title: Warfarin and aspirin in patients with heart failure and sinus rhythm.
abstract: 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 3.5) or aspirin (at a dose of 325 mg per day) is a better treatment for patients in sinus rhythm who have a reduced left ventricular ejection fraction (LVEF). We followed 2305 patients for up to 6 years (mean [±SD], 3.5±1.8). The primary outcome was the time to the first event in a composite end point of ischemic stroke, intracerebral hemorrhage, or death from any cause.
  
  
  RESULTS
  The rates of the primary outcome were 7.47 events per 100 patient-years in the warfarin group and 7.93 in the aspirin group (hazard ratio with warfarin, 0.93; 95% confidence interval [CI], 0.79 to 1.10; P=0.40). Thus, there was no significant overall difference between the two treatments. In a time-varying analysis, the hazard ratio changed over time, slightly favoring warfarin over aspirin by the fourth year of follow-up, but this finding was only marginally significant (P=0.046). Warfarin, as compared with aspirin, was associated with a significant reduction in the rate of ischemic stroke throughout the follow-up period (0.72 events per 100 patient-years vs. 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33 to 0.82; P=0.005). The rate of major hemorrhage was 1.78 events per 100 patient-years in the warfarin group as compared with 0.87 in the aspirin group (P<0.001). The rates of intracerebral and intracranial hemorrhage did not differ significantly between the two treatment groups (0.27 events per 100 patient-years with warfarin and 0.22 with aspirin, P=0.82).
  
  
  CONCLUSIONS
  Among patients with reduced LVEF who were in sinus rhythm, there was no significant overall difference in the primary outcome between treatment with warfarin and treatment with aspirin. A reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage. The choice between warfarin and aspirin should be individualized. (Funded by the National Institute of Neurological Disorders and Stroke; WARCEF ClinicalTrials.gov number, NCT00041938.).
authors.affiliation: Columbia University Medical Center, New York, NY 10032, USA.
authors.forename: Shunichi
authors.initials: S
authors.lastname: Homma
authors.forename: John L P
authors.initials: JL
authors.lastname: Thompson
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Pullicino
authors.forename: Bruce
authors.initials: B
authors.lastname: Levin
authors.forename: Ronald S
authors.initials: RS
authors.lastname: Freudenberger
authors.forename: John R
authors.initials: JR
authors.lastname: Teerlink
authors.forename: Susan E
authors.initials: SE
authors.lastname: Ammon
authors.forename: Susan
authors.initials: S
authors.lastname: Graham
authors.forename: Ralph L
authors.initials: RL
authors.lastname: Sacco
authors.forename: Douglas L
authors.initials: DL
authors.lastname: Mann
authors.forename: J P
authors.initials: JP
authors.lastname: Mohr
authors.forename: Barry M
authors.initials: BM
authors.lastname: Massie
authors.forename: Arthur J
authors.initials: AJ
authors.lastname: Labovitz
authors.forename: Stefan D
authors.initials: SD
authors.lastname: Anker
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Lok
authors.forename: Piotr
authors.initials: P
authors.lastname: Ponikowski
authors.forename: Conrado J
authors.initials: CJ
authors.lastname: Estol
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.forename: Marco R
authors.initials: MR
authors.lastname: Di Tullio
authors.forename: Alexandra R
authors.initials: AR
authors.lastname: Sanford
authors.forename: Vilma
authors.initials: V
authors.lastname: Mejia
authors.forename: Andre P
authors.initials: AP
authors.lastname: Gabriel
authors.forename: Mirna L
authors.initials: ML
authors.lastname: del Valle
authors.forename: Richard
authors.initials: R
authors.lastname: Buchsbaum
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use*; D002545:Brain Ischemia / Q000517:prevention & control; D002543:Cerebral Hemorrhage / Q000139:chemically induced; D004311:Double-Blind Method; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D006470:Hemorrhage / Q000139:chemically induced / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D012306:Risk; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control; D013318:Stroke Volume; D016896:Treatment Outcome; D014859:Warfarin / Q000009:adverse effects / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D014859:Warfarin; D001241:Aspirin