ARTICLE IN PRESS

Stroke and Heart Failure: Clinical Features, Access to Care,

and Outcomes
Jitphapa Pongmoragot, MD,* Douglas S. Lee, MD, PhD, Tai Hwan Park, MD, PhD,
Jiming Fang, PhD, Peter C. Austin, PhD,
Gustavo Saposnik, MD, MSc, FAHA, FRCPC* on behalf of the Investigators of the
Registry of the Canadian Stroke Network and the University of Toronto Stroke
Program for the Stroke Outcomes Research Canada (SORCanwww.sorcan.ca)
Working Group

Background and Objectives: Limited information is known regarding acute ischemic stroke (AIS) and heart failure (HF). The aim of the study was to evaluate
clinical characteristics, predisposing factors, and outcomes in AIS with HF. Methods:
We included AIS patients admitted to the institutions participating in the Registry of the Canadian Stroke Network. HF was defined as history of pre-existing
HF or pulmonary edema present at the time of arrival. The primary outcome was
death or disability at discharge (modified Rankin Scale score >3). Secondary outcomes included disposition, death at 3 months and at 1 year, and 30-day hospital
readmissions. Results: Among 12,396 patients, HF was found in 1124 (9.1%) patients. HF was associated with higher risk of death at 30 days (24.5% versus 11.2%,
P < .0001), at 1 year (44.3% versus 20.6, P < .0001), and disability at discharge (70.4%
versus 56%, P < .0001). In the multivariable analysis, HF was an independent predictor of death and disability (odds ratio 1.18, 95% confidence interval [CI] 1.011.37), death at 30 days (hazard ratio [HR] 1.22, 95% CI 1.05-1.41), and hospital
readmissions (HR 1.32, 95% CI 1.05-1.65) at 30 days. The results were unaltered

From the *Stroke Outcomes Research Center, Division of Neurology, Department of Medicine, St. Michaels Hospital, University of Toronto,
Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Joint Department of Medical Imaging, Institute for Clinical Evaluative Science, IHPME,
University Health Network, Toronto, Ontario, Canada; Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea; Department of Statistics, Institute of Clinical Evaluative Sciences (ICES), Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada;
and Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada.
Received August 23, 2015; revision received November 17, 2015; accepted January 2, 2016.
Grant support: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from
the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results, and conclusions reported in this paper are those of
the authors and are independent from the funding sources. No endorsement by ICES or the MOHLTC is intended or should be inferred.
These data sets were held securely in a linked, deidentified form and were analyzed at the ICES.
Dr. Austin was supported in part by a Career Investigator Award from the Heart and Stroke Foundation of Canada. Dr. Lee is supported
by a clinicianscientist award from the Canadian Institutes of Health Research. Dr. Saposnik is supported by the Distinguished Clinician
Scientist Award from Heart of Stroke Foundation of Canada following an open peer-review competition.
Authors contributions: Dr. Pongmoragot drafted the manuscript and provided a critical review. Dr. Pongmoragot and Dr. Fang have access
to the data to act as guarantors. Dr. Saposnik, Dr. Lee, Dr. Park, Dr. Fang, and Dr. Austin all contributed in the design, planning, and conduct
of the study, and provided critical revisions to the manuscript.Address correspondence to Gustavo Saposnik, MD, MSc, FAHA, FRCPC,
Stroke Outcomes Research Center, Department of Medicine, St. Michaels Hospital, University of Toronto, 55 Queen St E, Toronto, Ontario
M5C 1R6, Canada. E-mail: saposnikg@smh.ca.
1052-3057/$ - see front matter
2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.01.013

Journal of Stroke and Cerebrovascular Diseases, Vol. , No. (), 2016: pp

ARTICLE IN PRESS
J. PONGMORAGOT ET AL.

when adjusting for pneumonia with the exception of death or disability at discharge.
Conclusions: In this large cohort study, HF was observed in 9.1% of AIS patients.
HF is an independent predictor of death and disability and hospital readmissions after stroke at 30 days. Key Words: Strokeheart failurequality of
careoutcomes.
2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Introduction
Stroke is a major cause of death and disability worldwide. Some pre-existing medical conditions (e.g., atrial
fibrillation [AF] and diabetes) directly influence stroke
outcomes.1,2 Heart failure (HF) is a complex clinical syndrome that results from structural or functional impairment
of ventricular filling or reduction in the ability of the ventricle to eject blood.3 The prevalence of HF is approximately
10 per 1000 after 65 years of age,4 increasing to over 80
per 1000 populations among those aged 85 years and older.5
HF carries high mortality with 1-year mortality of approximately 30%-45%.6 After the onset of HF, only 50%
will survive in 5 years.7 Similarly, mortality is 2-fold higher
in stroke patients with HF compared to those without
HF.8-10 With the growth in the aging population, the increasing prevalence of stroke and HF in patients is
expected. However, there is not much known about acute
ischemic stroke (AIS) with HF. The aim of our study was
to evaluate (1) clinical characteristics, predisposing factors,
and outcomes in patients who have AIS with HF and
(2) to determine if HF is an independent predictor of stroke
outcomes.

Methods
Study Population
We identified consecutive patients aged 18 years old
or older who were admitted with a diagnosis of ischemic stroke to participating institutions in the Registry
of the Canadian Stroke Network (RCSN) between July
1, 2003, and June 30, 2008. Patients with missing Canadian Neurological Scale (CNS) scores (n = 304) and baseline
glucose levels (n = 701) were excluded from the study.
The study population and exclusions are shown in Figure 1.

Data Sources
The RCSN is a large prospective quality monitoring
stroke care registry that comprises acute stroke patients
admitted to 11 stroke centers in Ontario, Canada. Details
of the RCSN can be obtained from http://www.ices.on.ca/
Research/Research-programs/Cardiovascular/Ontario
-Stroke-Registry and are published elsewhere.11 The
poststroke mortality was obtained through linkages to the
Ontario Registered Persons Database at the Institute for
Clinical Evaluative Sciences. The Registered Persons

Figure 1. Study population. Abbreviations: CNS, Canadian Neurological Scale; RCSN, Registry of the Canadian Stroke Network.

Database was linked with the RCSN for capturing

postdischarge mortality. Demographic data and clinical
variables, including vascular risk factors, medical history
of AF, and cardiac comorbidity, were recorded from clinical data. Stroke severity on admission was determined
by the CNS score: mild (CNS score 8), moderate (CNS
score 4-7), severe (CNS 4).12 We applied the iScore, a
validated risk assessment tool, to estimate prognosis and
outcomes in AIS with and without HF.2
Exposure
HF was defined as a pre-existing history of HF or pulmonary edema present at the time of arrival documented
in emergency room records/notes, history and physical
exam, and physicians admission notes. HF is one of the
main variables captured in the RCSN.

ARTICLE IN PRESS
STROKE AND HEART FAILURE: CLINICAL FEATURES, ACCESS TO CARE, AND OUTCOMES

Outcome Measures
The primary outcome was death or disability at discharge, with disability defined as a modified Rankin scale
(mRS) score equal to or greater than 3. Secondary outcomes included admission to the intensive care unit,
discharge disposition, length of hospital stay (LOS), death
at 3 months and at 1 year, and 30-day hospital
readmissions.
St. Michaels Hospital review board and RCSN Publications Committee approvals were obtained.
Statistical Analysis
We used chi-square tests to compare categorical variables. Students t-test and KruskalWallis test were used
for means and medians of continuous variables, respectively. Multivariable logistic analysis adjusting for age,
stroke severity, and comorbid conditions was used to determine the independent effect of HF on outcomes in
patients with AIS. Survival analysis was conducted using
Cox proportional hazard models. All the analyses were
conducted with the use of SAS software (version 9.3; SAS
Institute, Inc., Cary, NC). All reported P values are 2-sided.

Results
Among 12,396 eligible patients with AIS, 1124 (9.1%)
had HF. AIS with HF patients were older than AIS without
HF patients (mean age 78.6 versus 71.4 years, P < .0001),
with 53% occurring in those older than 80 years and more
likely female (53.8% versus 46.9%, P < .0001) (Table 1).
AIS with HF patients were more likely to have vascular
risk factors including hypertension (80.2% versus 67%,
P < .0001); diabetes mellitus (33.9% versus 24.7%, P < .0001);
history of cardiac disease, including coronary artery disease
(54.4% versus 20.8%, P < .0001); myocardial infarction (35.6%
versus 13.3%, P < .0001); AF (43.1% versus 14.6%, P < .0001);
valvular heart disease (12.9% versus 3.8%, P < .0001); and
prior CABG surgery (17.7% versus 9.2%, P < .0001) compared to AIS without HF patients. The most common
clinical presentation for AIS with HF was aphasia, visual
field defect, and weakness. AIS with HF patients presented with more severe stroke (25.9% versus 14.1%,
P < .0001), with the most likely stroke mechanism being
cardioembolic (42% versus 21.3%, P < .0001). There was
no difference in recombinant tissue plasminogen activator administration between AIS with HF and without HF.
AIS with HF had higher iScore usually associated with
an expected poorer outcome (Table 1).

Outcome Measures
Overall, 1324 (10.7%) AIS patients died during hospital admission. Death and disability at discharge (mRS
score 3) were significant higher in AIS with HF patients than in AIS without HF patients (70.4% versus
56%, P < .0001) (Table 2, Fig 2). Mortality rate at discharge

was higher in AIS with HF patients than in AIS without

HF patients (21.4% versus 9.6%, P < .0001) (Table 2). AIS
with HF patients had longer LOS (15.3 versus 12.6 days,
P < .0001) than AIS without HF patients. There was no
difference in the rate of admission to stroke unit or intensive care unit between AIS patients with and without
HF. AIS patients with HF were more often discharged
to a long-term care facility (18.1% versus 8.4%, P < .0001).
Only approximately one third of AIS patients with HF
were discharged home compared to nearly half for AIS
patients without HF. Moreover, AIS patients with HF
more often developed in-hospital complications including cardiac or respiratory arrest (8.4% versus 3.8%,
P < .0001), myocardial infarction (3.6% versus 2.0%,
P = .0009), and pneumonia (11.5% versus 5.5%, P < .0001)
(Table 2). After discharge, AIS patients with HF had a
higher readmission rate at 30 days (7.8% versus 6.3%,
P = .046).

Multivariable Analysis
HF (odds ratio 1.18, 95% confidence interval 1.011.37) was an independent predictor of poor outcome (mRS
score 3-6) (Table 3) and lower survival at 30 days and 3
years (Fig 3, A,B). HF was also an independent predictor of 30-day readmissions after stroke hospital discharge
(hazard ratio 1.32, 95% confidence interval 1.05-1.65). The
addition of pneumonia in the adjusted analysis did not
alter the results with the exception of the attenuation of
the effect of HF for disability at discharge (Table 3).
We also included an interaction term, pneumonia HF. The interaction term was not significant for
any of the outcomes (mRS score 2, P value for the interaction term .988; for 30-day mortality: P value for the
interaction term .0733).

Discussion
HF is a leading cause of hospital readmissions carrying high morbidity and mortality. The prevalence of HF
increases with age. Hence, HF is expected to increase with
the aging of the population. Previous studies revealed
that HF is a common comorbid condition in stroke
patients.1 However, limited information is available regarding presenting symptoms and outcomes in AIS with
HF.
In this large cohort study, HF was found in 9.1% of
12,396 AIS patients. HF among stroke patients was associated with higher disability and hospital readmissions
and lower survival. One fifth of AIS with HF died during
hospitalization. Only 50% of AIS patients with HF survived at 1 year. Thirty-day and 1-year mortality were
double in AIS patients with HF compared to AIS patients without HF. In addition, AIS patients with HF had
longer LOS and higher incidence of in-hospital
complications.

ARTICLE IN PRESS
J. PONGMORAGOT ET AL.

Table 1. Clinical characteristics of patients with and without heart failure

Characteristics
Age (years)
Mean SD
Younger than 60
60-79
80 or older
Female
Risk factors
Hypertension
Diabetes mellitus
Hyperlipidemia
Coronary artery disease
Previous MI
Atrial fibrillation or atrial flutter
Previous PCI/PTCA/CABG
Valvular heart disease
Valve replacement
Peripheral vascular disease
Asthma or (COPD)
Previous DVT/PE
Cancer
Renal dialysis
Cirrhosis
Current smoker (last 6 months)
Preadmission medication
Antiplatelet therapy
Anticoagulant therapy
Presenting stroke symptoms
Aphasia
Visual field defect
Dysarthria
Weakness
Sensory
Brainstem or cerebellar signs
Seizures
Vital signs on arrival
Mean SD (n)
Systolic BP
Diastolic BP
Stroke severity on admission
Mild
Moderate
Severe
Stroke subtype*
Lacunar
Cardioembolic
Large-artery atherosclerosis
Other
Undetermined
Laboratory on arrival
Mean SD
Hb
INR
Glucose
Creatinine
Thrombolysis therapy
rtPA intravenous
Medication at discharge
Antiplatelet
Anticoagulant for AF
ACE inhibitor
ARB
Beta blocker
Diuretic
iScore 30 days
Mean SD (n)
iScore higher than 200
iScore 365 days
Mean SD (n)
iScore higher than 200

Total (n = 12,396)
(%)

Stroke with HF
(n = 1,124) (%)

Stroke without HF
(n = 11,272) (%)

72.09 13.8
2,279 (18.4)
5,863 (47.3)
4,254 (34.3)
5,888 (47.5)

78.62 11.15
70 (6.2)
458 (40.7)
596 (53.0)
605 (53.8)

71.44 13.87
2,209 (19.6)
5,405 (48.0)
3,658 (32.5)
5,283 (46.9)

8,452 (68.2)
3,169 (25.6)
4,332 (34.9)
2,961 (23.9)
1,894 (15.3)
2,128 (17.2)
1,231 (9.9)
568 (4.6)
243 (2)
789 (6.4)
1561 (12.6)
317 (2.6)
1,215 (9.8)
107 (.9)
62 (.5)
2,424 (19.6)

901 (80.2)
381 (33.9)
451 (40.1)
612 (54.4)
400 (35.6)
485 (43.1)
199 (17.7)
145 (12.9)
52 (4.6)
155 (13.8)
289 (25.7)
48 (4.3)
128 (11.4)
23 (2.0)
14 (1.2)
124 (11.0)

7,551 (67.0)
2,788 (24.7)
3,881 (34.4)
2,349 (20.8)
1,494 (13.3)
1,643 (14.6)
1,032 (9.2)
423 (3.8)
191 (1.7)
634 (5.6)
1,272 (11.3)
269 (2.4)
1,087 (9.6)
84 (.7)
48 (.4)
2,300 (20.4)

<.0001
<.0001
.0001
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
.0001
.0607
<.0001
.0002
<.0001

5,097 (41.1)
1,387 (11.2)

546 (48.6)
318 (28.3)

4,551 (40.4)
1,069 (9.5)

<.0001
<.0001

3,938 (31.8)
1,617 (13)
4,933 (39.8)
10,041 (81)
3,583 (28.9)
2,648 (21.4)
165 (1.3)

495 (44.0)
194 (17.3)
442 (39.3)
955 (85.0)
260 (23.1)
184 (16.4)
14 (1.2)

3,443 (30.5)
1,423 (12.6)
4,491 (39.8)
9,086 (80.6)
3,323 (29.5)
2,464 (21.9)
151 (1.3)

<.0001
<.0001
.7350
.0004
<.0001
<.0001
.7930

152.3 29.07
79.99 17.7

159.01 30.03
83.5 16.88

.0000
.0000
<.0001

8,081 (65.2)
2,440 (19.7)
1,875 (15.1)

583 (51.9)
250 (22.2)
291 (25.9)

7,498 (66.5)
2,190 (19.4)
1,584 (14.1)

2,095 (16.9)
2,870 (23.2)
1,859 (15)
346 (2.8)
4,928 (39.8)

147 (13.1)
472 (42.0)
131 (11.7)
21 (1.9)
343 (30.5)

1,948 (17.3)
2,398 (21.3)
1,728 (15.3)
325 (2.9)
4,585 (40.7)

158.4 30.01
83.18 16.98

P value
<.0001

<.0001

<.0001

136.32 18.86
1.14 .53
7.68 3.37
101.77 63.4

129.83 19.5
1.3 .7
8.14 3.3
122.87 87.14

136.97 18.68
1.12 .5
7.63 3.38
99.66 60.12

<.0001
<.0001
<.0001
<.0001
.0897

1681 (13.6)

171 (15.2)

1,510 (13.4)

8,646 (69.7)
2,393 (19.3)
4,831 (39)
1,114 (9)
3,403 (27.5)
2,823 (22.8)

592 (52.7)
357 (31.8)
419 (37.3)
109 (9.7)
469 (41.7)
478 (42.5)

8,054 (71.5)
2,036 (18.1)
4,412 (39.1)
1,005 (8.9)
2,934 (26)
2,345 (20.8)

<.0001
<.0001
.2218
.3823
<.0001
<.0001

166.83 43
295 (26.2)

132.27 40.43
762 (6.8)

<.0001
<.0001

141.59 31.56
42 (3.7)

111.24 30.17
69 (.6)

<.0001
<.0001

135.4 41.86
1,057 (8.5)
113.99 31.53
111 (.9)

Abbreviations: ACE, angiotensin-converting enzyme; AF, atrial fibrillation; ARB, angiotensin II receptor blockers; BP, blood pressure; CABG, coronary artery bypass surgery; COPD,
chronic obstructive pulmonary disease; DVT, deep vein thrombosis; Hb, hemoglobin; HF, heart failure; INR, International normalized ratio; MI, myocardial infarction; PCI, percutaneous coronary intervention; PE, pulmonary embolism; PTCA, percutaneous transluminal coronary angioplasty; rtPA, recombinant tissue plasminogen activator; SD, standard deviation.
P value less than .05 significant.
*Information available: total ischemic stroke 12,098; stroke with HF 1114; stroke without HF 10,984.

ARTICLE IN PRESS
STROKE AND HEART FAILURE: CLINICAL FEATURES, ACCESS TO CARE, AND OUTCOMES

Table 2. Outcome measures

Total (n = 12,396)
(%)
Primary outcome
Death or disability at discharge (mRS score 3) 7,103 (57.3)
Secondary outcomes
Admission to
Stroke unit
5,525 (53.2)
ICU
893 (8.6)
Medical ward
2,059 (19.8)
Other ward
1,904 (18.3)
In-hospital complication (within 30 days of admission)
Recurrent stroke (within 30 days of admission)
404 (3.3)
Ischemic
283 of 404 (70)
Hemorrhage
121 of 404 (30)
Cardiac or respiratory arrest
434 (4.2)
Myocardial infarct
270 (2.2)
Atrial fibrillation (new onset)
671 (6.5)
Pneumonia
744 (6)
GI hemorrhage
164 (1.7)
Deep vein thrombosis
95 (.8)
Disposition
Acute care facility
1,088 (9.8)
Home
5,382 (48.6)
Long-term care facility
1,016 (9.2)
Rehabilitation facility
3,239 (29.3)
Other
347 (3.1)
Length of hospital stay
Mean SD
12.83 20.0
Stroke fatality
At discharge
1,324 (10.7)
30 days
1,534 (12.4)
1 year
2,820 (22.7)
30 day hospital readmission
798 (6.4)

Stroke with HF
(n = 1,124) (%)

Stroke without HF
(n = 11,272) (%)

P value

791 (70.4)

6,312 (56.0)

<.0001

482 (49.8)
97 (10.0)
215 (22.2)
173 (17.9)

5,043 (53.6)
796 (8.5)
1,844 (19.6)
1,731(18.4)

.2303

44 (3.9)
31 of 44 (70.5)
13 of 44 (29.5)
81 (8.4)
40 (3.6)
64 (6.6)
129 (11.5)
24 (2.7)
7 (.6)
107 (12.1)
322 (36.4)
160 (18.1)
247 (27.9)
48 (5.4)
15.32 24
240 (21.4)
275 (24.5)
498 (44.3)
88 (7.8)

360 (3.2)
252 of 360 (70.0)
108 of 360 (30.0)
353 (3.8)
230 (2.0)
607 (6.5)
615 (5.5)
140 (1.6)
88 (.8)

.1943
.9505
.9505
<.0001
.0009
.8291
<.0001
.0648
.5626

981 (9.6)
5,060 (49.7)
856 (8.4)
2,992 (29.4)
299 (2.9)

<.0001

12.58 20

<.0001

1,084 (9.6)
1,259 (11.2)
2,322 (20.6)
710 (6.3)

<.0001
<.0001
<.0001
.0462

Abbreviations: GI, gastrointestinal; HF, heart failure; ICU, intensive care unit; mRS, modified Rankin Scale; SD, standard deviation.
P value less than .05 significant.

In the multivariable analysis, HF was an independent

predictor of disability at discharge (mRS score 3), 30day survival, and 30-day hospital readmissions after
adjusting for age, stroke severity, and comorbid conditions. The effect of HF on disability at discharge was
attenuated when the analysis was adjusted for pneumonia, but results remained unaltered for survival and hospital
readmissions.
The prevalence of HF in our stroke cohort was comparable with previous studies (9.5%-17.7%).9,10,13,14 Mortality
was higher than reported in HF patients in the general
population (3.8%,14 8.2%7). One-year mortality in AIS patients with HF was higher than that in HF patients in
the general population (44.3% versus 30.5%-32.9%).7,15 The
predictors of in-hospital mortality in HF in the general
population include older age, low systolic blood pressure, higher respiratory rate, higher urea nitrogen level,
and low sodium level.7,15 HF patients particularly with
left ventricular systolic dysfunction have higher risk of

thrombosis and thromboembolic syndromes given that

there is stasis of blood in cardiac akinesis or dyskinesis
and systemic prothrombotic state.16 Our study found that
the most common clinical presentations for AIS with HF
were aphasia, visual field defect, and weakness, whereas
the most common stroke mechanism was cardioembolic.
Nearly half of AIS patients with HF had AF or atrial flutter.
In AIS and AF patients, anticoagulation therapy has demonstrated reduction in thromboembolic event,17 and it is
one of the most effective treatments for the prevention
of a recurrent stroke.18 In our study, only one third of
AIS patients with HF and AF were prescribed anticoagulants at discharge and one fifth in AIS patients without
HF. In contrast to HF patients with reduced left ventricular ejection fraction who were in sinus rhythm,
anticoagulation therapy did not show a reduction in the
incident risk of stroke or death compared to aspirin.19
From the health policy perspective, HF represents the
most common reason for hospitalization in patients older

ARTICLE IN PRESS
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6
mR S
1

T otal

8.5

17.2

8.8

17.7

17.0

20.7

17.5

20.8

20.7

5.2 10.7

20.8

4.9 9.6

G roup

no HF

P<0.0001
p=0.000

HF 5.1 11.9

0.0

12.6

20.0

20.7

20.2

40.0

60.0

8.1

21.4

80.0

100.0

Figure 2. Functional outcomes at discharge according to the mRS score among AIS patients with and without HF. Abbreviations: AIS, acute ischemic
stroke; HF, heart failure; mRS, modified Rankin Scale.

Table 3. Multivariable analysis: variables associated with death and disability

Death or disability at discharge

30-day survival

30-day readmission

Variable

OR (95% CI)

HR (95% CI)

HR (95% CI)

Heart failure
Age group (years)
Ref younger than 60
60-79
80 or older
Stroke severity on admission
Mild
Moderate
Severe
Comorbidities
Hypertension
Diabetes mellitus
Atrial fibrillation
Prior MI
Heart failure in model also adjusted for pneumonia

1.18 (1.01-1.37)

1.22 (1.05-1.41)

1.32 (1.05-1.65)

1.0
1.49 (1.33-1.66)
2.42 (2.15-2.74)

1.0
1.55 (1.26-1.90)
2.71 (2.22-3.31)

1.0
1.30 (1.05-1.62)
1.60 (1.28-2.00)

1.0
6.08 (5.40-6.81)
21.3 (17.4-26.1)

1.0
4.33 (3.74-5.01)
11.6 (10.2-13.3)

1.11 (1.02-1.22)
1.31 (1.19-1.44)
1.25 (1.11-1.41)

NS
NS
1.29 (1.15-1.44)
1.24 (1.09-1.41)
1.21 (1.04-1.44)

1.13 (.97-1.32)

1.0
NS
NS
1.22 (1.04-1.44)
NS
NS
NS
1.29 (1.03-1.62)

Abbreviations: CI, confidence interval; HR, hazard ratio; MI, myocardial infarction; mRS, modified Rankin Scale; NS, nonsignificant; OR,
odds ratio.
Models adjusted for age, sex, stroke severity, and comorbidities (hypertension, diabetes, smoking, atrial fibrillation, and prior MI).

ARTICLE IN PRESS
STROKE AND HEART FAILURE: CLINICAL FEATURES, ACCESS TO CARE, AND OUTCOMES

Figure 3. (A) KaplanMeier survival at 30 days in AIS. (B) KaplanMeier survival at 3 years in AIS patients with and without HF. Abbreviations:
AIS, acute ischemic stroke; HF, heart failure.

than age 65 and also carries a high readmission rate.20

The readmission rate in the general population of HF patients ranged from 19% to 31%.20 In an effort to improve
quality of care in HF patients, the American College of
Cardiology Foundation/American Heart Association Task
Force on Practice guideline3 and The Canadian Cardiovascular Society Heart Failure management guidelines were
established. 21 Evidence-based practice guidelines
(angiotensin-converting enzyme [ACE] inhibitor22,23 or angiotensin II receptor blockers, 24,25 beta blockers, 26,27
aldosterone receptor antagonists28) are recommended to
reduce morbidity and mortality unless contraindicated.
HF is considered a medical condition with potentially avoidable readmission. Previous studies of ACE
inhibitors22,23 and beta blockers26 had proved in decreasing hospitalization. Recently, the Prospective Comparison

of ARNI (Angiotensin Receptor-Neprilysin Inhibitor) with

ACEI (Angiotensin-Converting Enzyme Inhibitor) to Determine Impact on Global Mortality and Morbidity in Heart
Failure Trial (PARADIGM-HF) study showed that angiotensin receptorneprilysin inhibitor was superior to enalapril
in reducing the risk of death and of hospitalization of
HF.29 However, our study found that only approximately 40% of AIS patients with HF were prescribed ACE
inhibitors or beta blockers at discharge. Together, our results
suggest that there is an opportunity for improvement by
optimizing the treatment of stroke patients with HF prior
to discharge.
Overall considering poor prognosis of AIS and HF, only
50% of AIS with HF survived at 1 year. This should raise
attention as a major public health problem. Our study
has practical clinical and health policy implications. For

ARTICLE IN PRESS
J. PONGMORAGOT ET AL.

example, improvement awareness among clinicians is

needed. In addition, early recognition signs and symptoms of HF, collaboration with cardiology service in the
management, and adherence to HF guidelines may improve
stroke outcome. Hospital managers, program directors,
and policy makers can implement strategies for closer
out-patient follow-up for AIS patients with HF to reduce
readmissions, which may also contribute lowering healthcare costs. Further studies are necessary to evaluate these
proposed health interventions and strategies.
Some limitations in our study should be considered.
First, we have no information of HF severity or titers of
biomarkers (e.g., Trop I, B-type natriuretic peptide). Second,
scarce information was available on the specific treatment received for the management of HF during stroke
hospitalization. Third, we cannot rule out the possibility of residual confounding. Despite these limitations, our
study comprises a large sample size of AIS patients (and
over 1100 AIS patients with HF), including a wide variety
of clinical factors and comorbid conditions with near complete follow-up assessment.

Conclusions
HF is a common comorbid condition affecting stroke
patients. Stroke patients with HF had a lower survival,
longer hospitalization, higher disability, medical complications, and 30-day hospital readmissions. Our results may
help increase the awareness of the impact of HF among
stroke patients. Specific interventions (e.g., consultation
with cardiology, integrated and programmed discharge,
and close follow-up in stroke prevention clinics) targeting this high-risk group may improve access to specialized
care and counseling for better patient and family adjustment post discharge, and may improve clinical outcomes.

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