Risk of Stroke in Chronic Heart Failure Patients Without Atrial Fibrillation

Abstract

Background— Our aim was to describe the incidence and predictors of stroke in patients who have heart failure without atrial fibrillation (AF). Methods and Results— We pooled 2 contemporary heart failure trials, the Controlled Rosuvastatin in Multinational Trial Heart Failure (CORONA) and the Gruppo Italiano per lo Studio della Sopravvivenza nell’Insufficienza cardiaca-Heart Failure trial (GISSI-HF). Of the 9585 total patients, 6054 did not have AF. Stroke occurred in 165 patients (4.7%) with AF and in 206 patients (3.4%) without AF (rates 16.8/1000 patient-years and 11.1/1000 patient-years, respectively). Using Cox proportional-hazards models, we identified the following independent predictors of stroke in patients without AF (ranked by χ 2 value): age (hazard ratio, 1.34; 95% confidence interval, 1.18–1.63 per 10 years), New York Heart Association class (1.60, 1.21–2.12 class III/IV versus II), diabetes mellitus treated with insulin (1.87, 1.22–2.88), body mass index (0.74, 0.60–0.91 per 5 kg/m 2 up to 30), and previous stroke (1.81, 1.19–2.74). N-terminal pro B-type natriuretic peptide (available in 2632 patients) was also an independent predictor of stroke (hazard ratio, 1.31; 1.11–1.57 per log unit) when added to this model. With the use of a risk score formulated from these predictors, we found that patients in the upper third of risk had a rate of stroke that approximated the risk in patients with AF. Conclusions— A small number of demographic and clinical variables identified a subset of patients who have heart failure without AF at a high risk of stroke.

Prediction of Thromboembolic Events in Heart Failure Patients in Sinus Rhythm: The Hong Kong Heart Failure Registry

“…[2–5] In our study, although the risk of TE was lower among HF patients in sinus rhythm than those with AF, the annual incidence was 2.91% per year, markedly higher than the reported incidence of 1.45 per 1000 persons per year in the general population. [31] Nevertheless, the risk of TE is not the same among all HF patients in sinus rhythm.…”

“…In a pooled analysis of two clinical trials largely consisting of patients with chronic HFREF, Abdul-Rahim and colleagues have shown that age, previous stroke, New York Heart Association class, diabetes mellitus treated with insulin and body mass index predicted stroke in HF patients without AF. [5] We did not include New York Heart Association class or body mass index in our analysis, as both parameters are dynamic and particularly inaccurate in patients with new-onset HF. [5] Furthermore, we did not find prescription of insulin predictive of TE, in contrast to the findings by Abdul-Rhaim et al[5] This is not surprising, as prescription of insulin in real-life situation can be affected by many factors.…”

“…[1] Although the condition is well-known for its poor prognosis due to pump failure and/or sudden death, significant morbidity and mortality also results from an increased risk of thromboembolism. [2–5] In fact, HF is the second most common cause of cardioembolic stroke after atrial fibrillation (AF). [6] Left ventricular dysfunction is associated with intra-cardiac stasis, endocardial and endothelial dysfunction, and a hypercoagulable state, all of which promote thrombus formation and subsequent embolization.…”

Practical approaches for the treatment of chronic heart failure: Frequently asked questions, overlooked points and controversial issues in current clinical practice

“…In the sub-group analysis of the WARCEF Trial, the risk of new ischemic cerebrovascular event has been found to be high in patients with EF <15% compared to other HF-REF patients (86). In an analysis performed recently, the risk of stroke was shown to be 60% higher in HF-REF patients in sinus rhythm with NYHA Class III-IV symptoms than patients with NYHA Class II symptoms (85). Hence, theoretically, anticoagulant therapy may be beneficial in HF-REF patients with low EF and high NYHA class.…”

“…Therefore, warfarin therapy has no benefit in patients with HF-REF in sinus rhythm (patients should be closely monitored regarding paroxysmal AF). On the other hand, in a study examining the recent CORONA and GISSI-HF collective dataset, it was suggested that a subgroup could be determined in which anticoagulant treatment might have been beneficial even if there was no AF in the high-risk patients with HF-REF (85). This expectation is being tested in the ongoing COMMANDER-HF Trial regarding the possible positive effect of NOAC therapy (69).…”