Rachel Forman, MD

Siedler G, Sommer K, Macha K, Marsch A, Breuer L, Stoll S, et al. Heart Failure in Ischemic Stroke: Relevance for Acute Care and Outcome. Stroke. 2019.

The topic of heart failure (HF) is not uncommon in the stroke world. It is a known risk factor for stroke and is related to prothrombotic/proinflammatory states, worsening of cerebral tissue oxygenation, and hemodynamic impairment. There is also consideration if HF may affect the safety and efficacy of acute stroke therapies. Some concerns include reduced circulation after tPA with low cardiac output or difficulties with anesthesia management during MT. This study by Siedler et al. aimed to look at the effects of HF on stroke patients who received tPA, mechanical thrombectomy (MT), or both. The authors note the importance of this study and that many of the prospective clinical trials have excluded HF patients.

Patients who received tPA or MT at a university stroke center were included into a prospective registry. Patients with HF were identified based on their echocardiograms (transthoracic or transesophageal) done as a part of the stroke evaluation. The impairment of left ventricular ejection fraction (LVEF) was categorized as mild if >35% EF, moderate if 25-35% EF, and severe if <25% EF. Functional outcome was assessed after 90 days by telephone interviews and favorable outcome was considered mRS 0-2.  

Out of 1,209 patients in the registry, there were 378 patients (31%) with identified HF, and this was found to be an independent predictor of unfavorable functional outcome at 90 days. As far as clinical characteristics: HF patients had significantly higher rates of AF and CAD. Importantly, recanalization rates (after tPA, MT, or both) were not significantly different between patients with and without HF. The rates of intracranial bleeding complications were equal between the two groups, as well as early mortality and need for mechanical ventilation in the first hours after treatment. The NIHSS at discharge (not admission) was higher in HF patients. Limitations of this study include: single center design and that reduced LVEF in acute stroke may be transient. 

The main take-home point of this study is that patients with HF had similar recanalization rates after tPA and MT, as well as early complications. They did, however, have higher rates of disability at the time of discharge (higher NIHSS) and at 3-month follow up (mRS score>2). This study is important when discussing acute stroke treatments for HF patients.