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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction Trial [WARCEF; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00041938\u0026amp;atom=%2Fspmdc%2F12%2F1%2F11.atom\u0022\u003ENCT00041938\u003C\/a\u003E] found no compelling evidence to use warfarin for all patients according to outcomes from the study.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure Clinical Trials\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EIschemia\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction Trial [WARCEF; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00041938\u0026amp;atom=%2Fspmdc%2F12%2F1%2F11.atom\u0022\u003ENCT00041938\u003C\/a\u003E] found no compelling evidence to use warfarin for all patients. Shunichi Homma, MD, Columbia University College of Physicians and Surgeons, New York, New York, USA, reported outcomes from the study.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EWARCEF was a randomized, double-blind, multicenter, international clinical trial. The primary outcome was to determine if warfarin or aspirin was superior for preventing the combined endpoint of death, ischemic stroke, or intracerebral hemorrhage (ICH) in patients with left ventricular ejection fraction (LVEF) \u226435% in sinus rhythm. The mean follow-up was 3.5 years, ranging from 1 to 6 years.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe main secondary aim was to determine if warfarin or aspirin was superior for preventing death, ischemic stroke, or ICH plus myocardial infarction or heart failure (HF) hospitalization in patients with LVEF \u226435% in sinus rhythm.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EA total of 2305 patients were randomized to receive either warfarin (target INR 2 to 3.5; n=1142) or 325 mg\/day of aspirin (n=1163). Key inclusion criteria included normal sinus rhythm, LVEF \u226435%, no defined cardioembolic source, and being on an optimal HF regimen.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EBaseline characteristics were similar between the two groups, as was baseline time in the therapeutic range (63%; 2 to 3.5). The mean INR was 2.5\u00b10.95. The number of patient-years in the aspirin group was 4033; in the warfarin group, the number of patient years was 4045. The primary analysis was treatment-by-time interaction.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EThe combined primary outcome was not significantly different between groups, occurring at a rate of 7.47% per year among warfarin patients versus 7.93% per year in those who were assigned to aspirin (HR, 0.93; 0.79 to 1.10; p=0.40; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). There was, however, a suggestive benefit of warfarin for the primary outcome at 4 years and beyond (HR, 0.894; 0.800 to 0.998; p=0.046; \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/1\/11\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Primary Outcome.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-87312090\u0022 data-figure-caption=\u0022Primary Outcome.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/1\/11\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/1\/11\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/1\/11\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12706\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003EPrimary Outcome.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from S. Homma, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/1\/11\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Warfarin vs Aspirin Hazard Ratios by Year of Follow-Up (Prespecified Time-Varying Analysis).\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-87312090\u0022 data-figure-caption=\u0022Warfarin vs Aspirin Hazard Ratios by Year of Follow-Up (Prespecified Time-Varying Analysis).\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/1\/11\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/1\/11\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/1\/11\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12707\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003EWarfarin vs Aspirin Hazard Ratios by Year of Follow-Up (Prespecified Time-Varying Analysis).\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from S. Homma, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-10\u0022\u003EThe warfarin group (n=268) had a death rate of 6.63% per year. The death rate in the aspirin group (n=263) was 6.52% per year (HR, 1.01; 95% CI, 0.85 to 1.21; p=0.91). However, the difference in ischemic stroke was significant, with the per-year death rate in the warfarin group (n=23) of 0.72% compared with 1.36% in the aspirin group (n=55; p=0.005).\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EThe main secondary outcome occurred at a rate of 12.7% per year in warfarin-treated patients versus 12.15% per year in the aspirin-treated group (p=0.33). Major hemorrhage per year, however, occurred in 1.78% of patients in the warfarin group versus 0.87% in patients who were taking aspirin (p\u0026lt;0.001). Significant differences were observed in gastrointestinal hemorrhage (p=0.01) and \u201call other bleeds\u201d (p=0.01). Importantly, no difference in intracerebral or intracranial bleeding was found; combined, the annual rates were 0.27% in the warfarin group compared with 0.22% in the aspirin group (p=0.82).\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EThe authors concluded that there was no overall difference for the primary outcome, although there was a suggestive benefit with warfarin at 4 years and beyond. Warfarin reduced ischemic stroke risk throughout follow-up, but patients who were on the drug had more major hemorrhages than those in the aspirin group (1.78% vs 0.87%). Intracerebral and intracranial outcomes were similar. No significant difference was observed for the main secondary outcome.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EGiven no overall benefit of warfarin and increased risk of bleeding, the study found no compelling evidence to use warfarin for all patients. Based on effectiveness in preventing stroke and the possible benefit of warfarin after 4 years, analyses are underway to better identify patients that will benefit from warfarin or aspirin.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/1\/11.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nznig1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznig1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}