INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal.
INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France.
Eur Heart J. 2016 Aug;37(31):2455-64. doi: 10.1093/eurheartj/ehw213. Epub 2016 Jun 1.
Atrial fibrillation (AF) and heart failure (HF) often coexist, and patients with AF and HF have a higher risk of thromboembolic events and overall mortality compared with those with AF without HF. Additionally, the prevalence of AF increases with the severity of HF. The use of vitamin K antagonists is more unstable in patients with concomitant AF and HF, which is an independent risk factor for reduced time under therapeutic range. More recently, non-vitamin K antagonists oral anticoagulants (NOACs) have emerged as therapeutic alternatives for stroke prevention in patients with non-valvular AF, as they have been shown to be at least as efficacious and safe, with less intracranial bleeding events, compared with vitamin K antagonists. The subgroup analyses of the NOAC trials in patients with AF and HF show that the efficacy and safety of these agents are likely to be similar to those observed in patients with AF and no HF. However, many gaps in evidence exist, since HF has not been consistently defined nor used as an endpoint in these trials. In patients with HF and sinus rhythm, the risk of stroke and other thrombotic events is high, and the use of warfarin has not, to date, been shown to confer outcome benefit. The benefit of the NOAC, rivaroxaban, is being investigated in HF without AF in the ongoing COMMANDER-HF trial. This review aims to provide an insightful perspective on the use of antithrombotic treatments in patients with both AF and HF, and in patients with HF and sinus rhythm, with particular attention to the NOACs, and provides background for therapeutic, outcome and trial improvement.
心房颤动 (AF) 和心力衰竭 (HF) 常并存，且 AF 合并 HF 患者发生血栓栓塞事件和全因死亡率的风险高于单纯 AF 患者。此外，AF 的患病率随 HF 严重程度的增加而升高。同时患有 AF 和 HF 的患者使用维生素 K 拮抗剂的稳定性较差，这是治疗范围达标时间减少的独立危险因素。最近，非维生素 K 拮抗剂口服抗凝剂 (NOAC) 已成为非瓣膜性 AF 患者预防卒中的治疗选择，因为与维生素 K 拮抗剂相比，它们在疗效和安全性方面至少同样有效，颅内出血事件更少。AF 和 HF 患者的 NOAC 试验亚组分析表明，这些药物的疗效和安全性可能与未合并 HF 的 AF 患者观察到的结果相似。然而，目前仍存在许多证据空白，因为 HF 并未在这些试验中得到一致定义或用作终点。在 HF 伴窦性心律的患者中，发生卒中和其他血栓栓塞事件的风险较高，且迄今为止，华法林的使用并未显示出对结局有益。正在进行的 COMMANDER-HF 试验正在研究 HF 不伴 AF 患者中 NOAC 利伐沙班的获益。本综述旨在深入了解 AF 合并 HF 患者以及 HF 伴窦性心律患者的抗血栓治疗，特别关注 NOAC，并为治疗、结局和试验改进提供背景。
