Ischemic stroke and heart failure: Frequently asked questions

Author: Maria Mirabela Manea, MD, PhD student
Affiliations: Department of Neurology, Stroke Unit – National Institute of Neurology and Neurovascular Diseases, Bucharest, Romania. University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

 

1. Is there an increased risk of stroke in patients with heart failure?

Heart failure (HF) and stroke are diseases associated with high mortality and morbidity.¹ There is an increased risk of stroke in patients with HF^2,3, which is maximum during the first 30 days after the diagnosis of HF². A correlation has also been observed between diastolic dysfunction and worsened neurological functional prognosis⁴.

2. What are the mechanisms?

Left ventricular diastolic dysfunction induces left atrial enlargement, which again may lead to atrial fibrillation and intra-atrial thrombus formation, and ultimately increase the risk of stroke⁵. We know from the SAVE trial (Survival and Ventricular Enlargement), for every 5% decrease in the EF there  the risk of stroke increases by up to 18%⁶. The thrombogenic mechanism of stroke in heart failure patients without documented atrial fibrillation, particularly in those with low EF, may be related to blood stasis, due to systolic dysfunction and myocardial dyskinesia, but also to the hypercoagulable status of these patients⁷.

However, the mechanisms of stroke in patients with HF are linked not only to cardiac embolism, but also to cerebral hypoperfusion. Resistance vessels can compensate for the decrease in blood flow secondary to HF and can maintain adequate cerebral perfusion to a certain point. In the setting arterial hypotension, either due to antihypertensive drugs or decompensated heart failure, the vasodilating capacity of cerebral arteries may reach the limit, resulting in a global reduction of cerebral blood flow^{8 9}.

3. 3. What about patient prognosis?

In terms of patient prognosis, cardioembolic stroke has the highest mortality rate of all types of ischemic stroke¹⁰. In the EUROSTROKE¹¹ study left ventricular hypertrophy was linked to a high risk of a potentially fatal stroke, and in the NOMASS study patients with low EF had more severe strokes than those with normal EF³.

Although most causes of death in the acute phase of stroke are correlated with the size of the cerebral ischemic lesion, about 2-6% of these patients die from a cardiovascular disorder in the first 3 month after the stroke¹² and as stroke physicians we must keep this in mind when discharging patients with cardioembolic stroke.

References:

1. Roger VL, Go AS, Lloyd-Jones DM, et al. Executive Summary: Heart Disease and Stroke Statistics–2012 Update: A Report From the American Heart Association. Circulation. 2012;125(1):188-197. doi:10.1161/CIR.0b013e3182456d46.
2. Alberts VP, Bos MJ, Koudstaal PJ, et al. Heart failure and the risk of stroke: the Rotterdam Study. Eur J Epidemiol. 2010;25(11):807-812. doi:10.1007/s10654-010-9520-y.
3. Hays AG, Sacco RL, Rundek T, et al. Left ventricular systolic dysfunction and the risk of ischemic stroke in a multiethnic population. Stroke. 2006;37(7):1715-1719. doi:10.1161/01.STR.0000227121.34717.40.
4. Park H-K, Kim BJ, Yoon C-H, Yang MH, Han M-K, Bae H-J. Left Ventricular Diastolic Dysfunction in Ischemic Stroke: Functional and Vascular Outcomes. J stroke. 2016;18(2):195-202. doi:10.5853/jos.2015.01697.
5. Seo J-Y, Lee KB, Lee J-G, et al. Implication of Left Ventricular Diastolic Dysfunction in Cryptogenic Ischemic Stroke. Stroke. 2014;45(9). http://stroke.ahajournals.org/content/45/9/2757. Accessed June 3, 2017.
6. Loh E, Sutton MSJ, Wun C-CC, et al. Ventricular Dysfunction and the Risk of Stroke after Myocardial Infarction. N Engl J Med. 1997;336(4):251-257. doi:10.1056/NEJM199701233360403.
7. Abdul-Rahim AH, Perez AC, Fulton RL, et al. Risk of stroke in chronic heart failure patients without atrial fibrillation: Analysis of the Controlled Rosuvastatin in Multinational Trial Heart Failure (CORONA) and the Gruppo Italiano per lo Studio della Sopravvivenza nell’Insufficienza cardiaca-Heart. Circulation. 2015;131(17):1486-1494. doi:10.1161/CIRCULATIONAHA.114.013760.
8. Georgiadis D, Sievert M, Cencetti S, et al. Cerebrovascular reactivity is impaired in patients with cardiac failure. Eur Heart J. 2000;21(5):407-413. doi:10.1053/euhj.1999.1742.
9. Choi B-R, Kim JS, Yang YJ, et al. Factors associated with decreased cerebral blood flow in congestive heart failure secondary to idiopathic dilated cardiomyopathy. Am J Cardiol. 2006;97(9):1365-1369. doi:10.1016/j.amjcard.2005.11.059.
10. Grau AJ, Weimar C, Buggle F, et al. Risk Factors, Outcome, and Treatment in Subtypes of Ischemic Stroke. Stroke. 2001;32(11). http://stroke.ahajournals.org/content/32/11/2559.long. Accessed June 4, 2017.
11. Bots ML, Nikitin Y, Salonen JT, et al. Left ventricular hypertrophy and risk of fatal and non-fatal stroke. EUROSTROKE: a collaborative study among research centres in Europe. J Epidemiol Community Health. 2002;56 Suppl 1(Suppl 1):i8-13. doi:10.1136/jech.56.suppl_1.i8.
12. Adams RJ, Chimowitz MI, Alpert JS, et al. Coronary Risk Evaluation in Patients With Transient Ischemic Attack and Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association. Circulation. 2003;108(10):1278-1290. doi:10.1161/01.CIR.0000090444.87006.CF.