Authors
Massie BM, Collins JF, Ammon SE, et al.
Title
Randomized trial of warfarin, aspirin, and clopidogrel in patients with chronic heart failure: the Warfarin and Antiplatelet Therapy in Chronic Heart Failure: (WATCH) trial.
References
Circulation 2009;119:1616-1624.
Background
The use of antithrombotic therapy in patients with heart failure has been controversial. As well, patients with heart failure may have weakening of ACE-I effect with concomitant aspirin. The benefit of clopidogrel (prostaglandin independent mechanism of action) in reducing cardiovascular events in this patient population is not known.
Purpose
To determine which antithrombotic is the best in preventing major cardiovascular outcomes for heart failure patients with systolic dysfunction who are in normal sinus rhythm.
Design
  • Prospective, randomized trial (open label warfarin, double-blind aspirin or clopidogrel)
  • 1,587 patients , aged ≥ 18 years, with heart failure (NYHA ll-IV, EF ≤35%, normal sinus rhythm, on ACE-I (or ARB or hydralazine/nitrate) and diuretic for at least 60 days)
Exclusion Criteria
None.
Follow-Up
2-5 years (mean 27 months).There was early discontinuation of the study due to low enrolment.
Treatment Regimen
  • Aspirin 182 mg/day or
  • Clopidogrel 75 mg/day or
  • Warfarin (target INR 2.5-3.0)
Results
Primary Endpoint: all-cause mortality, nonfatal MI, nonfatal stroke.

There was no difference in the primary endpoint between aspirin, clopidogrel or warfarin (20.7% vs 21.6% vs 19.6%). There were fewer nonfatal strokes in patients on warfarin compared to aspirin and clopidogrel (0.2% vs 1.7% vs 2.1%). Heart failure hospitalizations was lower in the warfarin group compared to the aspirin group (16.1% vs 22.2%, p=0.02). Patients on warfarin had a higher risk of major and minor bleeding than those on aspirin or clopidogrel.
Summary
In symptomatic heart failure patients, there is no difference in the primary outcome of death/MI/stroke in patients receiving either aspirin, clopidogrel or warfarin. The risk of major or minor bleeds is higher with anticoagulation.
Implications
None.
Related Figures
[12]