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

Is fluid retention a cardiovascular risk factor?

Endothelial dysfunction, the earliest manifestation of atherosclerosis, can be initiated by both biochemicals and biomechanical forces. Atherosclerosis occurs predominantly at arterial branch points, arterial bifurcations and the curved segments of great arteries. These are the regions that blood flows turbulently. Turbulence promotes endothelial dysfunction by reducing shear stress upon endothelial cells. The endothelial glycocalyx mediates the effect of shear stress upon the endothelium. A mathematical analysis of cardiovascular hemodynamics demonstrates that fluid retention increases turbulence of blood flow. While there is no empirical data confirming this relationship, fluid retention is associated with adverse cardiovascular events. Every medical condition that causes fluid retention is associated with increased risk of both atherosclerotic cardiovascular disease and venous thromboembolic disease. In addition, most medications that cause fluid retention are associated with increased adverse cardiovascular effects. Calcium channel blockers (CCBs) and pioglitazone are exceptions to this generalization. Even though data regarding CCBs and pioglitazone contradict the hypothesis that fluid retention is a cardiovascular risk factor, these medications have favorable cardiovascular properties which may outweigh the negative effect of fluid retention. Determining whether or not fluid retention is a cardiovascular risk factor would require empirical data demonstrating a relationship between fluid retention and turbulence of blood flow. While this issue should be relevant to cardiovascular researchers, clinicians and patients, it is especially pertinent to the pharmaceutical industry. Four-dimensional magnetic resonance imaging and vector flow Doppler ultrasound have the capability to quantify turbulence of blood flow. These technologies could be utilized to settle the matter.

Do SGLT2 inhibitors and GLP-1 receptor agonists modulate differently the risk of stroke ? Discordance between randomised controlled trials and observational studies

Stroke represents a major burden in patients with type 2 diabetes, yet this cerebrovascular complication has been less carefully investigated than the risk of cardiovascular mortality, heart failure and renal disease. Some data suggested that glucagon-like peptide-1 receptor agonists (GLP-1RAs) exert a better protection against stroke than sodium-glucose cotransporter 2 inhibitors (SGLT2is). However, this conclusion was derived from indirect comparisons in absence of any head-to-head randomised controlled trial (RCT). The present comprehensive review compares the effects of SGLT2is versus GLP-1RAs on nonfatal and fatal/nonfatal strokes in network meta-analyses of RCTs (mostly cardiovascular outcome trials) versus placebo, on the one hand, and in real-life observational cohort studies, on the other hand. Whereas network meta-analyses of placebo-controlled RCTs confirm a slight but significant (in 11 out of 13 meta-analyses) higher incidence of stroke in patients treated with SGLT2is compared with those treated with GLP-1RAs, a large majority of retrospective observational cohort studies (19 out of 21) failed to find any significant difference in the risk of stroke between the two pharmacological classes. Available, yet limited, findings suggest that SGLT2is may be more efficacious against haemorrhagic than ischaemic strokes, in patients at risk for atrial fibrillation and in patients with chronic kidney disease.

The Dilemma of Use of Anticoagulation in Patients With Heart Failure With Reduced Ejection Fraction and Sinus Rhythm: A Case Report and Literature Review

Heart failure results in significant morbidity and mortality. Heart failure with reduced ejection fraction (HfrEF) in the absence of atrial fibrillation has been increasingly considered an independent risk factor for ischemic stroke, partly because of the development of left ventricular thrombus and subsequent cardioembolic stroke and partly because of hemodynamic impairment. Here, we present a case of a 60-year-old male with heart failure with reduced ejection fraction, who presented with cardioembolic ischemic stroke. In the investigation to localize the source, he was found to have slow intra-ventricular blood flow, which over shorter periods of follow up lead to the development of left ventricle intra-mural thrombi. Meanwhile, the patient also developed hemorrhagic conversion in the ischemic stroke, which further complicated the choice of anticoagulation. To date, no consensus has been developed on the choice of anticoagulation and clinical criteria for the use of anticoagulation in patients having HfrEF and sinus rhythm. This case brings forth a need for further research on whether anticoagulation would be beneficial in patients with HfrEF and sinus rhythm.

Prevalence and incidence of stroke, white matter hyperintensities, and silent brain infarcts in patients with chronic heart failure: A systematic review, meta-analysis, and meta-regression

Introduction

Heart failure (HF) is associated with ischemic stroke (IS). However, there are limited studies on the prevalence of IS, white matter hyperintensities (WMHs), and silent brain infarcts (SBIs). Furthermore, interaction with ejection fraction (EF) is unclear.

Methods

We searched three databases (viz., PubMed, Embase, and Cochrane) for studies reporting the incidence or prevalence of IS, WMHs, and SBIs in HF. A total of two authors independently selected included studies. We used random-effects models, and heterogeneity was evaluated with I2 statistic. Meta-regression was used for subgroup analysis.

Results

In total, 41 articles involving 870,002 patients were retrieved from 15,267 records. Among patients with HF, the pooled proportion of IS was 4.06% (95% CI: 2.94–5.59), and that of WMHs and SBIs was higher at 15.67% (95% CI: 4.11–44.63) and 23.45% (95% CI: 14.53–35.58), respectively. Subgroup analysis of HFpEF and HFrEF revealed a pooled prevalence of 2.97% (95% CI: 2.01–4.39) and 3.69% (95% CI: 2.34–5.77), respectively. Subgroup analysis of WMH Fazekas scores 1, 2, and 3 revealed a decreasing trend from 60.57 % (95% CI: 35.13–81.33) to 11.57% (95% CI: 10.40–12.85) to 3.07% (95% CI: 0.95–9.47). The relative risk and hazard ratio of patients with HF developing IS were 2.29 (95% CI: 1.43–3.68) and 1.63 (95% CI: 1.22–2.18), respectively. Meta-regression showed IS prevalence was positively correlated with decreasing anticoagulant usage.

Conclusion

We obtained estimates for the prevalence of IS, WMH, and SBI in HF from systematic review of the literature.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=255126, PROSPERO [CRD42021255126].

Cardiovascular risk of gabapentin and pregabalin in patients with diabetic neuropathy

Background

Gabapentin and pregabalin are commonly prescribed medications to treat pain in patients with diabetic neuropathy. Gabapentin and pregabalin can cause fluid retention, which is hypothesized to be associated with cardiovascular diseases. However, whether long-term use of gabapentin and pregabalin is associated with adverse cardiovascular diseases remains unknown. This study aims to examine the association between gabapentin use, pregabalin use and several adverse cardiovascular events.

Methods

This retrospective cohort study used propensity score matching within patient electronic health records (EHRs) from a multicenter database with 106 million patients from 69 health care organizations in the US. The study population comprised 210,064 patients who had a diagnosis of diabetic neuropathy and were prescribed diabetic neuropathy medications in their EHRs. The exposure cohort comprised patients who were prescribed gabapentin or pregabalin to treat diabetic neuropathy. The comparison cohort comprised patients who were not prescribed either gabapentin or pregabalin but were prescribed other drugs to treat diabetic neuropathy. The outcomes of interest were myocardial infarcts, strokes, heart failure, peripheral vascular disease, and venous thromboembolic events. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for 3-month and 5-year risk for adverse cardiovascular events between the propensity score-matched cohorts.

Results

Both gabapentin and pregabalin were associated with increased risk of 5-year adverse cardiovascular events compared with the comparison group. In patients prescribed gabapentin, the highest risk was observed for deep venous thrombosis (HR: 1.58, 95% CI 1.37–1.82), followed by pulmonary embolism (HR: 1.5, 95% CI 1.27–1.76), peripheral vascular disease (HR: 1.37, 95% CI 1.27–1.47), stroke (HR: 1.31, 95% CI 1.2–1.43), myocardial infarction (HR: 1.25, 95% CI 1.14–1.38) and heart failure (HR: 1.14, 95% CI 1.07–1.21). In patients prescribed pregabalin, the highest risk was observed for deep venous thrombosis (HR: 1.57, 95% CI 1.31–1.88), followed by peripheral vascular disease (HR: 1.35, 95% CI 1.22–1.49), myocardial infarction (HR: 1.29, 95% CI 1.13–1.47), pulmonary embolism (HR: 1.28, 95% CI 1.04–1.59), stroke (HR: 1.26, 95% CI 1.12–1.42), and heart failure (HR: 1.2, 95% CI 1.11–1.3). There were significant associations between short-term (3 month) gabapentin use and heart failure, myocardial infarction, peripheral vascular disease, deep venous thrombosis, and pulmonary embolism. Short-term (3 month) pregabalin use was associated with deep venous thrombosis, peripheral vascular disease.

Conclusion

In patients with diabetic neuropathy who were prescribed gabapentin and pregabalin, there is an increased risk for heart failure, myocardial infarction, peripheral vascular disease, stroke, deep venous thrombosis, and pulmonary embolism with long-term use. Our findings suggest that increased risk for adverse cardiovascular events, along with other side effects, the efficacy of pain control and the degree of tolerance of the patient, should be considered when prescribing gabapentin and pregabalin long-term in patients with diabetic neuropathy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01610-9.

Risks of Ischemic Stroke/Transient Ischemic Attack Based on CHA2DS2-VASc Scores in Non-Atrial Fibrillation Chinese Patients with Sinus Rhythm

This study aims to evaluate the incidence of ischemic stroke or transient ischemic attack (TIA) based on CHA₂DS₂-VASc scores in non-AF Chinese patients with sinus rhythm.We used health check-up data of 101,510 participants from the Kailuan Cohort Study. Participants' risk levels were defined by their CHA₂DS₂-VASc scores (range 0-3): Men with scores of 0, 1, or ≥ 2 and women with scores of 1, 2, or ≥ 3 were considered at low, intermediate, or high risk, respectively. Cox proportional hazards model was used to assess the association between the CHA₂DS₂-VASc-determined risk and the incidence of ischemic stroke/TIA.The mean 7.5 year follow-up examination revealed 2968 ischemic strokes/TIA events. The incidence rates for ischemic stroke/TIA events in men and women were 3.8% and 1.5%, respectively. The incidence of ischemic stroke/TIA increased with elevated predicted risks based on CHA₂DS₂-VASc scores in men: 2.2% for low-risk, 4.1% for intermediate-risk, and 7.8% for high-risk groups (P < 0.001 for trend). The incidences of ischemic stroke/TIA also increased with elevated predicted risks in women: 0.8% for low-risk, 2.1% for intermediate-risk, and 5.0% for high-risk groups (P < 0.001 for trend). Compared with low-risk group, the crude hazard ratio (95% confidence interval) of ischemic stroke/TIA for men in moderate- and high-risk groups were 1.96 (1.79-2.14; P < 0.001) and 4.18 (3.81-4.57; P < 0.001). Similar findings were observed in women.Risks of ischemic stroke/TIA events was high, particularly among those with high CHA₂DS₂-VASc scores.

CHA2DS2-VASc score performance to predict stroke after acute decompensated heart failure with and without reduced ejection fraction

AIMS

To validate the utility of CHA2DS2-VASc score to predict the annual risk of stroke in patients admitted with acute heart failure, comparing those with preserved ejection fraction (HF-presEF) and reduced ejection fraction (HF-redEF).

METHODS AND RESULTS

We investigated 2922 patients with known atrial fibrillation who were admitted to the Sheba Medical Center for acute decompensated heart failure (HF). Anticoagulation therapy was prescribed based on CHA2DS2-VASc score or physician's discretion. Subjects were divided into four pre-specified groups based on HF type and median CHA2DS2-VASc score: HF-presEF with CHA2DS2-VASc <5(N = 731), HF-presEF with CHA2DS2-VASc ≥5 (N = 1102), HF-redEF with CHA2DS2-VASc <5 (N = 563), and HF-redEF with CHADS2-VASc ≥5 (N = 526). The primary endpoint was an ischaemic stroke at 1 year. Mean age of the study population was 79 ± 11 years, of whom more than half were women. The median CHA2DS2-VASc score for the entire study population was 5.0 (interquartile range 25-75%: 4-6). Stroke rate for the entire study population was 6.6%. Multivariate Cox regression proportional hazards regression analysis revealed that in both HF-redEF and HF-presEF patients, each one-point increment in CHA2DS2-VASc was associated with a corresponding 28% increase in stroke risk (P < 0.001). The Kaplan-Meier's survival analysis revealed that in the same CHADS2-VASc category (high vs. low), no difference was found between HF-redEF and HF-presEF with regards to the risk of stroke.

CONCLUSION

Our key finding is that the CHA2DS2-VASc score is a valid and powerful predictor of subsequent stroke among patients admitted with acute heart failure decompensation regardless of heart failure type.