Abstract
Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Due to the aging of the population it has become a growing public health problem in recent decades. Diagnosis of HF is clinical and there is no diagnostic test, although some basic complementary testing should be performed in all patients. Depending on the ejection fraction (EF), the syndrome is classified as HF with low EF or HF with normal EF (HFNEF). Although prognosis in HF is poor, HFNEF seems to be more benign. HF and ischemic stroke (IS) share vascular risk factors such as age, hypertension, diabetes mellitus, coronary artery disease and atrial fibrillation. Persons with HF have higher incidence of IS, varying from 1.7% to 10.4% per year across various cohort studies. The stroke rate increases with length of follow-up. Reduced EF, independent of severity, is associated with higher risk of stroke. Left ventricular mass and geometry are also related with stroke incidence, with concentric hypertrophy carrying the greatest risk. In HF with low EF, the stroke mechanism may be embolism, cerebral hypoperfusion or both, whereas in HFNEF the mechanism is more typically associated with chronic endothelial damage of the small vessels. Stroke in patients with HF is more severe and is associated with a higher rate of recurrence, dependency, and short term and long term mortality. Cardiac morbidity and mortality is also high in these patients. Acute stroke treatment in HF includes all the current therapeutic options to more carefully control blood pressure. For secondary prevention, optimal control of all vascular risk factors is essential. Antithrombotic therapy is mandatory, although the choice of a platelet inhibitor or anticoagulant drug depends on the cardiac disease. Trials are ongoing to evaluate anticoagulant therapy for prevention of embolism in patients with low EF who are at sinus rhythm.
Highlights
Heart failure (HF) is a major and growing public health problem in the United States, with approximately 5 million cases and over 550 000 patients diagnosed with HF for the first time each year [1]
Sources of embolism of thrombotic origin -Left atrial thrombus -Left ventricular thrombus -Atrial fibrillation -Paroxysmal atrial fibrillation -Sick sinus syndrome -Sustained atrial flutter -Recent myocardial infarction -Rheumatoid mitral or aortic valve disease -Bioprosthetic and mechanical heart valves -Chronic myocardial infarction together with low ejection fraction less than 28% -Symptomatic congestive heart failure with ejection fraction less than 30% -Dilated cardiomyopathy -Nonbacterial thrombotic endocarditis Sources with embolism not predominantly of thrombotic origin -Infective endocarditis -Papillary fibroelastoma -Left atrial myxoma
HF was independently associated with 1-year dependency but not with survival or stroke recurrence [90]. These findings suggested that patients with HF who have an incident stroke have a high risk of early mortality or midterm dependency due to the index stroke severity
Summary
Heart failure (HF) is a major and growing public health problem in the United States, with approximately 5 million cases and over 550 000 patients diagnosed with HF for the first time each year [1]. In a metaanalysis of independent risk factors for stroke in patients with AF, the associated variables were prior stroke/TIA (RR: 2.5), increasing age (RR: 1.5 per decade), history of hypertension (RR: 2.0) and diabetes mellitus (RR: 1.7).
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