While guidelines warn against giving anticoagulation to patients with heart failure but without atrial fibrillation, there may be some evidence that a subgroup of these patients may be at increased risk for stroke and could benefit from additional therapy.
According to a meta-analysis published online March 25 in Circulation, risk factors for stroke in patients with heart failure but not atrial fibrillation included age, diabetes treated with insulin, body mass index, prior strokes, and levels of N-terminal pro B-type natriuretic peptide (NT-proBNP).
Lead researcher Azmil H. Abdul-Rahim, MBChB, MRCP, of the Institute of Cardiovascular and Medical Sciences at the University of Glasgow, and colleagues combined data from the CORONA (Controlled Rosuvastatin in Multinational Trial Heart Failure) and GISSI-HF (Gruppo Italiano per lo Studio della Sopravvivenza nell'Insufficienza cardiac- Heart Failure) for this analysis.
Out of a combined 9,585 patients between the two studies, 6,054 did not have atrial fibrillation. Stroke rates for those with and without atrial fibrillation were 16.8 and 11.1 per 1,000 patient-years, respectively. While the two highest risk factors pointing to potential strokes in heart failure patients without atrial fibrillation were insulin-treated diabetes (hazard ratio 1.87) and prior stroke (1.81), in patients where NT-proBNP data was collected, this, too, was a strong indicator of stroke risk (1.31).
Abdul-Rahim et al noted that for the patients without atrial fibrillation in the upper third of risk, at 1.98 percent, it corresponded to the risks for stroke seen among patients with heart failure and atrial fibrillation. In these patients, they suggested, oral anticoagulation should be considered, pending randomized controlled clinical trials.