Copyright © 2004 by the European Society of Cardiology.
Letter to the Editor
Authors reply to the letter titled: ‘Mortality in congestive heart failure complicated by atrial fibrillation’
ANMCO Research Center, Florence, Italy
* Corresponding author: Dr A. P. Maggioni, ANMCO Research Center, Via La Marmora 34, 50121 Florence, Italy. Tel.: +39-055-5001703; +39-055-583400
E-mail address: centro_studi{at}anmco.it
Received 21 November 2002; accepted 7 August 2003
We greatly appreciate the comments and suggestions by Sosin et al. They underline the role of a hypercoagulable state in patients with CHF and atrial fibrillation or left bundle branch block. We did not specifically perform an assessment of the possible role of thromboembolism on the outcome of our study population, but we share the comments of Sosin et al. with the following specific observations.
Recently Hirsh et al. in a AHA/ACC Scientific statement published on Circulation1confirm that warfarin is frequently used in patients with left ventricular dysfunction also in the absence of atrialfibrillation although no evidence-based data from randomized clinical trials are available concerning the effects on mortality of this therapeutic approach.
The rate of use of oral anticoagulants in our study population (data not showed in the article) confirms a statistically significant higher utilization in the groups C and D (32.3% and 51.4% respectively) than in patients without any electrical disturbances (17.0%).
The increased thrombotic tendencyrelated to the presence of these two electrical disturbances could contribute to increase the risk of death in patients with CHF but probably the most significant mechanism involved in the prognostic role of atrial fibrillation and left bundle branch block is the marked deterioration of haemodynamic profile and the increased susceptibility to sudden death due to ventricular fibrillation.2,3
We confirm that the prevalent aetiology of CHF in groups C and D was not ischaemic but the possible confounding role of aetiology has been taken into account because this variable was entered, together with the electrical disturbances, in the multivariate analysis. The same considerations may be applied for age. The number of older patients was greater in groups C and D, and, in the multivariate analysis model, age was considered. Beta-blockers are markedly underused in all four groups of patients and particularly in group D. A lower use of beta-blockers in this subgroup of patients can be due to the more advanced age. The low rate of use of beta-blockers can be associated with a worse clinical and haemodynamic profile of these patients, thus justifying the high all-cause mortality rate. In patients with HF, many evidences confirmed that beta-blockade can significantly reduce mortality in CHF, independently of the degree of the cardiovascular functional impairment and age.4
Finally we must emphasize how no definite evidence-based indications are available to strongly recommend warfarin therapy in patients with CHF in the absence of atrial fibrillation.
References
- Hirsh J, Fuster V, Ansell J et al. American Heart Association/American College of Cardiology Foundation Guide to warfarin therapy. Circulation. 2003;107:1692–1711.
[Free Full Text] - Chugh SS, Blackshear JL, Shen WK et al. Epidemiology and natural history of atrial fibrillation: clinical implications. J Am Coll Cardiol. 2001;37:371–378.
[Abstract/Free Full Text] - Flowers NC. Left bundle branch block: a continuously concept. J Am Coll Cardiol. 1987;9(3):684–697.[Abstract]
- Sin DD, McAlister FA. The effects of beta-blockers on morbidity and mortality in a population based cohort of 1 elderly patients with heart failure. Am J Med. 2002;113:650–656.[CrossRef][ISI][Medline]
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