Review Article
The Incidence of Ischemic Stroke in Chronic Heart Failure: A Meta-Analysis

https://doi.org/10.1016/j.cardfail.2007.01.009Get rights and content

Abstract

Background

There is marked variability in the reported stroke rates among persons with heart failure (HF). We performed a meta-analysis to provide summary estimates of the stroke rate in HF and to explain heterogeneity in the existing literature. We will summarize the ischemic stroke rate at various time points during follow-up among adults with chronic heart failure.

Methods and Results

A systematic review of the electronic literature in Medline and PubMed as well as hand searching of the reference lists of identified articles and of the meeting abstracts for the 1995–2004 American College of Cardiology and American Heart Association scientific sessions was performed to identify qualifying studies. Articles were included if they included a population with chronic HF and reported the number (or percent) of persons with HF who experienced an ischemic stroke during follow-up. Studies were excluded if the study population included ≥50% of persons with acute (postmyocardial infarction) HF, or if ≥50% of the study population required artificial support with a ventricular assist device or parenteral inotropic medications. Case reports, case series, and nonoriginal research articles were not included. Determination of study eligibility and data extraction were conducted by 2 independent reviewers using standardized forms. Results are reported as stroke rate per 1000 cases of HF, with 95% Poisson confidence intervals. Pooled estimates of the stroke rate were calculated with fixed and random effects models. Heterogeneity was explored according to a priori specified subgroup analyses. Overall, 26 studies met inclusion criteria. Eighteen of every 1000 persons suffered a stroke during the first year after the diagnosis of HF. The stroke rate increased to a maximum of 47.4 per 1000 at 5 years. Studies with fewer women, those conducted in 1990 or earlier, and cohort studies reported higher stroke rates than studies with more women, those conducted after 1990, and clinical trials.

Conclusions

Stroke is an important complication among persons with HF. Variability among reported stroke rates can be explained in part by differences in study design, patient population, and HF standards of care at the time of the study. Despite the heterogeneity in reported stroke rates, this meta-analysis shows that stroke prevention in HF represents an opportunity to prevent morbidity and save many lives in this highly fatal disease.

Section snippets

Study Identification

Potential studies were identified by electronic search of the Medline and PubMed databases. Four separate searches were conducted during the week of January 24, 2005. All searches used the exploded terms “heart failure, congestive,” “ventricular dysfunction, left,” and “cardiac output, low” combined with the “or” operator. For the first search, the exploded terms “pacemaker, artificial,” “defibrillators, implantable,” “cardiac pacing, artificial,” and the text word “resynchronization” were

Search

Electronic database searches yielded 830 potential articles. Twenty-four of these met eligibility criteria; however, 4 reported on the same population and were excluded. Hand searching of the American College of Cardiology and American Heart Association meeting proceedings and the reference lists of the included articles yielded another 5 articles. An additional 11 studies reported stroke as part of a combined outcome. An attempt was made to contact the authors of these studies. One provided

Discussion

HF represents a growing public health problem.1 Despite advances in treatment, HF remains a highly fatal disease with mortality approaching 50% at 5 years.1, 2 Stroke more than doubles the risk of death among persons with HF.49 Thus stroke prevention in HF represents an opportunity to improve survival in this highly fatal disease. However, the true risk of stroke among persons with HF remains poorly defined because of differences in study design. Furthermore, predictors of stroke in HF are

Conclusions

The stroke rate among persons with HF is similar to that experienced among persons with AF who are not on anticoagulant therapy and is much higher than the stroke rate in the general population. Given the high mortality rate observed in HF, stroke prevention represents an opportunity to save many lives in this already highly fatal disease. Prospective studies are needed to clarify the risk of stroke among HF patients with AF and the risk of stroke at different levels of left ventricular

Acknowledgment

The authors thank Ryan Lennon, MS, and Jill Killian, BS, for assistance with statistical analyses, and Kristie Shorter for secretarial support.

References (57)

  • B. Andersson et al.

    Spectrum and outcome of congestive heart failure in a hospitalized population

    Am Heart J

    (1993)
  • S.D. Katz et al.

    Low incidence of stroke in ambulatory patients with heart failure: a prospective study

    Am Heart J

    (1993)
  • N.D. Sharma et al.

    Left ventricular thrombus and subsequent thromboembolism in patients with severe systolic dysfunction

    Chest

    (2000)
  • J. Setaro et al.

    Long-term outcome in patients with congestive heart failure and intact systolic left ventricular performance

    Am J Cardiol

    (1992)
  • M. Hochleitner et al.

    Usefulness of physiologic dual-chamber pacing in drug-resistant idiopathic dilated cardiomyopathy

    Am J Cardiol

    (1990)
  • J. Mathew et al.

    Incidence, predictive factors, and prognostic significance of supraventricular tachyarrhythmias in congestive heart failure

    Chest

    (2000)
  • J. Cleland et al.

    The Warfarin/Aspirin Study in Heart failure (WASH): a randomized trial comparing antithrombotic strategies for patients with heart failure

    Am Heart J

    (2004)
  • C. Granger et al.

    Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial

    Lancet

    (2003)
  • J. McMurray et al.

    Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial

    Lancet

    (2003)
  • B. Pitt et al.

    Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial—the Losartan Heart Failure Survival Study ELITE II

    Lancet

    (2000)
  • M. Pfeffer et al.

    Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme

    Lancet

    (2003)
  • F. Waagstein et al.

    Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy

    Lancet

    (1993)
  • B. Witt et al.

    The risk of ischemic stroke in heart failure: a population-based study in Olmsted County, Minnesota

    Am Heart J

    (2006)
  • S.P. Graham

    To anticoagulate or not to anticoagulate patients with cardiomyopathy

    Cardiol Clin

    (2001)
  • S. Hunt et al.

    ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult

    J Am Coll Cardiol

    (2001)
  • P. Froom et al.

    Healthy volunteer effect in industrial workers

    J Clin Epidemiol

    (1999)
  • American Heart Association. Heart disease and stroke statistics—2005 update. Available at: www.americanheart.org,...
  • V.L. Roger et al.

    Trends in heart failure incidence and survival in a community-based population

    JAMA

    (2004)
  • Cited by (100)

    • Risk of Ischemic Stroke in Patients Newly Diagnosed With Heart Failure: Focus on Patients Without Atrial Fibrillation

      2019, Journal of Cardiac Failure
      Citation Excerpt :

      Moreover, the difference in the risk of stroke observed between patients with HF and patients without HF increased over time from 1 percentage point at 12 months to 3 percentage point at 36 months (Kaplan-Meier rates of 5.9% vs 3.3%, P < .001). Although numerous studies support that the overall population of patients with HF,9,21 and particularly those with AF,22,23 are at higher risk of stroke, such evidence in patients with HF without AF is not as clear. For example, in the population-based Reasons for Geographic and Racial Differences in Stroke study, the rates of ischemic stroke reached 0.69 (95% CI 0.49–0.93) among patients with HF without AF, and 0.40 (95% CI 0.37–0.44) among patients with neither HF nor AF.22

    View all citing articles on Scopus

    Funded by grants AR30582, HL59205, and HL68765 from the Public Health Service, National Institutes of Health. Grant support used to fund data analysis.

    View full text