Response by Di Tullio et al to Letter Regarding Article, “Left Ventricular Ejection Fraction and Risk of Stroke and Cardiac Events in Heart Failure: Data From the Warfarin Versus Aspirin in Reduced Ejection Fraction Trial”
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In their interesting letter, Chen et al point out that there was no placebo arm in the WARCEF trial (Warfarin Versus Aspirin in Reduced Cardiac Ejection Fraction), preventing an estimation of stroke incidence without antithrombotic treatment and, therefore, of the benefit, if any, of such treatment for stroke prevention. Although this is true, it should be noted that some antithrombotic treatment is usually prescribed to patients with systolic heart failure, whether because of a previous myocardial infarction, and therefore the need of antiplatelet treatment for secondary prevention, or of past episodes of atrial fibrillation, which are frequent in heart failure and mandate systemic anticoagulation. Also, heart failure is associated with blood hypercoagulability,1,2 and an ischemic, possibly embolic, mechanism is involved in the majority of strokes observed in patients with systolic heart failure,2 …