CAD patients with heart failure: Managing the risk of thrombotic complications

Patient case: Reducing the burden of heart failure

Imagine how a diagnosis of heart failure (HF) would affect your management of the following patient:

John is 70 years old
He first diagnosed with CAD following stable angina and was prescribed an ACE inhibitor to manage his blood pressure but receives no further treatment
Nine months later, John presents to primary care complaining of fatigue and breathlessness
His doctor observes swelling of both ankles and a rattling sound in the lungs
An ECG suggests HF, and an echocardiogram confirms John has a left ventricular ejection fraction of 35%

John has stable angina

Based on the 2016 ESC guidelines for acute and chronic heart failure, John receives a beta-blocker to lower his heart rate and a diuretic to alleviate the congestion.1

But how should John’s thrombotic risk be addressed?

Heart failure is linked to poor CV outcomes in patients with chronic CAD

HF occurs frequently in patients with CAD. In the REACH registry, 13.6% of patients with chronic CAD had co-morbid HF; this increased to 17.9% in patients with a prior ischaemic event.2

Co-morbid heart failure in patients with chronic CAD in the REACH registry

Furthermore, patients with HF had a significantly higher 4-year risk of major adverse CV events (MACE; comprising MI, stroke or CV death) than patients without HF. In fact,

"the additional risk associated with a diagnosis of HF is the same as that associated with a recent ischaemic event"

and higher than that associated with diabetes, an ischaemic event more than 1 year ago or smoking.2

Relative increase in 4-year risk of MACE associated with different risk factors in the REACH registry

HF is also a serious risk factor for events in patients who have CAD that is sufficiently advanced to require PCI.3 In a study of 5006 patients in the Melbourne Interventional Group registry, the 189 patients with HF had more than double the risk of death, MI or target revascularization within 1 year of PCI than patients without HF (28.6% vs 12.5%). This further underlines the importance of addressing the high thrombotic risk in patients with HF.

High thrombotic risk CAD patients with heart failure

COMPASS had a median follow-up of 23 months and recruited 27,325 patients with chronic CAD or PAD. A substudy of the COMPASS trial looked at the effect of rivaroxaban 2.5 mg bid plus aspirin versus aspirin alone in CAD patients with and without HF.4 Of these, about 20% had a diagnosis of HF at baseline. Approximately one-third of patients with HF were described as New York Heart Association (NYHA) class I and approximately two-thirds were described as NYHA class II. The study excluded patients with severe HF with known left ventricular ejection fraction <30% or NYHA class III or IV symptoms.

In CAD patients with HF, rivaroxaban 2.5 mg bid plus aspirin was associated with a 2.4% absolute reduction in the risk of MACE versus aspirin alone; this means that 42 patients would need to be treated to prevent one MACE. In CAD patients without HF, there was a 0.9% absolute reduction in the risk of MACE with rivaroxaban 2.5 mg bid plus aspirin versus aspirin alone, although the interaction between patients with or without HF did not achieve statistical significance.

Outcomes in patients with and without heart failure in the COMPASS trial

The risk of modified ISTH major bleeding was significantly increased by rivaroxaban 2.5 mg bid plus aspirin versus aspirin alone, although there was no significant interaction between the size of this risk in CAD patients with or without HF.

Conclusion

Overall, CAD patients with HF, like John, were among the patients who received the highest benefit from rivaroxaban 2.5 mg bid plus aspirin in the COMPASS trial. As explained by Professor Kelley Branch in the video below,

“The COMPASS regimen with the vascular protection dose of rivaroxaban 2.5 mg bid plus aspirin provides an additional protection for those CAD patients at high risk for atherothrombosis with heart failure predominantly with preserved ejection fraction.”

PP-XAR-ALL-0820-1

References

Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37:2129–2200. Return to content
Bhatt DL, et al. JAMA. 2010;301(12):1350-7. Return to content
Lu KJ, Yan BP, Ajani AE et al. Impact of concomitant heart failure on outcomes in patients undergoing percutaneous coronary interventions: analysis of the Melbourne Interventional Group registry. Eur J Heart Fail 2011;13:416–422. Return to content
Branch K. Rivaroxaban plus aspirin compared with aspirin in patients with and without heart failure. European Society of Cardiology Heart Failure Congress. Vienna, Austria, 26–29 May 2018, Abstract 1591. Return to content

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