Heart Failure in Ischemic Stroke: Relevance for Acute Care and Outcome

Gabriela Siedler, MD; Kim Sommer; Kosmas Macha, MD; Armin Marsch, MD; Lorenz Breuer, MD; Svenja Stoll, MD; Tobias Engelhorn, MD; Arnd Dörfler, MD; Martin Arnold, MD; Stefan Schwab, MD; Bernd Kallmünzer, MD

Disclosures

Stroke. 2019;50(11):3051-3056. 

In This Article

Abstract and Introduction

Abstract

Background and Purpose: Heart failure (HF) in patients with acute ischemic stroke constitutes the source of various detrimental pathophysiologic mechanisms including prothrombotic and proinflammatory states, worsening of cerebral tissue oxygenation, and hemodynamic impairment. In addition, HF might affect the safety and efficacy of the acute recanalization stroke therapies.

Methods: Patients treated with intravenous recombinant tissue-type plasminogen activator or mechanical recanalization at a universitary stroke center were included into a prospective registry. Patients received cardiological evaluation, including echocardiography, during acute care. Functional outcome was assessed after 90 days by structured telephone interviews. Safety and efficacy of intravenous thrombolysis and mechanical thrombectomy were investigated among patients with HF and compared with patients with normal cardiac function after propensity score matching.

Results: One thousand two hundred nine patients were included. HF was present in 378 patients (31%) and an independent predictor of unfavorable functional outcome. Recanalization rates were equal among patients with HF after intravenous thrombolysis and after mechanical recanalization or combined treatment. The rate of secondary intracranial hemorrhage was not different (7% versus 8%; P=0.909 after thrombolysis and 15% versus 20%, P=0.364 after mechanical recanalization or combined therapy). Early mortality within 48 hours after admission was equal (<1.5% in both groups).

Conclusions: In this real-world cohort of patients with stroke, HF was an independent predictor of unfavorable functional long-term outcome, while the safety and efficacy of intravenous thrombolysis and mechanical recanalization appeared unaffected.

Introduction

Chronic heart failure (HF) is a risk factor for ischemic stroke due to cardioembolism and hemodynamic infarction.[1–3] It worsens the long-term prognosis of stroke survivors via various mechanisms, including prothrombotic and proinflammatory states, pulmonary edema, hypoxia, cardiac arrhythmia, and fatigue.[4–6] In addition, HF is of particular relevance for the acute treatment of stroke: the efficacy of recombinant tissue-type plasminogen activator (r-tPA) in the cerebral circulation might be reduced in patients with low cardiac output and the mechanical recanalization of occluded vessels, as well as the anesthesiologic management during the procedure, are rated more complicated than among patients with normal cardiac function.[7–9] Furthermore, previous studies suggested higher rates of bleeding complications,[4,10] and HF was associated with higher mortality after 90 days.[11–13] In this study, we particularly focused on the recanalizing therapies and their safety and efficacy in HF. While patients with HF were excluded from the participation in many prospective clinical trials, the data in this study are based on an unselected real-world cohort of patients.

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