Warfarin Increases Bleeding Without Mortality Benefit in Heart Failure with Sinus Rhythm

In a June 2025 update to a longstanding Cochrane systematic review, researchers re-evaluated the role of oral anticoagulation in patients with chronic heart failure and sinus rhythm, comparing warfarin to antiplatelet therapy (primarily aspirin).

Across six randomized controlled trials involving 5,170 participants:

• All-cause mortality: No significant difference between warfarin and antiplatelets (RR 0.97; 95% CI 0.90–1.05).
• Non-fatal cardiovascular events: Warfarin modestly reduced stroke (RR 0.80; 95% CI 0.68–0.94) and non-fatal MI (RR 0.87; 95% CI 0.78–0.98).
• Major bleeding: Warfarin significantly increased bleeding risk (RR 2.01; 95% CI 1.60–2.53), especially gastrointestinal and intracranial hemorrhage.

The authors emphasize the absence of trials evaluating direct oral anticoagulants (DOACs) or preserved ejection fraction (HFpEF) populations. In light of modest ischemic benefits and elevated bleeding risk, the review discourages routine warfarin use in HF patients without other clear indications for anticoagulation.

Editorial note: This content was developed with the support of artificial intelligence technologies to optimize writing and information structuring. All material was carefully reviewed, validated, and supplemented by human experts prior to publication, ensuring scientific accuracy and adherence to good editorial practices.