Quality of anticoagulation control in preventing adverse events in patients with heart failure in sinus rhythm: Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial substudy

Circ Heart Fail. 2015 May;8(3):504-9. doi: 10.1161/CIRCHEARTFAILURE.114.001725. Epub 2015 Apr 7.

Abstract

Background: The aim of this study is to examine the relationship between time in the therapeutic range (TTR) and clinical outcomes in heart failure patients in sinus rhythm treated with warfarin.

Methods and results: We used data from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial to assess the relationship of TTR with the WARCEF primary outcome (ischemic stroke, intracerebral hemorrhage, or death), with death alone, ischemic stroke alone, major hemorrhage alone, and net clinical benefit (primary outcome and major hemorrhage combined). Multivariable Cox models were used to examine how the event risk changed with TTR and to compare the high TTR, low TTR, and aspirin-treated patients, with TTR being treated as a time-dependent covariate. A total of 2217 patients were included in the analyses; among whom 1067 were randomized to warfarin and 1150 were randomized to aspirin. The median (interquartile range) follow-up duration was 3.6 (2.0-5.0) years. Mean (±SD) age was 61±11.3 years, with 80% being men. The mean (±SD) TTR was 57% (±28.5%). Increasing TTR was significantly associated with reduction in primary outcome (adjusted P<0.001), death alone (adjusted P=0.001), and improved net clinical benefit (adjusted P<0.001). A similar trend was observed for the other 2 outcomes, but significance was not reached (adjusted P=0.082 for ischemic stroke and adjusted P=0.109 for major hemorrhage).

Conclusions: In patients with heart failure in sinus rhythm, increasing TTR is associated with better outcome and improved net clinical benefit. Patients in whom good quality anticoagulation can be achieved may benefit from the use of anticoagulants.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00041938.

Keywords: anticoagulant; heart failure; hemorrhage; stroke.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Anticoagulants / adverse effects
  • Anticoagulants / therapeutic use*
  • Aspirin / adverse effects
  • Aspirin / therapeutic use*
  • Brain Ischemia / diagnosis
  • Brain Ischemia / etiology
  • Brain Ischemia / mortality
  • Brain Ischemia / prevention & control*
  • Cerebral Hemorrhage / diagnosis
  • Cerebral Hemorrhage / etiology
  • Cerebral Hemorrhage / mortality
  • Cerebral Hemorrhage / prevention & control*
  • Chi-Square Distribution
  • Double-Blind Method
  • Drug Monitoring
  • Female
  • Heart Failure / complications
  • Heart Failure / diagnosis
  • Heart Failure / drug therapy*
  • Heart Failure / mortality
  • Heart Failure / physiopathology
  • Heart Rate*
  • Humans
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Platelet Aggregation Inhibitors / adverse effects
  • Platelet Aggregation Inhibitors / therapeutic use*
  • Predictive Value of Tests
  • Proportional Hazards Models
  • Risk Factors
  • Stroke / diagnosis
  • Stroke / etiology
  • Stroke / mortality
  • Stroke / prevention & control*
  • Stroke Volume*
  • Time Factors
  • Treatment Outcome
  • Ventricular Function, Left*
  • Warfarin / adverse effects
  • Warfarin / therapeutic use*

Substances

  • Anticoagulants
  • Platelet Aggregation Inhibitors
  • Warfarin
  • Aspirin

Associated data

  • ClinicalTrials.gov/NCT00041938