From the Guidelines
For patients with severe heart failure (EF 5-10%), biventricular thrombi despite heparin therapy, and a new stroke after non-compliance with apixaban, I recommend transitioning to warfarin therapy with a target INR of 2.0-3.0 for long-term anticoagulation, as suggested by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1. Initially, continue the heparin infusion while starting warfarin until the INR reaches therapeutic range. Consider adding low-dose aspirin (81mg daily) if there are no contraindications. For the severe heart failure, optimize guideline-directed medical therapy including an ARNI (sacubitril/valsartan), beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), mineralocorticoid receptor antagonist (spironolactone or eplerenone), and SGLT2 inhibitor (dapagliflozin or empagliflozin), as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. Evaluate for advanced heart failure therapies including ICD placement for primary prevention, cardiac resynchronization therapy if QRS duration is prolonged, and referral to an advanced heart failure center for consideration of mechanical circulatory support or transplant evaluation given the severely reduced ejection fraction. Address medication adherence through social work consultation, pill organizers, simplified medication regimens, and frequent follow-up. This comprehensive approach targets both the thromboembolic risk and underlying severe heart failure while addressing the critical issue of medication adherence that led to the current complications. Key considerations include:
- The use of warfarin for long-term anticoagulation, with a target INR of 2.0-3.0, as recommended by the 2014 AHA/ACC/HRS guideline 1
- The optimization of guideline-directed medical therapy for severe heart failure, including the use of an ARNI, beta-blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor, as recommended by the 2016 ESC guidelines 1
- The evaluation for advanced heart failure therapies, including ICD placement, cardiac resynchronization therapy, and referral to an advanced heart failure center
- The importance of addressing medication adherence through social work consultation, pill organizers, simplified medication regimens, and frequent follow-up.
From the Research
Treatment Options for Heart Failure Patients with Biventricular Thrombi
- For patients with heart failure (HF) and biventricular thrombi, treatment options are limited, and the current evidence does not provide a clear guideline for management 2.
- However, anticoagulation therapy is crucial in preventing further thromboembolic events, and novel oral anticoagulants (NOACs) have shown promise in reducing stroke risk in HF patients with atrial fibrillation 3.
- In patients with reduced ejection fraction, the use of warfarin has been disappointing, and NOACs may be a better alternative 3.
- Cardiac resynchronization therapy (CRT) may be beneficial for patients with HF and reduced ejection fraction, but its role in patients with biventricular thrombi is unclear 4.
Management of Atrial Fibrillation in Heart Failure Patients
- Atrial fibrillation (AF) is a common comorbidity in HF patients and increases the risk of stroke and systemic embolism 5, 6.
- Catheter ablation for AF has shown superiority in improving survival, quality of life, and ventricular function in HF patients with reduced ejection fraction 6.
- Oral anticoagulation is essential in preventing stroke in AF patients, and NOACs have been shown to be effective in reducing stroke risk 3, 5.
Specific Considerations for the Patient
- The patient's noncompliance with apixaban and development of stroke while on heparin gtt suggests the need for alternative anticoagulation strategies 3, 5.
- The presence of biventricular thrombi and HF with reduced ejection fraction requires careful consideration of anticoagulation therapy and potential interventions to reduce thromboembolic risk 2.