Relationship Between Degree of Left Ventricular Dysfunction, Symptom Status, and Risk of Embolic Events in Patients With Atrial Fibrillation and Heart Failure

Cardiac imaging correlates and predictors of stroke in patients with atrial fibrillation: a meta-analysis

BACKGROUND

New nonclinical parameters are needed to improve the current stroke risk stratification schemes for patients with atrial fibrillation. This study aimed to summarize data on potential cardiac imaging correlates and predictors of stroke or systemic embolism in patients with atrial fibrillation.

METHODS

MEDLINE, EMBASE, and Web of Science were searched to identify all published studies providing relevant data through 16 November 2022. Random effects meta-analysis method was used to pool estimates.

RESULTS

We included 64 studies reporting data from a pooled population of 56 639 patients. Left atrial spontaneous echo-contrast [adjusted odds ratio (aOR) 3.32, 95% confidence interval (CI) 1.98-5.49], nonchicken wing left atrial appendage (LAA) morphology (aOR 2.15, 95% CI 1.11-4.18), left atrial enlargement (aOR 2.12, 95% CI 1.45-3.08), and higher LAA orifice diameter (aOR 1.56, 95% CI 1.18-2.05) were highly associated with stroke. Other parameters associated with stroke included higher left atrial sphericity (aOR 1.14, 95% CI 1.01-1.29), higher left atrial volume (aOR 1.03, 95% CI 1.01-1.04), higher left atrial volume index (aOR 1.014, 95% CI 1.004-1.023), lower left atrial reservoir strain [adjusted hazard ratio (aHR) 0.86, 95% CI 0.76-0.98], higher left ventricular mass index (aOR 1.010, 95% CI 1.005-1.015) and E / e' ratio (aOR 1.12, 95% CI 1.07-1.16). There was no association between LAA volume (aOR 1.37, 95% CI 0.85-2.21) and stroke.

CONCLUSION

These cardiac imaging parameters identified as potential predictors of thromboembolism may improve the accuracy of stroke risk stratification schemes in patients with atrial fibrillation. Further studies should evaluate the performance of holistic risk scores including clinical factors, biomarkers, and cardiac imaging.

Coagulation Disorders and Thrombotic Complications in Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is associated with multiple cardiovascular and noncardiovascular comorbidities and risk factors which increase the risk of thrombotic complications, such as atrial fibrillation, chronic kidney disease, arterial hypertension and type 2 diabetes mellitus. Subsequently, thromboembolic risk stratification in this population poses a great challenge. Since date from the large randomized clinical trials mostly include both patients with truly preserved EF, and those with heart failure with mildly reduced ejection fraction, there is an unmet need to characterize the patients with truly preserved EF. Considering the significant evidence gap in this area, we sought to describe the coagulation disorders and thrombotic complications in patients with HFpEF and discuss the specific thromboembolic risk factors in patients with HFpEF, with the goal to tailor risk stratification to an individual patient.

Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis

Heart failure (HF) is a major disease in our society that often presents with multiple comorbidities with mutual interaction and aggravation. The comorbidity of HF and stroke is a high risk condition that requires particular attention to ensure early detection of complications, efficient diagnostic workup, close monitoring, and consequent treatment of the patient. The bi-directional interaction between the heart and the brain is inherent in the pathophysiology of HF where HF may be causal for acute cerebral injury, and - in turn - acute cerebral injury may induce or aggravate HF via imbalanced neural and neurovegetative control of cardiovascular regulation. The present document represents the consensus view of the ESC Council on Stroke, the Heart Failure Association and the ESC Working Group on Thrombosis to summarize current insights on pathophysiological interactions of the heart and the brain in the comorbidity of HF and stroke. Principal aspects of diagnostic workup, pathophysiological mechanisms, complications, clinical management in acute conditions and in long-term care of patients with the comorbidity are presented and state-of-the-art clinical management and current evidence from clinical trials is discussed. Beside the physicians perspective, also the patients values and preferences are taken into account. Interdisciplinary cooperation of cardiologists, stroke specialists, other specialists and primary care physicians is pivotal to ensure optimal treatment in acute events and in continued long-term treatment of these patients. Key consensus statements are presented in a concise overview on mechanistic insights, diagnostic workup, prevention and treatment to inform clinical acute and continued care of patients with the comorbidity of HF and stroke.

Current perspectives on the clinical management of cryptogenic stroke

INTRODUCTION

Cryptogenic stroke is a heterogeneous entity defined as an ischemic stroke for which no probable cause is identified despite thorough diagnostic evaluation. Since about a quarter of all ischemic strokes are classified as cryptogenic, it is a commonly encountered problem for providers as secondary stroke prevention is guided by stroke etiology.

AREAS COVERED

In this review, the authors provide an overview of stroke subtype classification schemes and diagnostic evaluation in cryptogenic stroke. They then detail putative cryptogenic stroke mechanisms, their therapeutic implications, and ongoing research. This review synthesizes the available evidence on PubMed up to December 2022.

EXPERT OPINION

Cryptogenic stroke is an evolving concept that changes with ongoing research. Investigations are focused on improving our diagnostic capabilities and solidifying useful constructs within cryptogenic stroke that could become therapeutically targetable subgroups within an otherwise nonspecific entity. Advances in technology may help move specific proposed cryptogenic stroke mechanisms from undetermined to known source of ischemic stroke.

Heart failure and the risk of left atrial thrombus formation in patients with atrial fibrillation or atrial flutter

AIMS

The aim of the study was to evaluate the prevalence of left atrial thrombus (LAT) on transoesophageal echocardiography (TOE) in patients with atrial fibrillation or atrial flutter (AF/AFl) with reference to the presence of heart failure (HF) and its subtypes.

METHODS AND RESULTS

The research is a sub-study of the multicentre, prospective, observational Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry, which comprised 3109 consecutive patients with AF/AFl undergoing TOE prior to direct current cardioversion or catheter ablation. TOE parameters, including presence of LAT, were compared between patients with and without HF and across different subtypes of HF, including HF with preserved (HFpEF), mid-range (HFmrEF), and reduced ejection fraction (HFrEF). HF was diagnosed in 1336 patients (43%). HF patients had higher prevalence of LAT than non-HF patients (12.8% vs. 4.4%; P < 0.001). LAT presence increased with more advanced type of systolic dysfunction (HFpEF vs. HFmrEF vs. HFrEF: 7.4% vs. 10.5% vs. 20.3%; P < 0.001). Univariate analysis revealed that HFrEF (odds ratio [OR] 4.13; 95% confidence interval [95% CI]: 3.13-5.46), but not HFmrEF or HFpEF, was associated with the presence of LAT. Multivariable logistic regression indicated that lower left ventricular ejection fraction (OR per 1%: 0.94; 95% CI 0.93-0.95) was an independent predictor of LAT formation. Receiver operator characteristic analysis showed LVEF ≤48% adequately predicted increased risk of LAT presence (area under the curve [AUC] 0.74; P < 0.0001).

CONCLUSION

The diagnosis of HFrEF, but neither HFmrEF nor HFpEF, confers a considerable risk of LAT presence despite widespread utilization of adequate anticoagulation.

The Thromboembolic Predictability of CHA2DS2-VASc Scores Using Different Echocardiographic Criteria for Congestive Heart Failure in Korean Patients with Nonvalvular Atrial Fibrillation

The association between congestive heart failure (CHF) of the CHA₂DS₂-VASc scores and thromboembolic (TE) events in patients with atrial fibrillation (AF) is a topic of debate due to conflicting results. As the importance of diastolic impairment in the occurrence of TE events is increasingly recognized, it is crucial to evaluate the predictive power of CHA₂DS₂-VASc scores with C criterion integrating diastolic parameters. We analyzed 4200 Korean nonvalvular AF patients (71 years of age, 59% men) to compare multiple echocardiographic definitions of CHF. Various guideline-suggested echocardiographic parameters for systolic or diastolic impairment, including left ventricular ejection fraction (LVEF) ≤ 40%, the ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral annulus (E/E’) ≥ 11, left atrial volume index > 34 mL/m², and many others were tested for C criteria. Multivariate-adjusted Cox regression analysis showed that CHA₂DS₂-VASc score was an independent predictor for composite thromboembolic events only when CHF was defined as E/E’ ≥ 11 (hazard ratio, 1.26; p = 0.044) but not with other criteria including the original definition (hazard ratio, 1.10; p = 0.359). Our findings suggest that C criterion defined as diastolic impairment, such as E/E’ ≥ 11, may improve the predictive value of CHA₂DS₂-VASc scores.

Atrial Fibrillation and Heart Failure with Preserved Ejection Fraction: Two Chronic Troublemakers

In this article, the definition; mechanisms; diagnostic strategies, including scoring systems; treatments; prognosis; and future perspectives in heart failure with preserved ejection fraction with atrial fibrillation, which are common comorbid conditions, are reviewed thoroughly.

Ischemic Stroke and Heart Failure: Facts and Numbers. An Update

Heart failure (HF) is a severe clinical syndrome accompanied by a number of comorbidities. Ischemic stroke occurs frequently in patients with HF as a complication of the disease. In the present review, we aimed to summarize the current state of research on the role of cardio–cerebral interactions in the prevalence, etiology, and prognosis of both diseases. The main pathophysiological mechanisms underlying the development of stroke in HF and vice versa are discussed. In addition, we reviewed the results of recent clinical trials investigating the prevalence and prevention of stroke in patients with HF.

Anticoagulation in Patients with Heart Failure and Sinus Rhythm

The risk of thromboembolic events is significantly increased among patients with heart failure, even in those without atrial fibrillation. However, it is still unclear whether patients with heart failure and sinus rhythm can benefit from prophylactic anticoagulant therapy.This was a retrospective review of the pathophysiological mechanisms, epidemiological studies, and clinical trials on anticoagulation in patients with heart failure and sinus rhythm.Some subgroup analyses of clinical trials found that prophylactic anticoagulant therapy could reduce the incidence of stroke in patients with heart failure and sinus rhythm, and the risk of bleeding was significantly increased. Regarding the incidence of primary endpoint outcomes, all results from clinical trials were negative.Prophylactic anticoagulation did not improve the clinical outcome in patients with heart failure and sinus rhythm.

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.

Atrial fibrillation in patients with heart failure with preserved ejection fraction

PURPOSE OF REVIEW

To review the shared pathology of atrial fibrillation and heart failure with preserved ejection fraction (HFpEF) and the prognostic, diagnostic, and treatment challenges incurred by the co-occurrence of these increasingly prevalent diseases.

RECENT FINDINGS

Multiple risk factors and mechanisms have been proposed as potentially linking atrial fibrillation and HFpEF, with systemic inflammation more recently being invoked. Nonvitamin K oral anticoagulants, left atrial appendage occlusion devices, and catheter ablation have emerged as alternative treatment options. Other novel pharmacological agents, such as neprilysin inhibitors, need to be studied further in this patient population.

SUMMARY

Atrial fibrillation and HFpEF commonly co-occur because of their shared risk factors and pathophysiology and incur increased morbidity and mortality relative to either condition alone. Although the presence of both diseases can often make each diagnosis difficult, it is important to do so early in the disease course as there are now a variety of treatment options aimed at improving symptoms and quality of life, slowing disease progression, and improving prognosis. However, more research needs to be performed on the role of catheter ablation in this population. Novel pharmacologic and procedural treatment options appear promising and may further improve the treatment options available to this growing population.

Non-invasive telemedical care in heart failure patients and stroke: post hoc analysis of TIM-HF and TIM-HF2 trials

AIMS

Patients with chronic heart failure (CHF) have an increased risk of ischaemic stroke. We aimed to identify the incidence rate and factors associated with ischaemic stroke or transient ischaemic attack (TIA) in CHF patients as well as the impact of non-invasive telemedical care (NITC) on acute stroke/TIA.

METHODS AND RESULTS

We retrospectively analysed baseline characteristics of 2248 CHF patients enrolled to the prospective multicentre Telemedical Interventional Monitoring in Heart Failure study (TIM-HF) and Telemedical Interventional Management in Heart Failure II study (TIM-HF2), randomizing New York Heart Association (NYHA) II/III patients 1:1 to NITC or standard of care. Hospitalizations due to acute ischaemic stroke or TIA during a follow-up of 12 months were analysed. Old age, hyperlipidaemia, lower body mass index, and peripheral arterial occlusive disease (PAOD) were independently associated with present cerebrovascular disease on enrolment. The stroke/TIA rate was 1.5 per 100 patients-years within 12 months after randomization (n = 32, 1.4%). Rate of stroke/TIA within 12 months was in the intervention group similar compared with the control group (50.0% vs. 49.8%; P = 0.98) despite that the rate of newly detected atrial fibrillation (AF) was higher in the intervention group (14.1% vs. 1.6%; P < 0.001). A history of PAOD (OR 2.7, 95% CI 1.2-6.2; P = 0.02) and the highest tertile (OR 3.0, 95% CI 1.1-8.3) of N-terminal pro-brain natriuretic peptide (NT-proBNP) on enrolment were associated with stroke/TIA during follow-up. In patients who suffered acute stroke or TIA during follow-up, echocardiography was part of the diagnostic workup in only 56% after hospital admission.

CONCLUSIONS

Annual rate of ischaemic stroke/TIA in NYHA II/III patients is low but higher in those with elevated NT-proBNP levels and history of PAOD at baseline. NITC showed no impact on the stroke rate during 1 year follow-up despite a significantly higher rate of newly detected AF. Irrespective of known CHF, echocardiography was often missing during in-hospital diagnostic workup after acute stroke/TIA.

Impact of Heart Failure Type on Thromboembolic and Bleeding Risk in Patients With Atrial Fibrillation on Oral Anticoagulation

Heart failure (HF) increases stroke risk in atrial fibrillation (AF) patients. Differential impact of HF category on thromboembolic and bleeding risk in AF patients on oral anticoagulation (OAC) is unknown. We used Medicare data for beneficiaries with new AF diagnosed between 2011 and 2013 to identify patients with HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and no HF. The primary endpoint of admission for ischemic stroke was evaluated using Cox proportional hazards regression models that controlled for patient demographics, comorbidities (including CHA₂DS₂-VASc and HASBLED scores), and OAC use as a time-dependent covariate. Secondary endpoints included all-cause mortality, admissions for gastrointestinal bleeding (GIB), intracranial hemorrhage (ICH), acute myocardial infarction (AMI), or HF. The 3groups included 47840, 32360, and 718392 patients respectively. Patients with HFrEF and HFpEF had higher comorbidity burden, CHA₂DS₂-VASc and HASBLED scores compared with patients without HF. In multivariable analysis adjusting for patient comorbidities and OAC, HFrEF and HFpEF were associated with higher risk of ischemic stroke, HF and AMI compared with no HF. HFrEF was associated with higher all-cause mortality and HF-hospitalization risk compared with HFpEF. In conclusion, in AF patients, HFrEF and HFpEF are both associated with higher risk of ischemic stroke, HF and AMI admissions, even after adjusting for OAC use, compared with patients without HF.

Biomarkers Associated with Stroke Risk in Atrial Fibrillation

Background:

Atrial fibrillation (AF) is associated with an increased risk of cardioembolic stroke. The risk of cardioembolism is not adequately reduced with the administration of oral anticoagulants, since a number of patients continue to experience thromboembolic events despite receiving treatment. Therefore, identification of a circulating biomarker to identify these high-risk patients would be clinically beneficial.

Objective:

In the present article, we aim to review the available data regarding use of biomarkers to predict cardioembolic stroke in patients with AF.

Methods:

We performed a thorough search of the literature in order to analyze the biomarkers identified thus far and critically evaluate their clinical significance.

Results:

A number of biomarkers have been proposed to predict cardioembolic stroke in patients with AF. Some of them are already used in the clinical practice, such as d-dimers, troponins and brain natriuretic peptide. Novel biomarkers, such as the inflammatory growth differentiation factor-15, appear to be promising, while the role of micro-RNAs and genetics appear to be useful as well. Even though these biomarkers are associated with an increased risk for thromboembolism, they cannot accurately predict future events. In light of this, the use of a scoring system, that would incorporate both circulating biomarkers and clinical factors, might be more useful.

Conclusions:

Recent research has disclosed several biomarkers as potential predictors of cardioembolic stroke in patients with AF. However, further research is required to establish a multifactorial scoring system that will identify patients at high-risk of thromboembolism, who would benefit from more intensive treatment and monitoring.

Stroke risk stratification in atrial fibrillation: a review of common risk factors

Atrial Fibrillation (AF) has become a major global health concern being the most common sustained arrhythmia in clinical practice. Risk factors for AF include congestive heart failure, hypertension, increasing age and diabetes. Many of these factors also increase the risk for thromboembolism and ischemic stroke in AF patients. Great efforts have been made from the latter part of the 20th century towards developing an ideal stroke risk stratification tool in AF with the aim of reducing the incidence of stroke in AF patients and the limiting unnecessary use of thromboprophylaxis. The thromboembolic risks posed by AF with valvular heart disease are an important subgroup that contributes to a significant proportion of stroke in AF patients globally. We review the evolution of stroke risk stratification and summarize the guidelines for stroke prevention in non-valvular AF as well as AF with valvular heart disease, and the most recent recommendations on stroke prevention in AF patients. Abbreviations: AF: Atrial Fibrillation; ACS: Acute Coronary Syndrome; CAD: Coronary Artery Disease; CCF: Congestive Cardiac Failure; DM: Diabetes Mellitus; EHRA: Evaluated Heartvalves, Rheumatic or Artificial; ICH: Intracranial Hemorrhage; NOACs: Novel Oral Anticoagulants; OAC: Oral Anticoagulants; PAD: Peripheral Arterial Disease ; TIA: Transient Ischemic Attack; VHD: Valvular Heart Disease.

Does Left Ventricular Systolic Function Matter? Treating Atrial Fibrillation in HFrEF Versus HFpEF

Atrial fibrillation (AF) and heart failure (HF) pose international health care challenges that contribute significantly to hospitalizations, morbidity, mortality, and significant health care costs. Both AF and HF contribute to the development of each other and both are associated with a worsened prognosis when they occur together. Assessment of systolic function via transthoracic echocardiography is essential in the investigation of the AF patient. Clinical and echocardiographic assessment may classify AF patients with HF into HF with reduced ejection fraction (HF-rEF) and HF with preserved ejection fraction (HF-pEF). Such classification can assist in numerous important management decisions in AF.

Left Ventricular Ejection Fraction and Clinically Defined Heart Failure to Predict 90-Day Functional Outcome After Ischemic Stroke

BACKGROUND

Heart failure (HF) is a risk factor for atrial fibrillation (AF), stroke, and post-stroke disability. However, differing definitions and application of HF-criteria may impact model prediction. We compared the predictive ability of left ventricular ejection fraction (LVEF), a readily available objective echocardiographic index, with clinical HF definitions for functional disability and AF in stroke patients.

METHODS

We retrospectively analyzed ischemic stroke patients evaluated between January 2013 and May 2015. Outcomes of interest were: (a) 90-day functional disability (modified Rankin score 3-6) and (b) AF. We compared: (1) LVEF (continuous variable), (2) left ventricular systolic dysfunction (LVSD)-categories (absent to severe), (3) clinical history of HF, and (4) HF/LVSD-categories: (i) HF absent without LVSD, (ii) HF absent with LVSD, (iii) HF with preserved ejection fraction (HFpEF), and (iv) HF with reduced ejection fraction (HFrEF). Multivariable logistic regression was used to determine the predictive ability for 90-day disability and AF, respectively.

RESULTS

Six hundred eighty five consecutive patients (44.5% female) fulfilled the study criteria and were included. After adjustment, the LVEF was independently associated with 90-day disability (OR .98, 95% CI .96-.99, P = .011) with similar predictive ability (area under the curve [AUC] = .85) to models including the LVSD-categories (AUC = .85), clinically define HF (AUC = .86), and HF/LVSD-categories (AUC = .86). The LVEF, HF, LVSD-, and HF/LVSD-categories were independently associated with AF (P < .01, each) with similar predictive ability (AUC = .74, .74, .73, and .75, respectively).

CONCLUSIONS

Compared to commonly defined HF definitions, the objectively determined LVEF possesses comparable predictive ability for 90-day disability and AF in stroke patients.

Risk of stroke in chronic heart failure patients with preserved ejection fraction, but without atrial fibrillation: analysis of the CHARM-Preserved and I-Preserve trials

Aims

The incidence and predictors of stroke in patients with heart failure and preserved ejection fraction (HF-PEF), but without atrial fibrillation (AF), are unknown. We described the incidence of stroke in HF-PEF patients with and without AF and predictors of stroke in those without AF.

Methods and results

We pooled data from the CHARM-Preserved and I-Preserve trials. Using Cox regression, we derived a model for stroke in patients without AF in this cohort and compared its performance with a published model in heart failure patients with reduced ejection fraction (HF-REF)—predictive variables: age, body mass index, New York Heart Association class, history of stroke, and insulin-treated diabetes. The two stroke models were compared and Kaplan–Meier curves for stroke estimated. The risk model was validated in a third HF-PEF trial. Of the 6701 patients, 4676 did not have AF. Stroke occurred in 124 (6.1%) with AF and in 171 (3.7%) without AF (rates 1.80 and 1.00 per 100 patient-years, respectively). There was no difference in performance of the stroke model derived in the HF-PEF cohort and the published HF-REF model (c-index 0.71, 95% confidence interval 0.57–0.84 vs. 0.73, 0.59–0.85, respectively) as the predictive variables overlapped. The model performed well in the validation cohort (0.86, 0.62–0.99). The rate of stroke in patients in the upper third of risk approximated to that in patients with AF (1.60 and 1.80 per 100 patient-years, respectively).

Conclusions

A small number of clinical variables identify a subset of patients with HF-PEF, but without AF, at elevated risk of stroke.

The CHA2DS2-VASc score: Not as simple as it seems

The CHA₂DS₂-VASc score has been widely adopted as a risk stratification tool for strokes in patients with atrial fibrillation and to help in deciding when anticoagulation therapy for stroke prophylaxis may be beneficial. The score as a whole has been well validated and has been included in the current major practice guidelines. An advantage of the CHA₂DS₂-VASc score is its ease of use, allowing clinicians to quickly estimate risk based on a short set of criteria. However, the benefit of simplicity may also be a weakness. Studies on individual components of the score suggest that only a subset of patients deemed to be at risk based on the current definition are actually at risk for stroke. Thus, users of the score should be aware of the nuances based on available evidence and avoid over-generalization. Accurate assessment of stroke risk has important clinical implications as it influences decision-making on initiation of anticoagulation.

Heart Failure With Preserved Ejection Fraction and Atrial Fibrillation: Vicious Twins

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are age-related conditions that are increasing in prevalence, commonly coexist, and share clinical features. This review provides a practical update on the epidemiology, pathophysiology, diagnosis, and management of patients with concomitant HFpEF and AF. Epidemiological studies highlight the close and complex links between HFpEF and AF, the shared risk factors, the high AF occurrence in the natural history of HFpEF, and the independent contribution of each condition to poor outcomes. Diagnosis of HFpEF in the setting of AF is challenging because the symptoms overlap. AF is associated with changes in echocardiographic parameters and circulating natriuretic peptides that confound HFpEF diagnosis. Symptomatic improvement with diuretic therapy supports the presence of HFpEF in patients with concomitant AF. Important knowledge gaps need to be addressed by a multidisciplinary and translational research approach to develop novel therapies that can improve prognosis.

Embolic stroke and after-admission atrial fibrillation

BACKGROUND

Although atrial fibrillation (AF) is a leading cause of recurrent embolic stroke, secondary AF after stroke has been reported frequently. Because of the different treatment each uses, it is important to detect the exact stroke-etiology.

OBJECTIVES

The aim of this study was to compare the embolic stroke in patients with known AF and after-admission AF (AAAF).

METHODS

Between October 2002 and July 2009, those who were diagnosed with AF (n=354) were enrolled in our study out of a total of 2026 acute ischemic stroke (IS) patients. The embolic lesion patterns were assessed by two stroke specialists who were blinded to the clinical information.

RESULTS

Among 354 IS patients with AF, the number of patients with embolic stroke was 314. Patients with embolic stroke were younger and more likely to have larger left atrial (LA)/Aortic diameter ratio. Approximately 90.4% of those with known AF had embolic stroke, while <60% of patients with AAAF had embolic stroke. Nevertheless, anticoagulants were prescribed similarly in both groups at discharge. The LA/Aortic diameter ratio<1.5 was significantly related to AAAF. After adjusting for multiple co-variables, compared to the patients with known AF, patients with AAAF had reduced risk of embolic stroke (Odds ratio 0.11, 95% Confidence interval 0.03-0.36, p-value<0.001).

CONCLUSIONS

Compared to AAAF after stroke, known AF was associated with embolic stroke. Therefore, we suggest that stroke etiology and some novel echocardiographic indicators such as LA enlargement might be contemplated before routine using of anticoagulants in IS patients with AF.

Anticoagulation in atrial fibrillation and chronic heart failure: the risk and drug of choice

PURPOSE OF REVIEW

This review seeks to provide an evidence-based update on the issue of atrial fibrillation and chronic heart failure with an emphasis on anticoagulation and the expanding use of the novel oral anticoagulants (NOACs).

RECENT FINDINGS

There is an increasing appreciation of the important reciprocal relationship between atrial fibrillation and heart failure and the negative prognostic impact that each condition has on the other. There are now four NOACs approved for stroke prevention in atrial fibrillation. There are increasing data to support their use in atrial fibrillation with heart failure, including in patients with nonmechanical or rheumatic valvular disease, and to facilitate direct current cardioversion. The choice of NOAC is heavily dependent on individual patient characteristics.

SUMMARY

The use of and indications for NOACs for patients with heart failure and atrial fibrillation are rapidly increasing.

Atrial fibrillation in heart failure with preserved ejection fraction: Insights into mechanisms and therapeutics

Atrial fibrillation (AF) and heart failure (HF) often coexist, and the outcomes of patients who have both AF and HF are considerably worse than those with either condition in isolation. Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical entity and accounts for approximately one-half of current HF. At least one-third of patients with HFpEF are burdened by comorbid AF. The current understanding of the relationship between AF and HFpEF is limited, but the clinical implications are potentially important. In this review, we explore 1) the pathogenesis that drives AF and HFpEF to coexist; 2) pharmacologic therapies that may attenuate the impact of AF in HFpEF; and 3) future directions in the management of this complex syndrome.

Atrial fibrillation and heart failure: Factors influencing the choice of oral anticoagulant

Atrial fibrillation (AF) and heart failure (HF) frequently coexist. AF is identified in approximately one third of patients with HF and is linked to increased morbidity and mortality than from either condition alone. AF is relatively more common in HF with preserved ejection fraction (HFpEF) than with reduced ejection fraction (HFrEF). Nevertheless, the risk of stroke and systemic embolism (SSE) is significantly increased with both HF types and the absolute risk is heavily influenced by the presence and severity of associated additional stroke risk factors. The European Society of Cardiology has very recently introduced a third HF subtype entitled HF with mid-range ejection fraction (HFmrEF). At present oral anticoagulation is recommended for all patients with AF and HF, independent of HF type. In addition to warfarin there are currently four non-vitamin K oral anticoagulants (NOACs, previously called novel oral anticoagulants) that have been approved for the prevention of SSE. They consist of one direct thrombin inhibitor, dabigatran and three factor Xa inhibitors: rivaroxaban, apixaban and, most recently, edoxaban. In this review article we present an overview of the evidence to support the use of NOACs for the prevention of SSE in patients with AF and HF and review the influence of HF subtype and co-morbidities on the potential choice of oral anticoagulant.

The importance of interactions between atrial fibrillation and heart failure

Heart failure (HF) and atrial fibrillation (AF) are among the commonest cardiovascular conditions encountered in clinical practice and frequently coexist. Over the last decade, they have evolved into global cardiovascular epidemics. This, in turn, has huge clinical and economic implications. There is ample evidence that AF and HF have a mutually deleterious effect on each other. AF is not only a marker of HF severity but also affects HF prognosis independently. This article presents the close pathophysiological relationship between AF and HF and the adverse prognostic consequences of this bidirectional interaction. The scope of various therapeutic modalities and their potential impacts are discussed briefly.

Vascular Disease and Risk Stratification for Ischemic Stroke and All-Cause Death in Heart Failure Patients without Diagnosed Atrial Fibrillation: A Nationwide Cohort Study

Background

Stroke and mortality risk among heart failure patients previously diagnosed with different manifestations of vascular disease is poorly described. We conducted an observational study to evaluate the stroke and mortality risk among heart failure patients without diagnosed atrial fibrillation and with peripheral artery disease (PAD) or prior myocardial infarction (MI).

Methods

Population-based cohort study of patients diagnosed with incident heart failure during 2000–2012 and without atrial fibrillation, identified by record linkage between nationwide registries in Denmark. Hazard rate ratios of ischemic stroke and all-cause death after 1 year of follow-up were used to compare patients with either: a PAD diagnosis; a prior MI diagnosis; or no vascular disease.

Results

39,357 heart failure patients were included. When compared to heart failure patients with no vascular disease, PAD was associated with a higher 1-year rate of ischemic stroke (adjusted hazard rate ratio [HR]: 1.34, 95% confidence interval [CI]: 1.08–1.65) and all-cause death (adjusted HR: 1.47, 95% CI: 1.35–1.59), whereas prior MI was not (adjusted HR: 1.00, 95% CI: 0.86–1.15 and 0.94, 95% CI: 0.89–1.00, for ischemic stroke and all-cause death, respectively). When comparing patients with PAD to patients with prior MI, PAD was associated with a higher rate of both outcomes.

Conclusions

Among incident heart failure patients without diagnosed atrial fibrillation, a previous diagnosis of PAD was associated with a significantly higher rate of the ischemic stroke and all-cause death compared to patients with no vascular disease or prior MI. Prevention strategies may be particularly relevant among HF patients with PAD.

Embolic Stroke in Cardiomyopathy: Should Patients be Anticoagulated?

Despite advances in the treatment of patients with heart failure, mortality is still substantial. Part of this mortality is explained by cardioembolic stroke. Patients with heart failure are predisposed to developing cardioembolic strokes owing to abnormalities in Virchow's triad (endothelial function, relative hypercoagulable state, and static blood flow). Several randomized controlled trials have addressed whether patients with heart failure benefit from anticoagulation. Overall, the results suggest the risk of bleeding with anticoagulation outweighs any small benefit conferred by anticoagulation.

Individualized approaches to thromboprophylaxis in atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmia worldwide. The prevalence of AF in persons older than 55 years is at least 33.5 million globally and is predicted to more than double in the next half-century. Anticoagulation, heart rate control, and heart rhythm control comprise the 3 main treatment strategies in AF. Anticoagulation is aimed at preventing debilitating stroke, systemic embolism, and associated mortality. Historically, anticoagulation in AF was achieved with a vitamin K antagonist such as warfarin, which is supported by evidence demonstrating reduced incident stroke and all-cause mortality. However, warfarin has unpredictable pharmacokinetics with many drug-drug interactions that require regular monitoring to ensure patients remain in the therapeutic anticoagulant range. Non-vitamin K antagonist oral anticoagulants including dabigatran, rivaroxaban, apixaban, and edoxaban provide a possible solution to these issues with their more predictable pharmacokinetics, rapid onset of action, and greater specificity. Results from large randomized, controlled trials indicate that these agents are at least noninferior to warfarin in prevention of stroke. These trials also demonstrate a consistently lower incidence of intracranial hemorrhage, almost always all life-threatening bleeds, and many forms of major bleeds with the possible exception of gastrointestinal and some other forms of mucosal bleeding, compared with warfarin. Patients with AF are a heterogeneous population with diverse risk of stroke and bleeding, and different subgroups respond differently to anticoagulation. Important clinical questions have arisen regarding optimal anticoagulation drug selection in distinct populations such as those with renal impairment, older age, coronary artery disease, and heart failure as well as those at particularly high risk for bleeding or thromboembolism. In this review, treatment strategies in AF management are discussed in the context of different individual subgroups of patients.

Diabetes mellitus and risk of ischemic stroke in patients with heart failure and no atrial fibrillation

OBJECTIVE

The risk of ischemic stroke, systemic thromboembolism, and all-cause death among heart failure patients previously diagnosed with diabetes mellitus is poorly described. We evaluated the risk of these endpoints among heart failure patients without diagnosed atrial fibrillation according to the presence of diabetes mellitus.

METHODS

Population-based nationwide cohort study of non-anticoagulated patients diagnosed with incident heart failure during 2000-2012, identified by record linkage between nationwide registries in Denmark. We calculated relative risks after 1year to evaluate the association between diabetes and risk of events in 39,357 heart failure patients, among whom 18.1% had diabetes. Analysis took into account competing risks of death.

RESULTS

Absolute risks of all endpoints were higher in patients with diabetes compared to patients without diabetes after 1-year follow-up (ischemic stroke: 4.1% vs. 2.8%; systemic thromboembolism: 11.9% vs. 8.6%; all-cause death: 22.1% vs. 21.4%). Diabetes was significantly associated with an increased risk of ischemic stroke (adjusted relative risk [RR]: 1.27, 95% confidence interval [CI]: 1.07-1.51); systemic thromboembolism (RR: 1.20, 95% CI: 1.11-1.30); and all-cause death (RR: 1.17, 95% CI: 1.11-1.23). Additionally, time since diabetes diagnosis was associated with higher adjusted cumulative incidences of ischemic stroke, systemic thromboembolism, and all-cause death (p for trend, p<0.001).

CONCLUSIONS

Among heart failure patients without atrial fibrillation, diabetes was associated with a significantly increased risk of ischemic stroke, systemic thromboembolism, and all-cause death compared to those without diabetes, even after adjustment for concomitant cardiovascular risk factors. Increased focus on secondary prevention in heart failure patients with diabetes may be warranted.

Residual Risk of Stroke and Death in Anticoagulated Patients According to the Type of Atrial Fibrillation

Background and Purpose—

Atrial fibrillation (AF) and heart failure frequently coexist and are associated with increased morbidity and mortality. We investigated the prognosis of anticoagulated patients with permanent AF and nonpermanent AF according to preexisting heart failure in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial.

Methods—

The primary outcome was a composite of cardiovascular death and stroke or systemic embolism, analyzed using a Cox proportional hazards model, adjusted for baseline age, sex, diabetes mellitus, hypertension, creatinine, and previous cardiovascular diseases. The median follow-up was 11.6 months (interquartile range, 6.2–15.2).

Results—

Nonpermanent AF was present in 2072 patients (46% of cohort), of which 339 (16%) had preexisting heart failure. A total of 2484 patients had permanent AF (54% of cohort), with a higher burden of heart failure including 730 patients (29%; P <0.001). Overall, death because of cardiovascular causes occurred in 57 patients and 45 had stroke or systemic embolism (1.4/100 person-years for each). Overall, the adjusted incidence of the composite outcome was higher in patients with permanent AF than in patients with nonpermanent AF. In multivariate analysis, permanency of AF, creatinine, prior cerebrovascular events, and previous coronary disease were independently associated with the primary outcome. The hazard ratio for permanent versus nonpermanent AF was 1.68 (95% confidence interval, 1.08–2.55; P =0.02). The presence of heart failure increased the risk of adverse outcomes in a similar way in both permanent and nonpermanent AF (interaction P value=0.76).

Conclusions—

The risk of cardiovascular death, stroke, or systemic embolism is higher in anticoagulated patients with permanent AF than in those with nonpermanent AF, regardless of preexisting heart failure.

Ischemic stroke and heart failure: facts and numbers

Heart failure (HF) is pandemic in the modern society. Comorbidities of HF come increasingly to the fore in today's patient presentation and demand multidisciplinary treatment concepts. Ischemic stroke is a major comorbidity in HF patients and frequently contributes to the adverse outcome and functional dependency. Patients with HF are two‐fold to three‐fold more likely to suffer an ischemic stroke, have more than two times higher mortality and show worse functional outcome after stroke compared with non‐HF subjects. The risk of recurrent stroke is about two‐fold elevated in patients with HF. The risk of stroke increased with time duration of HF from 18 per 100 cases in the first year of HF to 47 per 1000 patients within the next 4‐5 years. Moreover, so called ‘silent’ strokes (clinically asymptomatic brain lesions) are two to four times more likely in HF patients. In turn, 10–24% of stroke patients have HF. Specific characteristics of the interaction between ischemic stroke and HF have been uncovered in recent years. However, gaps in present knowledge need to be addressed in future studies. What are the detailed pathophysiologic links beyond atrial fibrillation, stroke patterns, and time courses in the interaction? What implication has HF with preserved versus reduced ejection fraction? Does treatment of HF prevents ischemic stroke or reduces stroke‐related sequelae? This editorial provides a condensed overview on current insights and presents facts and numbers on the interaction between heart failure and ischemic stroke.