title: Effect of warfarin on survival in patients with concomitant left ventricular systolic dysfunction and pulmonary hypertension: a population cohort study.
abstract: BACKGROUND
  The use of oral anticoagulation in patients with heart failure in sinus rhythm remains controversial as previous large randomized controlled trials (RCTs) have not shown a survival benefit. However, heterogeneity exists among heart failure patients and it is possible that high-risk subgroups may benefit from anticoagulation (warfarin). We hypothesize that one such subgroup are patients with heart failure and pulmonary hypertension (PH), conditions associated with coagulation abnormalities.
  
  
  METHODS
  We conducted a retrospective, population-based, longitudinal cohort study in patients with left ventricular systolic dysfunction (LVSD) and PH [defined as a right ventricular systolic pressure (RVSP) >35 mmHg] identified from echocardiograms performed between January 1994 to May 2011. This data was linked using a unique patient-specific identifier to community-dispensed prescriptions, hospital admissions, and mortality data. For comparison, we included patients with LVSD and no PH.
  
  
  RESULTS
  A total of 2619 subjects with LVSD and a measurable RVSP were identified (mean ± SD age of 73 ± 12 years); 1606 out of 2619 had PH and 1013 out of 2619 had no PH. The overall mean follow-up period was 2.56 ± 3.0 years. In patients with LVSD and PH, the use of warfarin was associated with an improved survival [hazard ratio (HR) = 0.72 95% confidence interval (CI) 0.58-0.90, P = 0.0003], fewer non-cardiovascular disease-related deaths (HR = 0.65, 95%CI 0.49-0.87, P = 0.0033 and showed a trend towards reduced cardiovascular disease-associated mortality (HR = 0.72, 95%CI 0.51-1.02). Warfarin did not improve survival in those with LVSD with no PH.
  
  
  CONCLUSIONS
  In patients with both LVSD and PH, the use of warfarin is associated with a 28% reduction in mortality. Further prospective trials are required to confirm our findings.
authors.affiliation: Division of Cardiovascular and Diabetes Medicine, Division of Medical Science, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Goudie
authors.forename: Douglas
authors.initials: D
authors.lastname: Elder
authors.forename: Harshal
authors.initials: H
authors.lastname: Deshmukh
authors.forename: Benjamin R
authors.initials: BR
authors.lastname: Szwejkowski
authors.forename: Chim C
authors.initials: CC
authors.lastname: Lang
authors.forename: Jacob
authors.initials: J
authors.lastname: George
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D016022:Case-Control Studies; D015331:Cohort Studies; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D013599:Systole; D018487:Ventricular Dysfunction, Left / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D014859:Warfarin / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Left ventricular dysfunction; heart failure; pulmonary hypertension; survival; warfarin