The Year in Cardiology

Heart Failure: the Year in Cardiology 2019

John G.F. Cleland; Alexander R. Lyon; Theresa McDonagh; John J.V. McMurray


Eur Heart J. 2020;41(12):1232-1248. 

In This Article

Coronary Artery Disease

In COMPASS (n = 27 395), 5902 with CAD, in sinus rhythm and with a diagnosis of heart failure (predominantly HFpEF) were randomly assigned them to aspirin 100 mg/day, rivaroxaban 5 mg bd or aspirin and rivaroxaban 2.5 mg bd.[75,76] The study was stopped early for benefit on the primary endpoint (a composite of CV death, stroke, or myocardial infarction) with the combination compared with aspirin alone. Further analysis suggested a reduction in all-cause mortality for patients with heart failure, especially HFpEF, assigned to combination therapy (HR: 0.63; 0.44–0.90) or rivaroxaban alone (HR: 0.75; 0.53–1.06) with an estimated 4% absolute difference at 2 years; rather similar to the magnitude of effect in HFrEF for sacubitril-valsartan[77] or dapagliflozin[78] (Figure 3). This suggests that coronary events might be an important driver of death in HFpEF (Take home figure), although effects of rivaroxaban on endothelial function, inflammation, and fibrosis should not be discounted. The analysis also suggests that those who do not have heart failure have little to gain from additional treatment with rivaroxaban.

Figure 3.

Effect of rivaroxaban 2.5 mg bd and aspirin 100 mg/day compared with aspirin alone for stable CAD, sinus rhythm and heart failure (predominantly heart failure with preserved ejection fraction) in COMPASS-HF. Reproduced with permission from ref.75

However, for patients with HFrEF, CAD in sinus rhythm with a recent hospital discharge for worsening heart failure, addition of rivaroxaban 2.5 mg bd to background anti-platelet therapy did not improve overall prognosis, although a composite of vascular outcomes (stroke, myocardial infarction, and sudden death) was reduced, driven mainly by a reduction in stroke.[79,80] This suggests that for patients with stable CAD and more advanced heart failure, hospitalizations, and deaths due to worsening heart failure are not greatly influenced by anti-thrombotic therapy (Take home figure).