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Stroke in Patients With HF and Reduced or Preserved EF
Quick Takes
- Patients with heart failure (HF) are at increased risk of stroke. Little is known about the clinical outcomes of patients with HF with a history of stroke compared to those without.
- In this meta-analysis, patients with HF with a history of stroke had a higher risk of CV death, all-cause death, and stroke compared to patients without a history of stroke.
- There is opportunity to improve outcomes for HF patients using medical management. The use of statins was only 71% in HF patients with arterial disease. The use of anticoagulation was only 70% in HF patients with AF.
Study Questions:
What are the clinical outcomes in heart failure (HF) patients with a history of stroke compared to those without, and do those outcomes vary by HF with reduced (HFrEF) and preserved ejection fraction (HFpEF)?
Methods:
This was a meta-analysis of patient-level data from seven clinical trials—three enrolling patients with HFrEF and four enrolling patients with HFpEF. Patients were considered to have HFpEF if EF was ≥45%. Outcomes of interest included HF hospitalization, cardiovascular (CV) death, stroke, and myocardial infarction (MI).
Results:
Of 20,159 patients with HFrEF, 1,683 (8.3%) had a history of stroke. Of the 13,252 patients with HFpEF, 1,287 (9.7%) had a history of stroke. Patients with a history of stroke were more likely to have longer-standing HF; an ischemic etiology of HF; and a history of atrial fibrillation (AF), diabetes, hypertension, chronic kidney disease, coronary artery disease, and peripheral artery disease. However, body mass index and current smoking did not differ between patients with and without a history of stroke.
After adjustment, HFrEF and HFpEF patients with a history of stroke had a higher risk of CV death, all-cause death, and stroke compared to patients without a history of stroke. HFpEF patients with a history of stroke had a higher risk of MI. The use of statins was only 71% in HF patients with arterial disease. The use of anticoagulation was only 70% in those with AF.
Conclusions:
Approximately 9% of patients in these seven HF trials had a history of prior stroke. In this meta-analysis of patient-level data, HF patients with a history of stroke compared to HF patients without a history of stroke had a higher risk of CV death, all-cause death, and stroke. This finding was true for patients with both HFrEF and HFpEF. Statins and anticoagulation appeared underutilized.
Perspective:
As a vascular neurologist, I have operated under the assumption that HFrEF is more strongly associated with ischemic stroke than HFpEF (because of the presumed opportunity for thrombus formation in a low EF state). The results of this study generally corroborate this assumption (adjusted hazard ratio for stroke was 2.24 in HFrEF compared to 1.84 in HFpEF), but I am struck by the high risk of stroke in the HFpEF patients. I am also struck by the opportunity we have as clinicians to potentially improve the outcomes of HF patients by prescribing anticoagulation to those with AF and statins to those with atherosclerotic vascular disease.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Hypertension
Keywords: Anticoagulants, Atrial Fibrillation, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Ischemic Stroke, Myocardial Infarction, Peripheral Arterial Disease, Renal Insufficiency, Chronic, Risk Factors, Secondary Prevention, Stroke, Stroke Volume, Thrombosis, Vascular Diseases
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