NEJM Audio Summary - May 17, 2012

Excerpted Script

0:54| "Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm", by  Shunichi Homma, from Columbia University Medical Center, New York. Patients with heart failure and sinus rhythm benefit from anticoagulation. This trial assessed whether warfarin or aspirin is a better treatment for patients with a reduced left ventricular ejection fraction (LVEF) who were in sinus rhythm. The rates of the primary outcome which was the first event of ischemic stroke, intracerebral hemorrhage, or death from any cause were 7.47 events per 100 patient-years in the warfarin group and 7.93 in the aspirin group. 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. 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 ). 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. 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.
2:47| In editorial, John Eikelboom from McMaster University, Hamilton, Ontario, Canada, writes that the results of this trial are consistent with those of three previous smaller randomized, controlled trials in showing that warfarin anticoagulant therapy, as compared with aspirin, is not associated with a reduction in mortality among patients with heart failure. This trial provides clear evidence that anticoagulant therapy prevents stroke, probably embolic stroke, in patients with heart failure who have severe systolic dysfunction, but the rates of stroke are too low to justify the routine clinical use of warfarin in most patients with heart failure, in light of the increase in the risk of bleeding.

内容は2月に行われた国際脳卒中学会で発表されたもの。著者の本間俊一教授はこのような方。