. Warfarin is used frequently in patients with reduced cardiac left ventricular ejection fraction (EF), although no randomized trials have confirmed that anticoagulation benefits these patients.
METHODS: A literature review was performed pertaining to the frequency of stroke and mortality, and the effect of antithrombotic agents on stroke and mortality rates, in patients with cardiac failure or reduced cardiac EF. We also reviewed the main features of two new proposed studies (Warfarin and Antiplatelet Therapy in Chronic Heart Failure [WATCH] and Warfarin Versus Aspirin in Reduced Cardiac Ejection Fraction [WARCEF]) comparing warfarin and antiplatelet agents in patients with low EF.
RESULTS: The risk of stroke increases with decreasing EF and the risk of mortality increases with the clinical severity of cardiac failure (New York Heart Association class). Data from heart failure treatment studies suggest that warfarin may reduce stroke and mortality in patients with reduced EF, but definitive answers are lacking. The stroke rate alone is too low to be used as a primary endpoint, but an endpoint combining stroke and death (as WARCEF and WATCH propose) should allow an assessment of the effect of antithrombotics in cardiac failure. Amalgamating the data on stroke from these two trials should yield enough statistical power to compare the effects of warfarin and aspirin on stroke as an independent secondary endpoint.
CONCLUSION: Whether warfarin is superior to aspirin in reducing stroke and mortality in patients with low ejection fraction is an important clinical issue that warrants prospective evaluation.
Key words: Stroke—Heart failure—Ejection fraction—Warfarin—Aspirin
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