Bayer Pharma AG

Essence of this article

Coronary artery disease (CAD) is a major cause of chronic heart failure (HF). Breathlessness, ankle oedema and fatigue may be indicative of HF in patients with a history of CAD. Patients with CAD and HF are managed using a combination of drug therapy and lifestyle changes, and may be offered an implantable device. Patients with HF are at risk of thromboembolism. Anticoagulants are given to patients with atrial fibrillation who have HF, but there is a lack of evidence for use in patients with HF who have a normal sinus rhythm. The phase III COMMANDER HF study will assess rivaroxaban in patients with chronic HF and CAD.

Heart failure and coronary artery disease

Coronary artery disease (CAD) is a major cause of chronic heart failure (HF). Breathlessness, ankle oedema and fatigue may be indicative of HF in patients with a history of CAD. Patients with CAD and HF are managed using a combination of drug therapy and lifestyle changes, and may be offered an implantable device. Patients with HF are at risk of thromboembolism. Anticoagulants are given to patients with atrial fibrillation who have HF, but there is a lack of evidence for use in patients with HF who have a normal sinus rhythm. The phase III COMMANDER HF study will assess rivaroxaban in patients with chronic HF and CAD.

Coronary artery disease (CAD) is the primary cause of chronic heart failure (HF) in an estimated 65% of patients and leads to an increased risk of hospitalization and mortality.406, 407

The relationship between CAD and HF is related to the shared risk factors for each:408, 409

  • CAD may precipitate a myocardial infarction (MI),408 causing cell death and potentially leading to HF with the loss of left ventricular (LV) function and a reduced ejection fraction408, 409
  • Hypertension, diabetes mellitus and high cholesterol can lead to atherosclerosis and CAD, as well as HF associated with LV impairment but a preserved ejection fraction409
  • CAD may be associated with the development of cardiac arrhythmias such as atrial fibrillation and subsequently HF409

Improved survival in patients who have suffered a MI may be responsible for the increasing importance of CAD as a cause of chronic HF.407

The interlinked aetiology of coronary artery disease and heart failure409

Patients with a history of CAD who are breathless, have oedema of the ankle or fatigue may have HF, particularly if they have suffered a recent MI.409, 410 Diagnosis is often confirmed via echocardiography and electrocardiography, although natriuretic peptides are also increasingly used as biomarkers of heart disease or increased cardiac load.411

Patients with CAD and HF are managed using a combination of:

  • Pharmacological therapies including angiotensin-converting enzyme inhibitors and β­blockers (for patients with HF and reduced ejection fraction;{412–414} the effectiveness of these agents is not proven in patients with preserved ejection fraction415, 416)
  • Changes in lifestyle, such as cessation of smoking409
  • Drugs that help to manage ongoing risk factors such as high lipid levels and diabetes409
  • Devices such as implantable cardioverter-defibrillators to help prevent sudden cardiac death411
  • Surgical techniques including revascularization, mitral valve repair and ventricular restoration407

Patients with chronic HF are at risk of thromboembolic events because of the inability of the heart to pump blood effectively

  • Anticoagulation is given as standard for patients with HF and atrial fibrillation, but evidence is lacking in patients with HF who have a normal sinus rhythm417
  • The ongoing randomized, placebo-controlled phase III COMMANDER HF study (NCT01877915) will assess the efficacy and safety of rivaroxaban in reducing the risk of stroke, MI or death in 5000 patients with chronic HF and clinically significant CAD, and will provide valuable data on the potential use of rivaroxaban in this patient population

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