June 3, 2019Open Access
View Full PaperIndividual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes
Key Result
The combination of atrial fibrillation and heart failure was associated with increased odds of in-hospital mortality (OR 2.23; 95% CI 1.83-2.72) and long-term mortality (HR 2.20; 95% CI 1.96-2.46).
Study Design
Type
Cohort (n=10,816)
Multicenter
No
Structured PICO
Does the presence of atrial fibrillation, heart failure, or their combination worsen acute and long-term outcomes in patients with acute ischemic stroke?
P
Population
10,816 patients with acute ischemic stroke admitted to a UK center between 2004 and 2016, mean age 77.9±12.1 years, 48% male.
I
Intervention
Presence of atrial fibrillation (AF) without heart failure (HF), HF without AF, or combined AF and HF
C
Comparator
Patients with neither atrial fibrillation nor heart failure
O
Outcome
In-hospital mortality, length-of-stay, poststroke disability, long-term mortality, and stroke recurrencehard clinical
Both atrial fibrillation and heart failure, individually and in combination, significantly increase the risk of in-hospital mortality, long-term mortality, and stroke recurrence in patients with acute ischemic stroke.
Main Result
Effect estimate: OR 2.23 (95% CI 1.83-2.72)
Abstract
Background and Purpose- We aimed to determine individual and combined effects of atrial fibrillation (AF) and heart failure (HF) on acute ischemic stroke outcomes: in-hospital mortality, length-of-stay, and poststroke disability; long-term mortality and stroke recurrence. Methods- Prospective cohort study of patients with acute ischemic stroke admitted to a UK center with a catchment population of ≈900 000 between 2004 and 2016. Exposure groups were patients with neither AF nor HF (reference group), those with AF but without HF, those with HF but without AF, and those with AF+HF. Logistic and Cox regressions were used to model in-hospital and long-term outcomes, respectively. Results- A total of 10 816 patients with a mean age±SD =77.9±12.1 years, 48% male were included. Only 30 (4.9%) of the patients with HF but not AF were anticoagulated at discharge. Both AF (odds ratio, 1.24 95% CI, 1.07-1.43), HF (odds ratio, 1.40 1.10-1.79), and their combination (odds ratio, 2.23 1.83-2.72) were associated with increased odds of in-hospital mortality. All 3 exposure groups were associated with increased length-of-stay, while only AF predicted increased disability (1.36 1.12-1.64). Patients were followed for a median of 5.5 and 3.7 years for mortality and recurrence, respectively. Long-term mortality was associated with AF (hazard ratio, 1.45 95% CI, 1.33-1.59), HF (2.07 1.83-2.36), and their combination (2.20 1.96-2.46). Recurrent stroke was associated with AF 1.50 (1.26-1.78), HF (1.33 1.01-1.75), and AF with HF (1.62 1.28-2.07). Conclusions- The AF-associated excess risk of stroke recurrence was independent of comorbid HF. HF without AF was also associated with a significant risk of recurrence. Anticoagulation for secondary stroke prevention in patients with HF without AF may require further evaluation in a clinical trial setting.