Nationwide Frequency and Association of Heart Failure on Stroke Outcomes in the United States

doi:10.1016/j.cardfail.2008.09.001

Journal of Cardiac Failure

Volume 15, Issue 1, February 2009, Pages 11-16

https://doi.org/10.1016/j.cardfail.2008.09.001 Get rights and content

Abstract

Background

Few studies of the effect of heart failure (HF) on stroke outcomes have been published. This study was designed to determine the association of co-existing HF with in-hospital length-of-stay (LOS), cost, and mortality among acute stroke patients admitted to hospitals in the United States (US).

Methods and Results

All patients with a primary diagnosis of stroke admitted to the US hospitals in calendar years 1995 and 2005 were extracted using the National Inpatient Sample (NIS) database. Patients were categorized based on a secondary diagnosis of HF. Patients' demographics, LOS, in-hospital death, disposition, and hospitalization costs were determined. The odds ratio of in-hospital mortality rates for stroke patients with HF were 2.5 (95% CI: 2.4–2.7) and 2.2 (95% CI: 2.0–2.3) in 1995 and 2005, respectively, compared to those without HF. Stroke patients with HF also stayed longer in the hospital in both years studied, though a general decline in LOS was observed in 2005. The estimated increase in total hospitalization cost for stroke patients with HF was $1,100 (20% difference, 95% CI: 18%–23%) and $1,300 (18% difference, 95% CI: 16%–20%) for 1995 and 2005, respectively.

Conclusions

The results of our study suggest that there is an association between co-existing HF and mortality in stroke patients. Stroke patients with HF appear to have a higher mortality rate, longer LOS, and higher hospitalization cost compared to those without HF. The mechanism of higher stroke mortality and morbidity in patients with HF requires further investigation to identify modifiable factors and to tailor better treatment options.

Section snippets

Data Source

We extracted data for the study from the 1995 and 2005 National Inpatient Sample (NIS) database. The NIS, which is maintained as part of the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Quality and Research, is the largest all-payer inpatient care database that is publicly available in the United States (US). From 1988 to 2005, NIS captured discharge-level information on primary and secondary diagnoses and procedures, discharge vital signs, and demographics on 6

Results

We identified 632,225 stroke patients in 1995 and 555,915 in 2005. The hospitalization rates for stroke patients (per 100,000) in 1995 and 2005 were 333.4 and 258.9, respectively. After age standardization to the 2005 estimated census population, the hospitalization rate increased to 348.6 for stroke patients in 1995. The percentage of stroke patients with HF was 10.8% of all stroke admissions in 1995 and 12.3% in 2005. Demographic characteristics, procedures, co-morbidities and discharge

Discussion

This study presents the first nationwide report of the association of HF with outcomes in acute ischemic stroke in the US. In our study, the in-hospital mortality rates for stroke patients with HF were 2.5 and 2.2 times higher in 1995 and 2005, respectively, compared with stroke patients without HF.

As reported by Sharma et al.⁴, pre-existing HF has the highest adverse influence on stroke mortality, and it is independent of other known factors. In the Framingham Study¹⁹, stroke patients with

Conclusions

The results of our study suggest an association exists between co-existing HF and mortality in stroke patients. Stroke patients with HF appear to have a higher mortality rate, longer LOS, and higher hospitalization cost compared with those without HF. The mechanism of the higher stroke mortality and morbidity in patients with HF requires further investigation to identify modifiable factors and to determine better treatments.

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Revascularisation therapies improve the outcomes of ischemic stroke patients with atrial fibrillation and heart failure
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Citation Excerpt :
The Elixhauser co-morbidities were included as individual co-variates. Adjusting co-variates were selected based on clinical judgement and previous literature [3,5–7]. Table 1 and Supplementary Table S2 summarise the patient characteristics on admission in brief and in full, respectively.
Atrial fibrillation (AF) and heart failure (HF) carry a poor prognosis in acute ischaemic stroke (AIS). The impact of revascularisation therapies on outcomes in these patients is not fully understood.
National Inpatient Sample (NIS) AIS admissions (January 2004–September 2015) were included (n = 4,597,428). Logistic regressions analysed the relationship between exposures (neither AF nor HF-reference, AF-only, HF-only, AF + HF) and outcomes (in-hospital mortality, length-of-stay >median and moderate-to-severe disability on discharge), stratifying by receipt of intravenous thrombolysis (IVT) or endovascular thrombectomy (ET).
69.2% patients had neither AF nor HF, 16.5% had AF-only, 7.5% had HF-only and 6.7% had AF + HF. 5.04% and 0.72% patients underwent IVT and/or ET, respectively. AF-only and HF-only were each associated with 75–85% increase in the odds of in-hospital mortality. AF + HF was associated with greater than two-fold increase in mortality. Patients with AF-only, HF-only or AF + HF undergoing IVT had better or at least similar in-hospital outcomes compared to their counterparts not undergoing IVT, except for prolonged hospitalisation. Patients undergoing ET with AF-only, HF-only or AF + HF had better (in-hospital mortality, discharge disability, all-cause bleeding) or at least similar (length-of-stay) outcomes to their counterparts not undergoing ET. Compared to AIS patients without AF, AF patients had approximately 50% and more than two-fold increases in the likelihood of receiving IVT or ET, respectively.
We confirmed the combined and individual impact of co-existing AF or HF on important patient-related outcomes. Revascularisation therapies improve these outcomes significantly in patients with these comorbidities.
Prognostic Value of NT-proBNP After Ischemic Stroke: A Systematic Review and Meta-analysis of Prospective Cohort Studies
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Background: Many studies have evaluated the relationship between N-terminal pro-brain natriuretic peptide (NT-proBNP) and its prognostic value in ischemic stroke. However, a widespread consensus has not been reached. Therefore, we completed a meta-analysis to evaluate the prognostic significance of NT-proBNP for mortality and functional outcome in patients with ischemic stroke. Methods: We performed a systematic search and review using the PubMed and EMBASE databases to identify literature that reported a correlation between NT-proBNP and mortality and functional outcome in ischemic stroke patients. Results: Eleven studies inclusive of 10,498 patients met the inclusion criteria. Elevated plasma NT-proBNP levels were associated with increased risk of mortality in ischemic stroke patients (all-cause mortality: odds ratio [OR] = 2.43, 95% confidence interval [CI] 1.62-3.64, P < .001, I²=74.3%; cardiovascular mortality: OR = 2.01, 95% CI 1.55-2.61, P < .001, I² = 42.6%). In addition, unfavorable functional outcomes were observed in patients with higher levels of NT-proBNP (OR = 1.68, 95% CI 1.13-2.50, P = .01, I² = 90.8%) after ischemic stroke. Conclusions: This meta-analysis demonstrates that NT-proBNP could be a predictor of mortality and functional outcome in ischemic stroke patients.
Impact of Multiple Chronic Conditions in Patients Hospitalized with Stroke and Transient Ischemic Attack
2017, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
However, in the most published literature, the follow-up was longer and the focus was on rates of stroke or TIA recurrence and death at multiple time points. In our study population, CAD (the fourth most common CC) and cancer (the sixth most common CC) were associated with increased risk of both readmission and death at 30 days after index hospitalization; these findings are in agreement with a number of published studies.27,46-54 Previously published data showed that active cancer, regardless of type, was associated with increased risk of acute stroke and subsequent stroke-related morbidity.55,56
The prevalence and clinical impact of chronic conditions (CCs) have increasingly been recognized as an important public health concern. We evaluated the prevalence of coexisting CCs and their association with 30-day mortality and readmission in hospitalized patients with stroke and transient ischemic attack (TIA).
In a retrospective study of patients aged ≥18 years hospitalized for first-ever stroke and TIA, we assessed the prevalence of coexisting CCs and their predictive value for subsequent 30-day mortality and readmission.
Study cohort comprised 6771 patients, hospitalized for stroke (n = 4068) and TIA (n = 2703), 51.4% men, with mean age of 68.2 years (standard deviation: ±15.6), mean number of CCs of 2.9 (±1.7), 30-day mortality rate of 8.6% (entire cohort), and 30-day readmission rate of 9.7% (in 2498 patients limited to Olmsted and surrounding counties). In multivariable models, significant predictors of (1) 30-day mortality were coexisting heart failure (HF) (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.09-1.92), cardiac arrhythmia (OR: 1.74, 95% CI: 1.40-2.17), coronary artery disease (CAD) (OR: 1.64, 95% CI: 1.29-2.08), cancer (OR: 1.67, 95% CI: 1.31-2.14), and diabetes (HR: 1.28, 95% CI: 1.01-1.62); and (2) 30-day readmission (n = 2498) were CAD (OR: 1.50, 95% CI: 1.09-2.07), cancer (OR: 1.46, 95% CI: 1.01-2.10), and arthritis (OR: 1.62, 95% CI: 1.09-2.40).
In patients hospitalized with stroke and TIA, CCs are highly prevalent and influence 30-day mortality and readmission. Optimal therapeutic and lifestyle interventions for CAD, HF, cardiac arrhythmia, cancer, diabetes, and arthritis may improve early clinical outcome.
Association between Left Ventricular Dysfunction and Functional Outcomes at Three Months in Acute Ischemic Stroke
2016, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Another study found that poor outcome was related to initial stroke severity, HF without LVD, HF with LVD (EF < 50%), statin treatment, and thrombolysis treatment.15 Previous reports explain the higher functional disability rate in LVD patients due to these initial factors.5,19 Although our study showed same results, the differences of functional disability on 3 months among each group were larger than those on discharge (Fig 1).
Left ventricular dysfunction (LVD) was associated with stroke occurrence and mortality. However, few studies have published the impact of LVD on functional stroke outcomes in the acute stroke period.
We enrolled 1554 patients who were admitted to Dong-A University Hospital between January 2011 and November 2014. To determine the functional outcomes, the modified Rankin Scale (mRS) score at 3 months after stroke was used. The severity of LVD was defined depending on ejection fraction (EF): (1) severe (EF ≤ 40%); (2) mild (40% < EF < 55%); and (3) normal (EF ≥ 55%). EF was measured using transthoracic two-dimensional echocardiography. The distribution of mRS scores at 3 months after stroke was presented using LVD. Multivariable analysis was performed to predict poor functional outcomes.
Of the 1554 patients, 1417 had normal LV function, 87 had mild LVD, and 50 had severe LVD. Patients with LVD were older and had a high incidence of diabetes mellitus, atrial fibrillation, coronary artery disease, and severe stroke symptoms. With respect to treatment, patients with LVD received more thrombolysis and more anticoagulation medication after stroke. Strokerelated disability at discharge and at 3 months was significantly associated with LVD. In the multivariable analyses, old age, diabetes mellitus, high initial National Institutes of Health Stroke Scale score, stroke mechanism, and LVD were independent predictors of poor functional outcomes at 3 months.
LVD is associated with poor functional outcomes after acute ischemic stroke.
Stroke and Heart Failure: Clinical Features, Access to Care, and Outcomes
2016, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
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.
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.
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.
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] 1.01-1.37), 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 when adjusting for pneumonia with the exception of death or disability at discharge.
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.
Heart failure and the risk of ischemic stroke recurrence: A systematic review and meta-analysis
2016, Journal of the Neurological Sciences
Heart failure (HF) is known to be a major risk factor for first-ever ischemic stroke (IS), and is associated with greater stroke severity and higher rates of early mortality and residual disability. There are limited data regarding the association of HF with stroke recurrence. We sought to evaluate the relationship between HF and recurrent IS using a comprehensive meta-analytical approach. We performed a systematic literature review according to PRISMA guidelines to identify all prospective study protocols (randomized clinical trials or observational cohorts) that reported rates of IS recurrence in patients with concomitant HF. We pooled independently the reported corresponding risk ratios (RRs) and hazard ratios (HRs) from each study protocol using the random effects model. Heterogeneity across included studies was evaluated using Cochran Q and I² statistics. Our literature search identified 7 eligible studies including 9173 IS patients (18.2% with HF). The reported mean follow-up period in the included studies ranged from 7 days to 5 years. The pooled estimate of RRs and HRs for recurrent IS was 1.96 (95% CI: 1.49–2.60; p < 0.0001) and 1.93 (95% CI: 1.47–2.53; p < 0.0001). We found no evidence of heterogeneity within studies in both the RR (I² = 13.5%, p for Cochran Q statistic: 0.325) and HR (I² = 0%, p for Cochran Q statistic: 0.629) analyses. HF is associated with a continuous two-fold increase in the risk of IS recurrence in patients with prior history of cerebral ischemia. The benefit of anticoagulation in this high-risk group of patients may be studied along with additional risk factor modifications.

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Clinical InvestigationsNationwide Frequency and Association of Heart Failure on Stroke Outcomes in the United States

Abstract

Background

Methods and Results

Conclusions

Section snippets

Data Source

Results

Discussion

Conclusions

Lancet Neurol

J Stroke Cerebrovasc Dis

Am J Med

Risk factors for short-term mortality in older subjects with acute ischemic stroke

Gerontology

Long-term prognosis after a minor stroke: 10-year mortality and major stroke recurrence rates in a hospital-based cohort

Stroke

Manifestations of coronary disease predisposing to stroke. The Framingham Study

JAMA

Cardiovascular disease and outcome of acute stroke: Influence of pre-existing cardiac failure

Eur J Heart Fail

Outcome of congestive heart failure in elderly persons: Influence of left ventricular systolic function. The Cardiovascular Health Study

Ann Intern Med

Predicting survival for 1 year among different subtypes of stroke. Results from the Perth Community Stroke Study

Stroke

Relationship of cardiac disease to stroke occurrence, recurrence, and mortality

Stroke

Prognosis after stroke in diabetic patients. A controlled prospective study

Diabetologia

Prognosis for survival after an initial stroke

Stroke

Changes in cost and outcome among US patients with stroke hospitalized in 1990 to 1991 and those hospitalized in 2000 to 2001

Stroke

Disparities in outcomes among patients with stroke associated with insurance status

Stroke

Factors underlying racial disparities in hospital care of congestive heart failure

Ethn Dis

Intra-arterial thrombolysis for central retinal artery occlusion in United States: Nationwide in-patient survey 2001–2003

J Neuroimaging

Clinical Investigations
Nationwide Frequency and Association of Heart Failure on Stroke Outcomes in the United States