Thromboembolism and Antithrombotic Therapy in Patients With Heart Failure in Sinus Rhythm

H eart failure (HF) represents a major and growing public health problem because of its prevalence, incidence, morbidity, mortality, and economic costs.The prevalence of HF is 2% to 3% of the general population. 1 Five million Americans are affected, with Ͼ550 000 cases diagnosed each year. 2 The mortality rate from severe HF remains Ͼ60% within 5 years of diagnosis, and 50% of hospitalized patients with HF require readmission within 6 months of discharge.In the US estimated costs amount to Ͼ $35 billion per year. 3lthough several therapies (eg, ␤-blockers, angiotensinconverting enzyme [ACE] inhibitors, and cardiac resynchronization therapy) have been proven effective in improving HF outcomes, many unanswered questions about optimal treatment remain.One area of ongoing uncertainty is the appropriate role for antithrombotic therapy in patients with HF.Observational data suggest that patients with HF have an increased venous thromboembolism (VTE) risk (deep venous thromboembolism [DVT], pulmonary embolism [PE], peripheral arterial thromboembolism, and stroke). 4These epidemiological findings are supported by multiple mechanisms that can contribute to a hypercoagulable state in patients with HF.Despite this increased risk of VTE, the role of antithrombotic therapy remains unclear.In this article, we provide an overview of epidemiology, pathophysiology, clinical trial data, and therapeutic recommendations for prevention of thromboembolism in HF. Search StrategyWe searched PubMed for articles published between 1958 and 2010 using the following search terms: epidemiology of heart failure, thromboembolism and heart failure, thrombogenesis and heart failure, anticoagulation in heart failure, antiplatelet agent and heart failure, aspirin and heart failure, bleeding risk and anticoagulation, and aspirin and angiotensin-converting enzyme inhibitors.We also studied abstracts from national and international cardiovascular meetings to identify unpublished studies using the key words anticoagulation and dilated cardiomyopathy.