Predicting stroke in heart failure and reduced ejection fraction without atrial fibrillation

Kondo, T. et al. (2022) Predicting stroke in heart failure and reduced ejection fraction without atrial fibrillation. European Heart Journal, 43(42), pp. 4469-4479. (doi: 10.1093/eurheartj/ehac487) (PMID:36017729) (PMCID:PMC9637422)

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Background and Aims: Patients with heart failure with reduced ejection fraction (HFrEF) are at significant risk of stroke. Anticoagulation reduces this risk in patients with and without atrial fibrillation (AF), but the risk-to-benefit balance in the latter group, overall, is not favourable. Identification of patients with HFrEF, without AF, at the highest risk of stroke may allow targeted and safer use of prophylactic anticoagulant therapy. Methods: In a pooled patient-level cohort of the PARADIGM-HF, ATMOSPHERE, and DAPA-HF trials, a previously derived simple risk model for stroke, consisting of three variables (history of prior stroke, insulin-treated diabetes, and plasma N-terminal pro-B-type natriuretic peptide level), was validated. Results: Of the 20,159 patients included, 12,751 patients did not have AF at baseline. Among patients without AF, 346 (2.7%) experienced a stroke over a median follow-up of 2.0 years (rate 11.7 per 1000 patient-years). The risk for stroke increased with increasing risk score: fourth quintile HR 2.35 (95%CI 1.60-3.45); fifth quintile HR 3.73 (2.58-5.38), with the first quintile as reference. For patients in the top quintile, the rate of stroke was 21.2 per 1000 patient-years, similar to participants with AF not receiving anticoagulation (20.1 per 1000 patient-years). Model discrimination was good with a C-index of 0.84 (0.75-0.91). Conclusions: It is possible to identify a subset of HFrEF patients without AF with a stroke risk equivalent to that of patients with AF who are not anticoagulated. In these patients, the risk-to-benefit balance might justify the use of prophylactic anticoagulation, but this hypothesis needs to be tested prospectively.

Item Type:Articles
Glasgow Author(s) Enlighten ID:Abdul-Rahim, Dr Azmil and Kondo, Dr Toru and Talebi, Dr Atefeh and Jhund, Professor Pardeep and McMurray, Professor John and Petrie, Professor Mark and Kober, Professor Lars
Authors: Kondo, T., Abdul-Rahim, A. H., Talebi, A., Abraham, W. T., Desai, A. S., Dickstein, K., Inzucchi, S. E., Køber, L., Kosiborod, M. N., Martinez, F. A., Packer, M., Petrie, M., Ponikowski, P., Rouleau, J. L., Sabatine, M. S., Swedberg, K., Zile, M. R., Solomon, S. D., Jhund, P. S., and McMurray, J. J.V.
College/School:College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health
Journal Name:European Heart Journal
Publisher:Oxford University Press
ISSN (Online):1522-9645
Published Online:26 August 2022
Copyright Holders:Copyright © 2022 The Authors
First Published:First published in European Heart Journal 43(42): 4469-4479
Publisher Policy:Reproduced under a Creative Commons License

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Project CodeAward NoProject NamePrincipal InvestigatorFunder's NameFunder RefLead Dept
303944BHF Centre of ExcellenceColin BerryBritish Heart Foundation (BHF)RE/18/6/34217CAMS - Cardiovascular Science