Anticoagulation in Sinus Rhythm HFrEF — EECC MCQ

Correct answer: B — Routine anticoagulation is NOT recommended for HFrEF patients in sinus rhythm without other indications (AF, LV thrombus, prior thromboembolism, mechanical valve) — the COMMANDER-HF and WARCEF trials showed no net clinical benefit of rivaroxaban or warfarin in this population

Two major trials addressed anticoagulation in HFrEF patients in sinus rhythm: (1) WARCEF trial (warfarin vs aspirin): no significant difference in the composite of death, ischaemic stroke, or intracranial haemorrhage — warfarin reduced ischaemic stroke but increased haemorrhage, with no net benefit; (2) COMMANDER-HF trial (rivaroxaban 2.5 mg bd vs placebo): no reduction in the composite of death, MI, or stroke. Based on these results, the ESC HF Guidelines recommend AGAINST routine anticoagulation in HFrEF patients in sinus rhythm (Class III — no benefit). Anticoagulation IS indicated for: (1) AF (Class I); (2) LV thrombus (Class I); (3) prior cardioembolic event (Class I); (4) mechanical valve (Class I). Incidental finding of LV thrombus on echo/CMR remains the trigger for anticoagulation.

Reference: ESC (2023): HF Guidelines; WARCEF/COMMANDER-HF Trials