There are 5 randomized trials evaluating the effects of antithrombotic therapy on clinical out- comes, including strokes, in patients with heart failure and reduced LV EF in sinus rhythm.524 528 The WARCEF trial (Warfarin vs. Aspirin in Reduced Cardiac Ejection Fraction) documented no ben- efit of warfarin therapy compared with acetyl- salicylic acid at a mean follow-up of 3.5 years for the primary outcome (death, ischemic stroke, or although patients on warfarin had reduced incidence of stroke, par- ticularly patients with an EF 15%,550 The more recent COMMANDER HF trial (A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction or Stroke in Participants With Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure) randomized a total of 5022 patients with chronic heart failure, an EF of 40%, coronary artery disease, and elevated plasma natriuretic peptides to rivaroxaban 2.5 mg twice daily or placebo.528 After a median follow-up of 21.1 months, the primary end point (death, MI, or stroke) occurred in 25.0% of patients assigned to rivaroxaban versus 26.2% of those receiving pla- cebo. Patients with history of ischemic stroke and TIA were underrepresented in these trials, and the main end point always included death, which dwarfs Figure 4. Anticoagulant therapy for patients with cardiomyopathy, ischemic stroke, or transient ischemic attack (TIA) in sinus rhythm. Colors correspond to Class of Recommendation in Table 3. LV indicates left ventricle; and LVAD, left ventricular assist device. CLINICAL STATEMENTS AND GUIDELINES Kleindorfer the ischemic stroke outcomes. Therefore, the effectiveness of anticoagulation versus antiplatelet therapy is uncertain, and the choice should be indi- vidualized by taking into account bleeding risk and estimated risk of recurrent thromboembolism. 5. 