Management of Patients at Risk of Ischemic Stroke With Left Ventricular Systolic Dysfunction in the Absence of Intracardiac Thrombus: A Scientific Statement From the American Heart Association

Left ventricular (LV) systolic dysfunction, defined here as reduced LV ejection fraction ≤40% or left wall motion abnormality, is commonly found in patients with ischemic stroke. Although there is an increased risk of incident and recurrent embolic stroke among patients with LV dysfunction without thrombus detected, the data supporting anticoagulation in these patients are limited. In this scientific statement, we summarize the latest evidence regarding the risk of incident and recurrent stroke in patients with LV dysfunction as well as best practice recommendations regarding the management of this population after stroke. We provide a narrative summary and meta-analysis of secondary analyses of randomized clinical trials that evaluated outcomes following anticoagulation versus nonanticoagulation strategies. Whereas anticoagulation is associated with a lower risk of incident stroke in patients with LV dysfunction without thrombus, there remains no net benefit of this strategy over a nonanticoagulant strategy for primary stroke prevention. For patients with stroke and LV dysfunction, anticoagulation may be associated with a lower risk of recurrent stroke and a net benefit when compared with antiplatelet therapy. Anticoagulation treatment decisions in these patients may involve individualized consideration, shared decision-making between patients and healthcare professionals upon discussing risks and benefits, and multidisciplinary collaboration between cardiology and neurology clinicians to optimize cardiac and brain health. As a key modifiable stroke risk factor and therapeutic target, LV dysfunction represents a target for future research.