Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study).
BACKGROUND
In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database.


METHODS
The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors.


RESULTS
Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival.


CONCLUSIONS
Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.
Echemann
M
M
Service d'Epidémiologie et d'Evaluation cliniques, Hôpital Marin, CHU Nancy, France.
Alla
F
F
Briançon
S
S
Juillière
Y
Y
Virion
J M
JM
Mertès
P M
PM
Villemot
J P
JP
Zannad
F
F
Aliot
E
E
Breton
Ch
Ch
KhalifE
K
K
Neimann
J L
JL
Allam
S
S
Admant
Ph
P
Baille
N
N
Bellanger
Ph
P
D'Hôtel
R
R
Dambrine
P
P
Dodet
J F
JF
Graille
M
M
Kessler
M
M
Rebeix
G
G
Royer
Saulnier
J P
JP
Thisse
J Y
JY
Trutt
B
B
Vidal
Ph
P
Vuillemin
M Ch
MCh
Delahaye
Ducimetière
P
P
Fagnani
F
F
Guize
L
L
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use; D018849:Controlled Clinical Trials as Topic; D016208:Databases, Factual; D004305:Dose-Response Relationship, Drug; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D005602:France / Q000453:epidemiology; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality* / Q000503:physiopathology; D006801:Humans; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D013599:Systole / Q000187:drug effects / Q000502:physiology; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy* / Q000401:mortality* / Q000503:physiopathology
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000925:Anticoagulants; D005343:Fibrinolytic Agents; D000960:Hypolipidemic Agents; D001241:Aspirin