Anticoagulation in Patients with Dilated Cardiomyopathy, Low Ejection Fraction and Sinus Rhythm: Back to the Drawing Board

Heart failure patients present an important thrombo-embolic risk, including symptomatic or silent peripheral arterial embolism, pulmonary embolism and stroke. Patients in sinus rhythm that have concomitant depressed (<35%) left ventricular ejection fraction have a 4% rate of embolic events. Several prospective randomized trials of anticoagulation in this group of patients were either underpowered either had a short period of follow-up. Even though in two studies warfarin had a slight advantage over aspirin (in the WATCH and WARCEF trials), it was at the cost of a increased risk in major hemorrhage. In order to decrease bleeding rates and to improve anticoagulant effect, new treatment strategies have to be tested. Novel anticoagulants (dabigatran, rivaroxaban and apixaban) seem to be a promising alternative.