Low Ef And Stroke Risk: What's The Connection?

Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. A reduced ejection fraction (EF) is a known risk factor for ischemic stroke and systemic embolism in patients with heart failure, even in the absence of atrial fibrillation. The risk of stroke increases with decreasing EF, and the risk of mortality increases with the clinical severity of cardiac failure. People with improved or recovered ejection fractions tend to have fewer hospitalizations and better overall results.

The risk of stroke increases with decreasing ejection fraction

Overview

Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder impairing the ventricle's ability to fill with or eject blood. The risk of stroke in patients with HF has been linked to the coexistence of vascular risk factors, ejection fraction (EF), and left ventricle geometry. The risk of stroke increases with decreasing EF, and the risk of mortality increases with the clinical severity of cardiac failure.

Ejection Fraction and Stroke Risk

A reduced EF, independent of severity, is associated with a higher risk of stroke. The stroke mechanism in HF may be embolism, cerebral hypoperfusion, or both. Patients with HF have a higher incidence of strokes, with the rate increasing with the length of follow-up.

Clinical Outcomes

Studies have shown that patients with HF and a history of stroke had a higher risk of cardiovascular (CV) death, all-cause death, and stroke compared to patients without a history of stroke. This finding was true for patients with both heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF).

Treatment and Prevention

The use of anticoagulation and statins appeared underutilized in patients with HF and a history of stroke. Anticoagulation is recommended for patients with HF due to atrial fibrillation (AF), acute myocardial infarction (MI) with left ventricular thrombus, rheumatic mitral valve disease, or prosthetic heart valves.

Heart failure is a risk factor for stroke

Heart failure is a major cause of death worldwide and is a growing public health issue. It is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Heart failure and ischemic stroke share similar risk factors, and heart failure is associated with a higher risk of ischemic stroke.

In patients with heart failure, stroke is more severe and is associated with a higher rate of recurrence, dependency, and short- and long-term mortality. Cardiac morbidity and mortality are also high in these patients.

Anticoagulants may reduce stroke risk in patients with heart failure

Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Heart failure is a growing health problem due in part to population aging. Heart failure and stroke share similar risk factors, and heart failure is associated with a higher risk of ischemic stroke, especially in patients with low ejection fraction.

The risk of stroke in patients with heart failure has been related to the coexistence of vascular risk factors, the ejection fraction, and left ventricle geometry. While hypertension is the strongest risk factor for stroke, epidemiological studies have found an increased risk of stroke associated with other risk factors, including cardiovascular abnormalities such as coronary artery disease, heart failure, and atrial fibrillation.

Persons with heart failure have a higher incidence of stroke, and the stroke rate increases with the length of follow-up. Reduced ejection fraction, independent of severity, is associated with a higher risk of stroke. Anticoagulant therapy is mandatory, although the choice of a platelet inhibitor or anticoagulant drug depends on the cardiac disease. Trials are ongoing to evaluate anticoagulant therapy for the prevention of embolism in patients with low ejection fraction who are at sinus rhythm.

The new oral anticoagulants, including dabigatran etexilate, rivaroxaban, apixaban, and edoxaban, have been approved to reduce the risk of stroke in patients with nonvalvular atrial fibrillation, and others are in development. These newer agents may address some of the complexities of warfarin use while providing similar or better efficacy and safety.

In patients with non-ischemic dilated cardiomyopathy, the rate of stroke appears similar to that in patients with cardiomyopathy due to coronary artery disease. Again, there is high variability across studies, and most of the studies included small series of patients.

Several studies have assessed the specific risks of left ventricular hypertrophy and left ventricle geometry in the development of ischemic stroke. In a case-control study from the multiethnic cohort, left ventricular hypertrophy was associated with a 2.5-fold increase in stroke risk after adjustment for other stroke risk factors across all the racial and ethnic subgroups. Concentric hypertrophy carried the greatest stroke risk, followed by eccentric hypertrophy and concentric remodeling.

The influence of the lower left ventricular ejection fraction on the clinical outcome of ischemic stroke patients has a worsening of the neurological deficit outcome by considering the combination of several independent variables, including diabetes mellitus and low high-density lipoprotein.

In summary, there is still no indicator of how to optimize anti-thrombotic treatment in the case of a young heart failure patient with a reduced ejection fraction in sinus rhythm without co-existing vascular disease. Choice of treatment is still individual and off-label, and guidelines recommend not using any anti-thrombotic treatment.

Heart failure patients with sinus rhythm have a high risk of stroke

Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Heart failure patients with sinus rhythm have a high risk of stroke.

Heart failure and stroke share similar risk factors, and heart failure is a risk factor for stroke. Heart failure patients have a higher incidence of stroke, with the rate increasing with the length of follow-up. The stroke rate in heart failure patients varies from 1.7% to 10.4% per year across various cohort studies. The stroke mechanism in heart failure may be embolism, cerebral hypoperfusion, or both.

Several factors increase the risk of stroke in heart failure patients with sinus rhythm. These include older age, hypertension, diabetes, and cardiomegaly. In addition, non-white race has been associated with a higher risk of neurological deficits and death in heart failure patients with stroke.

Low ejection fraction is also a risk factor for stroke in heart failure patients. A reduced ejection fraction, independent of severity, is associated with a higher risk of stroke. Patients with heart failure and a reduced ejection fraction have a higher risk of stroke, with the risk increasing as the ejection fraction decreases.

The presence of atrial fibrillation further increases the risk of stroke in heart failure patients with sinus rhythm. Atrial fibrillation is common in heart failure patients and is associated with a higher risk of thromboembolic events, including stroke.

The risk of stroke in heart failure patients with sinus rhythm can be assessed using various tools, such as the National Institutes of Health Stroke Scale (NIHSS) and the left ventricular ejection fraction. The NIHSS is a quantitative measure used to assess the degree of stroke disability, while the left ventricular ejection fraction provides objective documentation of left ventricular dysfunction.

The treatment and prevention of stroke in heart failure patients with sinus rhythm is important. While oral anticoagulation is recommended for stroke prevention in patients with atrial fibrillation, the benefits of this therapy in heart failure patients with sinus rhythm are uncertain. However, recent studies have suggested that low-dose direct-acting oral anticoagulants may reduce the risk of thromboembolic events, including stroke, in this population.

Lifestyle changes can improve ejection fraction

Consult a doctor

Consult a doctor, whether it be a cardiologist or your primary care physician, to discuss your symptoms and treatment options. Doctors have many ways to help manage heart failure, from medications to implantable cardioverter defibrillators.

Identify and treat underlying causes

Identify and treat the underlying causes of low ejection fraction. For example, if hypothyroidism is part of the puzzle, doctors can work on managing your thyroid levels. Similarly, your blood pressure or diabetes may need attention, as well as other modifiable conditions.

Exercise

Exercise, in particular aerobic exercises, can help your heart meet your body’s demands. It is a classic case of doing more with less. Talk to your doctor about joining a cardiac rehabilitation program or about where to start if you want to do it on your own.

Lose weight

Although losing weight won't necessarily improve ejection fraction, it can make you feel better. Tracking your weight will also help you and your doctor determine whether fluid is being built up due to abnormal heart function.

Reduce sodium intake

Consuming too much sodium, or salt, can cause a domino effect of issues, including the retention of sodium and fluid in the body, which further impairs heart function. The excess fluid can go to the lungs, legs, liver, and abdomen, causing typical heart failure symptoms such as shortness of breath, fatigue, and swelling.

Eliminate harmful substances

Eliminate harmful substances such as alcohol, cocaine, amphetamines, and cigarettes. These vices can tank your ejection fraction and worsen your symptoms.

Reduce stress

Stress can raise your heart rate and blood pressure, which are heart failure no-nos. Reducing stress can help improve your heart condition and make you feel better.

Frequently asked questions