Abstract
Clinical congestive heart failure (CHF) is a major risk factor for strokes. Patients with CHF commonly have atrial fibrillation or flutter (AF), which is frequently associated with, may be a marker for, and may be the mechanism of, ischemic strokes. To determine whether stroke patients with CHF have a high incidence of AF (that may be intermittent and not diagnosed), we reviewed all the 12 lead ECGs in a fourteen year institutional ECG data base and the clinical records and the available echocardiograms of 985 patients who had an ischemic stroke over a 3-year period. We found that 31.3% of the stroke patients had evidence of AF. Clinical congestive heart failure was present in 168 stroke patients; 61.9% of these stroke patients with CHF had evidence of AF. In the total stroke population, patients with other risk factors for stroke (hypertension, advanced age, diabetes, coronary artery disease) had an increased incidence of AF; but among stroke patients with CHF, only advanced age (≥75 years) in addition to CHF increased the incidence of AF. To determine whether only the CHF stroke pts with systolic dysfunction had a high incidence of AF, we compared the incidence of AF in the 41.5% of the CHF patients with a depressed ejection fraction with the AF incidence in the 58.5% of CHF stroke patients with a normal ejection fraction (≥50%). The incidence of AF was the same (63.4% vs. 60.2%, p = 0.741) whether the ejection fraction was depressed or normal. These findings suggest that AF is common in patients with CHF who have strokes whether the ejection fraction is normal or depressed. CHF patients who have strokes and who are in sinus rhythm should be meticulously investigated for intermittent AF, so anticoagulation can be administered to prevent a further stroke.
Highlights
Patients with heart failure frequently have strokes [1]-[3]; most strokes are considered ischemic [4]
If we assume that warfarin mainly prevents strokes in patients with atrial fibrillation, atrial fibrillation or flutter (AF) would have been implicated as the cause for stroke in 34 of the 54 patients who would have been expected to have a stroke or 63.0%, similar to the incidence of AF we found in our congestive heart failure (CHF) pts
Using a 14-year ECG data base, we have found that ischemic stroke patients have a high incidence of AF that may be frequently intermittent and not diagnosed
Summary
Patients with heart failure frequently have strokes [1]-[3]; most strokes are considered ischemic [4]. The suggested mechanism for these strokes has included embolization of LV mural thrombi, spontaneous clots in the left atrium related to abnormalities of coagulation in patients (pts) with heart failure [5], periods of cerebral hypoperfusion due to low cardiac output and the usual causes of cerebral emboli including carotid disease, aortic endothelial ulcers and plaques, and thrombosis in the left atrial appendage in pts with atrial fibrillation. It may be that AF is much more common in these ischemic stroke pts and that AF, frequently intermittent, may be the mechanism whereby the stroke risk factors, especially heart failure, cause stroke in many pts. It is important to diagnose that AF has been present in stroke pts because anticoagulation in these pts can significantly decrease the incidence of a recurrent stroke [10]
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