Hyman David, Morales-Vidal Sarkis, Schneck Michael J
Department of Neurology, Loyola University Medical Center, Maguire Building, Suite 2700, 2160 South First Avenue, Maywood, IL, 6015, USA.
Curr Treat Options Cardiovasc Med. 2012 Jun;14(3):215-26. doi: 10.1007/s11936-012-0177-6.
Congestive heart failure (CHF) is associated with an increased risk of stroke mainly due stasis leading to increased risk of thrombus formation in the left ventricle and subsequent cerebral embolism. CHF patients are also at increased risk of atrial fibrillation (AF) that also leads to cerebral embolism. Aggressive medical management to prevent cardiac decompensation and maintain sinus rhythm is indicated in CHF patients. All patients with CHF and AF should be anticoagulated with warfarin or one of the newer oral anticoagulants. There is no clear indication for anticoagulation in CHF patients due to ischemic cardiomyopathy who are in sinus rhythm. Based on data from the WARCEF study (see below), those patients with CHF due to non-ischemic etiologies who are in sinus rhythm and have a left ventricular ejection fraction (LVEF) less than 30 % to 35 % may benefit from warfarin for the reduction of ischemic stroke risk, but warfarin does not increase survival. Whether warfarin is particularly beneficial for CHF patients who have a prior history of stroke or transient ischemic attack (TIA) is unknown. If, however, there is high enough suspicion that the stroke was of cardioembolic origin in patients with low LVEF, then anticoagulation would possibly be a reasonable option for prevention of recurrent stroke or TIA. Warfarin is indicated for stroke prophylaxis among those CHF patients who have an implanted mechanical device. The role of newer anticoagulants in patients with CHF who do not have AF is unknown at this time. Theoretically, there should be no reason against using these agents in place of warfarin in selected patients, particularly those with highly variable International Normalized Ratios (INR) in the context of warfarin therapy, but the newer anticoagulants have not yet been studied among CHF patients without concomitant AF.
充血性心力衰竭（CHF）与中风风险增加相关，主要原因是血液淤滞导致左心室血栓形成风险增加以及随后的脑栓塞。CHF患者发生心房颤动（AF）的风险也增加，这也会导致脑栓塞。对于CHF患者，需要积极的药物治疗以防止心脏失代偿并维持窦性心律。所有CHF合并AF的患者均应使用华法林或一种新型口服抗凝剂进行抗凝治疗。对于因缺血性心肌病处于窦性心律的CHF患者，目前尚无明确的抗凝指征。根据WARCEF研究的数据（见下文），那些因非缺血性病因导致CHF且处于窦性心律、左心室射血分数（LVEF）低于30%至35%的患者，可能从华法林中获益，以降低缺血性中风风险，但华法林不会提高生存率。华法林对有中风或短暂性脑缺血发作（TIA）病史的CHF患者是否特别有益尚不清楚。然而，如果对LVEF低的患者高度怀疑中风是心源性栓塞所致，那么抗凝可能是预防复发性中风或TIA的合理选择。对于植入了机械装置的CHF患者，华法林适用于预防中风。目前，新型抗凝剂在无AF的CHF患者中的作用尚不清楚。理论上，在特定患者中，尤其是那些在华法林治疗期间国际标准化比值（INR）波动较大的患者，没有理由不使用这些药物替代华法林，但新型抗凝剂尚未在无合并AF的CHF患者中进行研究。
