Clinical Heart Failure Patients with Ischemic Stroke Have a High Incidence (>60%) of Atrial Fibrillation or Flutter Whether Systolic Function Is Preserved or Depressed


Clinical congestive heart failure (CHF) is a major risk factor for strokes. Patients with CHF commonly have atrial fibrillation or flutter (AF), which is frequently associated with, may be a marker for, and may be the mechanism of, ischemic strokes. To determine whether stroke patients with CHF have a high incidence of AF (that may be intermittent and not diagnosed), we reviewed all the 12 lead ECGs in a fourteen year institutional ECG data base and the clinical records and the available echocardiograms of 985 patients who had an ischemic stroke over a 3-year period. We found that 31.3% of the stroke patients had evidence of AF. Clinical congestive heart failure was present in 168 stroke patients; 61.9% of these stroke patients with CHF had evidence of AF. In the total stroke population, patients with other risk factors for stroke (hypertension, advanced age, diabetes, coronary artery disease) had an increased incidence of AF; but among stroke patients with CHF, only advanced age (≥75 years) in addition to CHF increased the incidence of AF. To determine whether only the CHF stroke pts with systolic dysfunction had a high incidence of AF, we compared the incidence of AF in the 41.5% of the CHF patients with a depressed ejection fraction with the AF incidence in the 58.5% of CHF stroke patients with a normal ejection fraction (≥50%). The incidence of AF was the same (63.4% vs. 60.2%, p = 0.741) whether the ejection fraction was depressed or normal. These findings suggest that AF is common in patients with CHF who have strokes whether the ejection fraction is normal or depressed. CHF patients who have strokes and who are in sinus rhythm should be meticulously investigated for intermittent AF, so anticoagulation can be administered to prevent a further stroke.

Share and Cite:

Haft, J. and Teichholz, L. (2014) Clinical Heart Failure Patients with Ischemic Stroke Have a High Incidence (>60%) of Atrial Fibrillation or Flutter Whether Systolic Function Is Preserved or Depressed. World Journal of Cardiovascular Diseases, 4, 455-464. doi: 10.4236/wjcd.2014.49055.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Appelros, P. (2006) Heart Failure and Stroke. Stroke, 37, 1637.
[2] Witt, B.J., Brown, R.D., Jacobsen, S.J., Weston, S.A., Ballman, K.V., Meverden, R.A. and Roger, V.L. (2006) Ischemic Stroke after Heart Failure: A Community-Based Study. American Heart Journal, 152, 102-109.
[3] Alberts, V.P., Bos, M.J., Koudstaal, P.J., Hofman, A., Witteman, J.C.M., Stricker, B.H.C. and Breteler, M.M.B. (2010) Heart Failure and the Risk of Stroke: The Rotterdam Study. European Journal of Epidemiology, 25, 807-812.
[4] Roger, V.L., Go, A.S., Lloyd-Jones, D.M., Benjamin, E.J., Berry, J.D., Borden, W.B., et al. on Behalf of AHA Statistics Committee and Stroke Statistics Subcommittee (2012) Heart Disease and Stroke Statistics—2012 Update: A Report from the American Heart Association. Circulation, 125, e2-e220.
[5] Lip, G.Y.H. and Gibbs, C.R. (1999) Does Heart Failure Confer a HypercoagulableState? Virchows Triad Revisited. Journal of the American College of Cardiology, 33, 1424-1426.
[6] Fuster, V., Ryden, L.E., Cannom, D.S., Crijns, H.J., Curtis, A.B., Ellenbogen, K.A., et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation): Developed in Collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation, 114, e257-e354.
[7] Stroke Risk in Atrial Fibrillation Working Group (2008) Comparison of 12 Risk Stratification Schemes to Predict Stroke in Patients with Nonvalvular Atrial Fibrillation. Stroke, 39, 1901-1910.
[8] Hart, R.G.G., Benavente, O., McBride, R. and Pearce, L.A. (1999) Antithrombotic Therapy to Prevent Stroke in Patients with Atrial Fibrillation: A Meta-Analysis. Annals of Internal Medicine, 131, 492-501.
[9] Hohnloser, S.H., Pajitnev, D., Pogue, J., Healey, J.S., Pfeffer, M.A., Yusuf, S., et al. (2007) Incidence of Stroke in Paroxysmal versus Sustained Atrial Fibrillation in Pts taking Oral Anticoagulation or Combined Antiplatelet Therapy: An Active W Substudy. Journal of the American College of Cardiology, 50, 2156-2161.
[10] Singer, D.E., Albers, G.W., Dalen, J.E., Go, A.S., Halperin, J.L., Manning, W.J., et al. (2008) Antithrombotic Therapy in Atrial Fibrillation: American College of Chest Physicians Evidence Based Practice Guidelines (8th Edition). Chest, 133, 546S-592S.
[11] Haft, J.I. and Teichholz, L.E. (2012) Atrial Fibrillation/Flutter Is Found in over 60% of Heart Failure Patients Who Have Strokes. Journal of Cardiac Failure, 18, S97.
[12] Haft, J.I. and Teichholz, L.E. (2012) Atrial Fibrillation or Flutter Is the Common Mechanism Whereby the Stroke Risk Factors Cause Stroke. Chest, 142, A110a.
[13] Haft, J.I. and Teichholz, L.E. (2012) Atrial Fibrillation or Flutter Is Found in 45.4% of Elderly Patients with Nonhemorrhagic Stroke. Stroke, 43, A2349.
[14] Wolf, P.A., Dawber, T.R., Thomas, H.E. and Kannel, W.B. (1978) Epidemiologic Assessment of Chronic Atrial Fibrillation and Risk of Stroke: The Framingham Study. Neurology, 28, 973-977.
[15] Pisters, R., Lane, D.A., Marin, F., Camm, A.J. and Lip, G.Y.H. (2012) Stroke and Thromboembolism in Atrial Fibrillation-Systematic Review of Stroke Risk Factors and Risk Stratification Schema. Circulation Journal, 76, 2789-2304.
[16] Lip, G.Y.H. (2012) Can We Predict Sstroke in Atrial Fibrillation? Clinical Cardiology, 35, S21-S27.
[17] Hart, R.G., Pearce, L.A., Rothbart, R.M., McAnulty, J.H., Asinger, R.W. and Halperin, J.L. (2000) Stroke with Intermittent Atrial Fibrillation: Incidence and Predictors during Aspirin Therapy. Journal of the American College of Cardiology, 35, 183-187.
[18] Liao, J., Zahira, K., Scallan, C., Morillo, C. and O’Donnell, M. (2007) Noninvasive Cardiac Monitoring for Detecting Paroxysmal Atrial Fibrillation or Flutter after Acute Ischemic Stroke. A Systematic Review. Stroke, 38, 2935-2940.
[19] Gage, B.F., van Walraven, C., Pearce, L., Hart, R.G., Koudstaal, P.J., Boode, B.S.P. and Petersen, P. (2004) Selecting Patients with Atrial Fibrillation for Anticoagulation. Stroke Risk Stratification in Patients Taking Aspirin. Circulation, 110, 2287-2292.
[20] Haft, J.I. (2013) Stroke Prevention in Atrial Fibrillation: Impact of Novel Anticoagulants. Clinical and Applied Thrombosis/Hemostasis, 19, 241-248.
[21] Tayal, A.H., Tian, M., Kelly, K.M., Jones, S.C., Wright, D.G., Singh, D., Jarouse, J., Brillman, J., Murali, S. and Gupta, R. (2008) Atrial Fibrillation Detected by Mobile Cardiac Outpatient Telemetry in Cryptogenic TIA or Stroke. Neurology, 71, 1696-1701.
[22] Elijovich, L., Josephson, S.A., Fung, G.L. and Smith, W.S. (2009) Intermittent Atrial Fibrillation May Account for a Large Proportion of Otherwise Cryptogenic Strokes: A Study of 30-Day Cardiac Event Monitors. Journal of Stroke & Cerebrovascular Diseases, 18, 185-189.
[23] Gladstone, D.J., Blakeley, J., Dorian, P., Fang, J., Silver, F.L. and Kapral, M.K. (2008) Detecting Paroxysmal Atrial Fibrillation after Ischemic Stroke and Transient Ischemic Attack: If You Don’t Look, You Won’t Find. Stroke, 39, e78- e79.
[24] Ziegler, P.D., Glotzer, T.V., Daoud, E.G., Wyse, D.G., Esekowitz, M.D., Koehler, J.L. and Hilker, C.E. (2010) Incidence of Newly Detected Atrial Arrhythmia via Implantable Devices in Patients with a History of Thromboembolic Events. Stroke, 41, 256-260.
[25] Haft, J.I. (2012) The Importance of Atrial Fibrillation/Flutter as a Cause of Ischemic Stroke. International Journal of Cardiology, 158, 143-144.
[26] Wolf, P.A., Abbott, R.D. and Kannel, W.B. (1991) Atrial Fibrillation as an Independent Risk Factor for Stroke: The Framingham Study. Stroke, 22, 983-988.
[27] Haft, J.I. and Teichholz, L.E. (2008) Echocardiographic and Clinical Risk Factors for Atrial Fibrillation in Hypertensive Patients with Ischemic Stroke. American Journal of Cardiology, 102, 1348-1351.
[28] Homma, S., Thompson, J.L., Pullicino, P.M., Levin, B., Freudenberger, R.S., Teerlink, J.R., Ammon, S.E., Graham, S., et al. (2012) Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm. The New England Journal of Medicine, 366, 1859-1869.

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.