Cognitive Decline Over Time in Patients With Systolic Heart Failure: Insights From WARCEF.

Objectives: This study sought to characterize cognitive decline (CD) over time and its predictors in patients with systolic heart failure (HF).

Background: Despite the high prevalence of CD and its impact on mortality, predictors of CD in HF have not been established.

Methods: This study investigated CD in the WARCEF (Warfarin versus Aspirin in Reduced Ejection Fraction) trial, which performed yearly Mini-Mental State Examinations (MMSE) (higher scores indicate better cognitive function; e.

Association between mortality and implantable cardioverter-defibrillators by aetiology of heart failure: a propensity-matched analysis of the WARCEF trial.

Aims: There is debate on whether the beneficial effect of implantable cardioverter-defibrillators (ICDs) is attenuated in patients with non-ischaemic cardiomyopathy (NICM). We assess whether any ICD benefit differs between patients with NICM and those with ischaemic cardiomyopathy (ICM), using data from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial.

Methods And Results: We performed a post hoc analysis using WARCEF (N = 2293; ICM, n = 991 vs.

Pulse pressure and prognosis in patients with heart failure with reduced ejection fraction.

Background: A high pulse pressure (PP) is associated with adverse cardiovascular (CV) outcomes; however, this relationship may be reversed in patients with heart failure with reduced ejection fraction (HFREF).

Methods: Patients from the WARCEF trial with left ventricular ejection fraction ≤35% were included. PP was divided into tertiles: ≤42, 42-54 and >54 mm Hg.

Heart Failure Severity and Quality of Warfarin Anticoagulation Control (From the WARCEF Trial).

Previous studies in patients with atrial fibrillation showed that a history of heart failure (HF) could negatively impact anticoagulation quality, as measured by the average time in therapeutic range (TTR). Whether additional markers of HF severity are associated with TTR has not been investigated thoroughly. We aimed to examine the potential role of HF severity in the quality of warfarin control in patients with HF with reduced ejection fraction.

Left atrial volume and cardiovascular outcomes in systolic heart failure: effect of antithrombotic treatment.

Aims: Left atrium (LA) dilation is associated with adverse cardiovascular (CV) outcomes. Blood stasis, thrombus formation and atrial fibrillation may occur, especially in heart failure (HF) patients. It is not known whether preventive antithrombotic treatment may decrease the incidence of CV events in HF patients with LA enlargement.

Aspirin Does Not Increase Heart Failure Events in Heart Failure Patients: From the WARCEF Trial.

Objectives: The aim of this study was to determine whether aspirin increases heart failure (HF) hospitalization or death in patients with HF with reduced ejection fraction receiving an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB).

Background: Because of its cyclooxygenase inhibiting properties, aspirin has been postulated to increase HF events in patients treated with ACE inhibitors or ARBs. However, no large randomized trial has addressed the clinical relevance of this issue.

Resting Heart Rate and Ischemic Stroke in Patients with Heart Failure.

Background: Although high resting heart rate (RHR) is known to be associated with an increased risk of mortality and hospital admission in patients with heart failure, the relationship between RHR and ischemic stroke remains unclear. This study is aimed at investigating the relationship between RHR and ischemic stroke in patients with heart failure in sinus rhythm.

Methods: We examined 2,060 patients with systolic heart failure in sinus rhythm from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial.

CHA DS -VASc score and adverse outcomes in patients with heart failure with reduced ejection fraction and sinus rhythm.

Aims: The aim of this study was to determine whether the CHA DS -VASc score can predict adverse outcomes such as death, ischaemic stroke, and major haemorrhage, in patients with systolic heart failure in sinus rhythm.

Methods And Results: CHA DS -VASc scores were calculated for 1101 patients randomized to warfarin and 1123 patients randomized to aspirin. Adverse outcomes were defined as death or ischaemic stroke, death alone, ischaemic stroke alone, and major haemorrhage.

Left Ventricular Ejection Fraction and Risk of Stroke and Cardiac Events in Heart Failure: Data From the Warfarin Versus Aspirin in Reduced Ejection Fraction Trial.

Background And Purpose: In heart failure (HF), left ventricular ejection fraction (LVEF) is inversely associated with mortality and cardiovascular outcomes. Its relationship with stroke is controversial, as is the effect of antithrombotic treatment. We studied the relationship of LVEF with stroke and cardiovascular events in patients with HF and the effect of different antithrombotic treatments.

Clinical and Echocardiographic Factors Associated With New-Onset Atrial Fibrillation in Heart Failure - Subanalysis of the WARCEF Trial.

Background: Heart failure (HF) patients have a high incidence of new-onset AF. Given the adverse prognostic influence of AF in HF, identifying patients at high risk of developing AF is important.

Methods and results: The incidence and factors associated with new-onset AF were investigated in patients in sinus rhythm with reduced LVEF enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial.

The first prognostic model for stroke and death in patients with systolic heart failure.

Background: Patients with systolic heart failure (HF) are at increased risk of both ischemic stroke and death. Currently, no risk scores are available to identify HF patients at high risk of stroke or death. The Warfarin vs.

Bleeding Risk and Antithrombotic Strategy in Patients With Sinus Rhythm and Heart Failure With Reduced Ejection Fraction Treated With Warfarin or Aspirin.

We sought to assess the performance of existing bleeding risk scores, such as the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) score or the Outpatient Bleeding Risk Index (OBRI), in patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm (SR) treated with warfarin or aspirin. We calculated HAS-BLED and OBRI risk scores for 2,305 patients with HFrEF in SR enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial. Proportional hazards models were used to test whether each score predicted major bleeding, and comparison of different risk scores was performed using Harell C-statistic and net reclassification improvement index.

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.

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.

Cognitive function in ambulatory patients with systolic heart failure: insights from the warfarin versus aspirin in reduced cardiac ejection fraction (WARCEF) trial.

We sought to determine whether cognitive function in stable outpatients with heart failure (HF) is affected by HF severity. A retrospective, cross-sectional analysis was performed using data from 2, 043 outpatients with systolic HF and without prior stroke enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) Trial. Multivariable regression analysis was used to assess the relationship between cognitive function measured using the Mini-Mental Status Exam (MMSE) and markers of HF severity (left ventricular ejection fraction [LVEF], New York Heart Association [NYHA] functional class, and 6-minute walk distance).

Stroke in heart failure in sinus rhythm: the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial.

Background: The Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial found no difference between warfarin and aspirin in patients with low ejection fraction in sinus rhythm for the primary outcome: first to occur of 84 incident ischemic strokes (IIS), 7 intracerebral hemorrhages or 531 deaths. Prespecified secondary analysis showed a 48% hazard ratio reduction (p = 0.005) for warfarin in IIS.

Benefit of warfarin compared with aspirin in patients with heart failure in sinus rhythm: a subgroup analysis of WARCEF, a randomized controlled trial.

Background: The Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial found no difference in the primary outcome between warfarin and aspirin in 2305 patients with reduced left ventricular ejection fraction in sinus rhythm. However, it is unknown whether any subgroups benefit from warfarin or aspirin.

Methods And Results: We used a Cox model stepwise selection procedure to identify subgroups that may benefit from warfarin or aspirin on the WARCEF primary outcome.

Warfarin and aspirin in patients with heart failure and sinus rhythm.

Background: It is unknown whether warfarin or aspirin therapy is superior for patients with heart failure who are in sinus rhythm.

Methods: We designed this trial to determine whether warfarin (with a target international normalized ratio of 2.0 to 3.

What is the appropriate approach to prevention of thromboembolism in heart failure?

Many studies suggest a higher incidence of thromboembolic syndromes such as stroke, peripheral arterial thrombosis and pulmonary embolism in patients with heart failure (HF), particularly those with left ventricular systolic dysfunction. As a result, some clinicians have chosen to treat patients with HF with anticoagulants as primary prevention against thromboembolic events. However, this practice is not well-supported by scientific data.

Right heart pressure increases after acute increases in ambient particulate concentration.

Objectives: We explored the association between acute changes in daily mean pulmonary artery (PA) and right ventricular (RV) pressures and concentrations of ambient fine particulate matter [PM with aerodynamic diameter < or = 2.5 microm (PM(2.5))] as an explanation for previous associations between congestive heart failure (HF) hospital admissions and PM.

What do we know about anticoagulation in patients with heart failure?

Purpose Of Review: The risk of thromboembolic events in heart failure patients is estimated to be in the range of 1-4.5% per year. To date, there are insufficient data to guide us in appropriate use of antithrombotic or antiplatelet drug therapy to decrease the risk of events in this population.

Comparison of rate versus rhythm control for atrial fibrillation in patients with left ventricular dysfunction (from the AFFIRM Study).

Optimal treatment for patients with atrial fibrillation (AF) and left ventricular (LV) dysfunction is not well defined. It is unclear if sinus rhythm is of greater benefit in patients with significantly reduced ejection fraction (EF) than in patients with normal or mildly depressed LV function. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study compared 2 treatment strategies: "rhythm control," attempting to maintain sinus rhythm, principally with antiarrhythmic drugs, and "rate control," allowing AF to persist or recur while controlling the ventricular rate.

Beta-blocker contraindications: are there patients or situations where use is inappropriate?

beta-blockers have been conclusively proven to increase survival and improve symptoms of heart failure, yet there is underutilization of these agents most commonly because of misunderstandings of the relative contraindications and adverse events during treatment. In this manuscript, we discuss the potential contraindications to beta-blockers in heart failure and compare the true risks against the significant benefits.