Anticoagulación en la miocardiopatía dilatada
Mujer de 21 años con uma miocardiopatía dilatada, FE del 20% y en ritmo sinusal. ¿Se debe anticoagular?
Categorías: MBE, MBE preguntas
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Medicina Interna 
Población: mujeres con miocardiopatía dilatada y FEVI disminuida en ritmo sinusal.
Intervención: anticoagulación.
Comparativa: no anticoagulación.
Outcome: fenómenos tromboembólicos.
Utilizando la suscripción de «Up to Date» para encontrar respuesta a la pregunta, encontramos (Indications for anticoagulation in heart failure. Author
Wilson S Colucci, MD):
-La población con esta alteración tiene aumentados los fenómenos tromboembólicos.
-Las diferentes guías de práctica clínica de las sociedades no encuentra hallazgos concluyentes para recomendar la anticoagulación en este tipo de pacientes (Ver artículo completo para ver recomendaciones individualizadas de las guías).
SUMMARY AND RECOMMENDATIONS
Patients with systolic heart failure are at increased risk for thromboembolic events. (See ‘Incidence of thromboembolic events’ above.)
Risk factors for thromboembolism in patients with systolic function have not been definitively established. Some evidence has suggested that severity of systolic dysfunction, presence of protuberant thrombus in the left ventricular cavity, a hypercoagulable state, and presence of atrial fibrillation may be factors but study results have been mixed. (See ‘Risk factors for thromboembolism’ above.)
Data are inconclusive on the utility of anticoagulation to reduce thromboembolic events or mortality in patients with systolic heart failure who are in sinus rhythm. The best data come from the WATCH trial in which there was no difference between aspirin, clopidogrel, and warfarin in the risk of all central nervous system events (all stroke plus central nervous system bleeds). (See ‘Antithrombotic therapy compared to placebo’ above.)
For patients with systolic left ventricular dysfunction and/or heart failure without left ventricular thrombus or other indication for antiplatelet or anticoagulant therapy we suggest not using antiplatelet or warfarin therapy since the benefits and risks of aspirin or warfarin in this setting are unclear. (See ‘Our approach’ above.)
We suggest oral anticoagulant therapy (eg, warfarin) in patients with heart failure due to systolic dysfunction and prior thromboembolic event, although supportive data are limited. (See ‘Our approach’ above.)
Treatment of patients with heart failure and atrial fibrillation should be governed by applicable guidelines for nonvalvular atrial fibrillation (or for valvular atrial fibrillation, when appropriate). (See «Antithrombotic therapy to prevent embolization in nonvalvular atrial fibrillation».)