From the Guidelines
For patients with severe heart failure (EF 5-10%) and biventricular thrombi, anticoagulation therapy with heparin is a crucial initial treatment, followed by oral anticoagulation, alongside comprehensive heart failure management including guideline-directed medical therapy and consideration of device therapy. The management of such patients involves a multifaceted approach to reduce morbidity, mortality, and improve quality of life.
Anticoagulation Therapy
- Heparin can be used as initial therapy, typically unfractionated heparin as an intravenous infusion with a target aPTT of 1.5-2.5 times normal, as seen in clinical practice guidelines 1.
- Transition to oral anticoagulation with warfarin (target INR 2.0-3.0) for at least 3-6 months is recommended, given the stronger evidence for warfarin in intracardiac thrombi.
- Direct oral anticoagulants (DOACs) may be considered in some cases, though the evidence is less robust compared to warfarin for intracardiac thrombi.
Comprehensive Heart Failure Management
- Optimized guideline-directed medical therapy is essential, including the use of beta-blockers, ACE inhibitors/ARBs, aldosterone antagonists, and potentially SGLT2 inhibitors as tolerated, based on the latest guidelines and evidence 1.
- Device therapy should be considered, including cardiac resynchronization therapy (CRT) and/or implantable cardioverter-defibrillator (ICD) for appropriate candidates, as outlined in guidelines for heart failure management 1.
Advanced Options
- For patients with refractory symptoms despite optimal medical therapy, advanced options such as left ventricular assist devices (LVADs) or heart transplantation evaluation should be considered, emphasizing the importance of a multidisciplinary approach in managing severe heart failure.
The rationale behind these recommendations is to minimize the risk of thromboembolic events, reduce symptoms, and improve survival in patients with severe heart failure and biventricular thrombi, aligning with the principles of managing heart failure with reduced ejection fraction as discussed in recent guidelines and studies 1.
From the Research
Treatment Options for Heart Failure with Reduced Ejection Fraction (EF 5-10%)
- For patients with heart failure and reduced ejection fraction, the primary goal is to start the four key life-saving therapies as quickly as possible, with titration to 'target dose' as a secondary consideration 2.
- The treatment of heart failure with reduced ejection fraction has been well established, with therapies such as ACE-inhibitors, angiotensin receptor blockers, beta-blockers, and cardiac resynchronization proven to be effective 3.
Biventricular Thrombi and Anticoagulation Therapy
- In patients with heart failure and biventricular thrombi, anticoagulation therapy may be considered to reduce the risk of stroke and systemic embolism 4.
- Heparin can be used as an anticoagulant, but the decision to use it should be individualized based on the patient's risk factors and clinical presentation.
- Non-Vitamin K oral anticoagulants (NOACs) such as rivaroxaban may also be considered for stroke prevention in patients with heart failure and reduced ejection fraction 4.
Specific Considerations for Patients with EF 5-10%
- Patients with heart failure and severely reduced ejection fraction (EF 5-10%) may require more aggressive treatment and closer monitoring due to their high-risk profile.
- The use of anticoagulation therapy in these patients should be carefully considered, weighing the potential benefits against the risks of bleeding 4.
- Further research is needed to determine the optimal treatment strategy for patients with heart failure and severely reduced ejection fraction, including the use of anticoagulation therapy and other interventions.