Individual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes

A Prospective Hospital Register Cohort Study

Tiberiu A Pana, David J McLernon, Mamas A Mamas, Joao H Bettencourt-Silva, Anthony K Metcalf, John F Potter, Phyo K Myint (Corresponding Author)

Research output: Contribution to journalArticle

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.
Original languageEnglish
Pages (from-to)1838-1845
Number of pages8
JournalStroke
Volume50
Issue number7
Early online date3 Jun 2019
DOIs
Publication statusPublished - Jul 2019

Fingerprint

Atrial Fibrillation
Cohort Studies
Heart Failure
Stroke
Recurrence
Odds Ratio
Hospital Mortality
Mortality
Length of Stay
Secondary Prevention
Logistic Models
Clinical Trials

Keywords

  • atrial fibrillation
  • heart failure
  • cerebrovascular disease
  • stroke
  • mortality
  • recurrence
  • POPULATION
  • DEMENTIA
  • FOLLOW-UP
  • CLINICAL-FEATURES
  • ASPIRIN
  • population
  • TRIAL
  • RISK-FACTOR
  • WARFARIN
  • PREDICTORS

Cite this

Individual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes : A Prospective Hospital Register Cohort Study. / Pana, Tiberiu A ; McLernon, David J; Mamas, Mamas A; Bettencourt-Silva, Joao H; Metcalf, Anthony K; Potter, John F; Myint, Phyo K (Corresponding Author).

In: Stroke, Vol. 50, No. 7, 07.2019, p. 1838-1845.

Research output: Contribution to journalArticle

Pana, Tiberiu A ; McLernon, David J ; Mamas, Mamas A ; Bettencourt-Silva, Joao H ; Metcalf, Anthony K ; Potter, John F ; Myint, Phyo K. / Individual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes : A Prospective Hospital Register Cohort Study. In: Stroke. 2019 ; Vol. 50, No. 7. pp. 1838-1845.
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title = "Individual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes: A Prospective Hospital Register Cohort Study",
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.",
keywords = "atrial fibrillation, heart failure, cerebrovascular disease, stroke, mortality, recurrence, POPULATION, DEMENTIA, FOLLOW-UP, CLINICAL-FEATURES, ASPIRIN, population, TRIAL, RISK-FACTOR, WARFARIN, PREDICTORS",
author = "Pana, {Tiberiu A} and McLernon, {David J} and Mamas, {Mamas A} and Bettencourt-Silva, {Joao H} and Metcalf, {Anthony K} and Potter, {John F} and Myint, {Phyo K}",
note = "We thank the data team of the Norfolk and Norwich University Hospital Stroke Services, Prof Kristian Bowles (one of the co-Principal Investigators of the stroke register) and our lay steering committee members and independent chair Prof Alastair Forbes (Chief of Research & Innovation, Norfolk and Norwich University Hospital). SOURCES OF FUNDING TAP received the Medical Research Scotland 2018 Vacation Scholarship [grant number Vac-1211-2018] to perform the research. The Norfolk and Norwich Stroke Register is maintained by the Norfolk and Norwich University Hospital Stroke Services.",
year = "2019",
month = "7",
doi = "10.1161/STROKEAHA.119.025481",
language = "English",
volume = "50",
pages = "1838--1845",
journal = "Stroke",
issn = "0039-2499",
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TY - JOUR

T1 - Individual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes

T2 - A Prospective Hospital Register Cohort Study

AU - Pana, Tiberiu A

AU - McLernon, David J

AU - Mamas, Mamas A

AU - Bettencourt-Silva, Joao H

AU - Metcalf, Anthony K

AU - Potter, John F

AU - Myint, Phyo K

N1 - We thank the data team of the Norfolk and Norwich University Hospital Stroke Services, Prof Kristian Bowles (one of the co-Principal Investigators of the stroke register) and our lay steering committee members and independent chair Prof Alastair Forbes (Chief of Research & Innovation, Norfolk and Norwich University Hospital). SOURCES OF FUNDING TAP received the Medical Research Scotland 2018 Vacation Scholarship [grant number Vac-1211-2018] to perform the research. The Norfolk and Norwich Stroke Register is maintained by the Norfolk and Norwich University Hospital Stroke Services.

PY - 2019/7

Y1 - 2019/7

N2 - 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.

AB - 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.

KW - atrial fibrillation

KW - heart failure

KW - cerebrovascular disease

KW - stroke

KW - mortality

KW - recurrence

KW - POPULATION

KW - DEMENTIA

KW - FOLLOW-UP

KW - CLINICAL-FEATURES

KW - ASPIRIN

KW - population

KW - TRIAL

KW - RISK-FACTOR

KW - WARFARIN

KW - PREDICTORS

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UR - http://www.mendeley.com/research/individual-combined-impact-heart-failure-atrial-fibrillation-ischemic-stroke-outcomes

U2 - 10.1161/STROKEAHA.119.025481

DO - 10.1161/STROKEAHA.119.025481

M3 - Article

VL - 50

SP - 1838

EP - 1845

JO - Stroke

JF - Stroke

SN - 0039-2499

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ER -