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Heart Failure Should Be Treated Rigourously in Comorbid Stroke Patients: Presented at ISC

By Kristina Rebelo

SAN DIEGO -- February 22, 2009 -- Ten percent of stroke patients have coexisting heart failure, requiring lengthier hospital stays, more intensive care, additional procedures, and overall greater cost of care compared to those stroke patients without heart failure, according to a study presented here at the International Stroke Conference (ISC) 2009.

"Of about 600,000 stroke patients in the US in 1995 and in 2005, around 10% had heart failure," noted lead author Afshin A. Divani, PhD, Stroke Center, University of Minnesota, Minneapolis, Minnesota, speaking here at a presentation on February 19. "These stroke patients with heart failure should be looked at more seriously and rigourously for treating both stroke and heart failure. Physicians have to look for heart failure in stroke patients in order to find it," he added.

Dr. Divani and colleagues estimated that the increase in total hospitalisation cost for stroke patients with heart failure was $1,100 per person in 1995 (20% difference; 95% confidence interval [CI], 18%-23%) and $1,300 per person in 2005 (18% difference; 95% CI, 16%-20%), representing a major impact on public health.

The team compared intrayear demographics, comorbidities, and procedures for stroke patients with heart failure versus those without heart failure in the years 1995 and 2005, using summary statistics (frequency distributions and means) to determine the association of coexisting heart failure with in-hospital length of stay, cost, and mortality among acute stroke patients admitted to hospitals in the United States.

The researchers also performed inter- and intrayear analyses of the outcome characteristics of stroke patients with and without heart failure.

Data were extracted from the 1995 and 2005 National Inpatient Sample database, abstracting demographic information such as age, gender, and race. Comorbidities such as ischaemic heart disease, atrial fibrillation (AF), diabetes, and hypertension were included, as was information on smoking and alcohol abuse, medical procedures (mechanical ventilation, gastrostomy, tracheostomy), discharge, and outcome variables (in-hospital mortality, hospitalisation cost, in-hospital length of stay).

"It's very common in stroke patients to come into the hospital with other comorbid conditions -- and one is heart failure, another burden to stroke patients," said coauthor Gabriela Vazquez, PhD, also from the Stroke Center, University of Minnesota.

"Having coexisting heart failure can severely impair the recovery from stroke," Dr. Divani explained. "In ischaemic stroke, you have a lack of blood flow into the brain tissue. Couple that with inability of the heart to pump blood to the brain in general, and you have a compounded problem."

Of the 632,225 stroke patients in 1995 and the 555,915 stroke patients in 2005, the percentage of those with heart failure was 10.8% in 1995 and 12.3% in 2005. The in-hospital adjusted mortality rate for stroke patients with heart failure was higher than for those without heart failure in both years (13.9% vs 5.0% [odds ratio (OR): 2.5; 95% CI, 2.4-2.7] in 1995 and 9.1% vs 4.2% [OR: 2.2; 95% CI, 2.0-2.3] in 2005; P < .01 for 1995 and 2005).

Stroke patients with heart failure required more intensive care and additional procedures -- such as tracheotomy, mechanical ventilation, and gastrostomy -- than those patients without heart failure. The stroke patients with heart failure also had lengthier hospital stays (geometric mean of 5.9 vs 4.6 days in 1995 [P < .01] and 4.4 vs 3.3 days in 2005 [P < .01]), although there was a general decline in the length of stay observed in 2005.

The precise mechanisms of higher stroke associated with increased mortality and morbidity will, according to the study, require further investigation to identify modifiable factors and to identify improved treatments for improved outcomes.

Cardiovascular factors, including AF, hypertension, ischaemic disease, and heart failure, are all known predisposing risk factors for stroke.

This study was also published in the February 2009 edition of Journal of Cardiac Failure.

[Presentation title: Nationwide Frequency and Association of Coexisting Heart Failure on Stroke Outcomes in the United States: 1995-2005. Abstract P368]

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