Individual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes: A Prospective Hospital Register Cohort Study

Tiberiu A Pana, David J McLernon, Mamas A Mamas, Joao H Bettencourt-Silva, Anthony K Metcalf, John F Potter, Phyo K Myint* (Corresponding Author)

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

11 Citations (Scopus)
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Background and Purpose—
We aimed to determine individual and combined effects of atrial fibrillation (AF) and heart failure (HF) on acute ischemic stroke outcomes: in-hospital mortality, length-of-stay, and poststroke disability; long-term mortality and stroke recurrence.

Prospective cohort study of patients with acute ischemic stroke admitted to a UK center with a catchment population of ≈900 000 between 2004 and 2016. Exposure groups were patients with neither AF nor HF (reference group), those with AF but without HF, those with HF but without AF, and those with AF+HF. Logistic and Cox regressions were used to model in-hospital and long-term outcomes, respectively.

A total of 10 816 patients with a mean age±SD =77.9±12.1 years, 48% male were included. Only 30 (4.9%) of the patients with HF but not AF were anticoagulated at discharge. Both AF (odds ratio, 1.24 [95% CI, 1.07–1.43]), HF (odds ratio, 1.40 [1.10–1.79]), and their combination (odds ratio, 2.23 [1.83–2.72]) were associated with increased odds of in-hospital mortality. All 3 exposure groups were associated with increased length-of-stay, while only AF predicted increased disability (1.36 [1.12–1.64]). Patients were followed for a median of 5.5 and 3.7 years for mortality and recurrence, respectively. Long-term mortality was associated with AF (hazard ratio, 1.45 [95% CI, 1.33–1.59]), HF (2.07 [1.83–2.36]), and their combination (2.20 [1.96–2.46]). Recurrent stroke was associated with AF 1.50 (1.26–1.78), HF (1.33 [1.01–1.75]), and AF with HF (1.62 [1.28–2.07]).

The AF-associated excess risk of stroke recurrence was independent of comorbid HF. HF without AF was also associated with a significant risk of recurrence. Anticoagulation for secondary stroke prevention in patients with HF without AF may require further evaluation in a clinical trial setting.
Original languageEnglish
Pages (from-to)1838-1845
Number of pages8
Issue number7
Early online date3 Jun 2019
Publication statusPublished - Jul 2019

Bibliographical note

We thank the data team of the Norfolk and Norwich University Hospital Stroke Services, Prof Kristian Bowles (one of the co-Principal Investigators of the stroke register) and our lay steering committee members and independent chair Prof Alastair Forbes (Chief of Research & Innovation, Norfolk and Norwich University Hospital).


TAP received the Medical Research Scotland 2018 Vacation Scholarship [grant number Vac-1211-2018] to perform the research. The Norfolk and Norwich Stroke Register is maintained by the Norfolk and Norwich University Hospital Stroke Services.


  • atrial fibrillation
  • heart failure
  • cerebrovascular disease
  • stroke
  • mortality
  • recurrence
  • population


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