Heart failure patients are at higher risk for any type of stroke

Risk of Stroke in Patients With Heart Failure: A Population-Based 30-Year Cohort Study

Literature - Adelborg K, Szépligeti S, Sundbøll J, et al. - Stroke. 2017; published online ahead of print


Heart failure (HF) is associated with an increased risk of ischaemic stroke, due to thromboembolic complications and increased activity of pro-coagulant factors. It is also associated with low blood pressure, which may protect against stroke [1]. The role of HF as a risk factor for stroke has not been studied adequately [2-4].

In this study, the short- and long-term risk of ischaemic stroke, intracerebral haemorrhage (ICH) and subarachnoid haemorrhage (SAH) were evaluated in a large cohort of 289 353 HF patients, and compared with 1 446 765 individuals in the general population. Moreover, the influence of comorbidities on the relationship between HF and stroke were assessed.

Main results

  • During the first 5 years, HF patients had a slightly higher absolute risk of ischaemic stroke compared with the general population, whereas after 5 years, this risk was somewhat lower for HF patients, due to competing mortality.
  • The 30-day adjusted stroke rate ratio (aSRR, hazard ratio for stroke) was 5.08 (95% CI 4.58–5.63). It declined, but remained elevated during 31 to 365 days of follow-up (aSRR=2.08, 95% CI 1.99–2.18) and during 1 to 30 years of follow-up (aSRR=1.54, 95% CI 1.51–1.58).
  • The associations between HF and ischaemic stroke persisted in patients without atrial fibrillation or atrial flutter.
  • During the first 5 years of follow-up, absolute risks of ICH and SAH were similar for HF patients and the general population, and after 5 years, the absolute risks decreased for the HF cohort, due to competing mortality.
  • The 30-day aSRRs of ICH and SAH were increased (2.13, 95% CI 1.53–2.97 and 3.52, 95% CI 1.54–8.08, respectively) and remained 1.1- to 1.8-fold increased from 31 days to 30 years of follow-up.
  • Regarding trends of risks, the 30-day aSRR for ischaemic stroke slightly increased during 30 years, whereas the 31-365 day and 1-5 year aSRR’s for ischaemic stroke slightly decreased over those 30 years.
  • The aSRR for ICH remained stable during the 3 decades.
  • The aSRRs were similar for men and women.
  • Within the first year of follow-up, the association between HF and ischaemic stroke was stronger for patients admitted to the intensive care unit, compared with those not admitted, and for those with length of stay >7 days compared with those with length of stay ≤7 days.


In a large cohort study of 30 years, HF was associated with an increased risk of ischaemic stroke, ICH and SAH, especially in the short term, but also in the long term. These findings suggest that HF is an important risk factor for all types of stroke, and that it is important to pay clinical attention to the stroke risk of HF patients.


1. Haeusler KG, Laufs U, Endres M. Chronic heart failure and ischemic stroke. Stroke. 2011;42:2977–2982.

2. Alberts VP, Bos MJ, Koudstaal P, et al. Heart failure and the risk of stroke: the Rotterdam Study. Eur J Epidemiol. 2010;25:807–812.

3. Witt BJ, Brown RD Jr, Jacobsen SJ, et al. Ischemic stroke after heart failure: a community-based study. Am Heart J. 2006;152:102–109.

4. Pullicino PM, McClure LA, Wadley VG, et al. Blood pressure and stroke in heart failure in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study.

Find this article online at Stroke

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