Vascular Disease and Risk Stratification for Ischemic Stroke and All-Cause Death in Heart Failure Patients without Diagnosed Atrial Fibrillation: A Nationwide Cohort Study

Background
Stroke and mortality risk among heart failure patients previously diagnosed with different manifestations of vascular disease is poorly described. We conducted an observational study to evaluate the stroke and mortality risk among heart failure patients without diagnosed atrial fibrillation and with peripheral artery disease (PAD) or prior myocardial infarction (MI).
Methods
Population-based cohort study of patients diagnosed with incident heart failure during 2000–2012 and without atrial fibrillation, identified by record linkage between nationwide registries in Denmark. Hazard rate ratios of ischemic stroke and all-cause death after 1 year of follow-up were used to compare patients with either: a PAD diagnosis; a prior MI diagnosis; or no vascular disease.
Results
39,357 heart failure patients were included. When compared to heart failure patients with no vascular disease, PAD was associated with a higher 1-year rate of ischemic stroke (adjusted hazard rate ratio [HR]: 1.34, 95% confidence interval [CI]: 1.08–1.65) and all-cause death (adjusted HR: 1.47, 95% CI: 1.35–1.59), whereas prior MI was not (adjusted HR: 1.00, 95% CI: 0.86–1.15 and 0.94, 95% CI: 0.89–1.00, for ischemic stroke and all-cause death, respectively). When comparing patients with PAD to patients with prior MI, PAD was associated with a higher rate of both outcomes.
Conclusions
Among incident heart failure patients without diagnosed atrial fibrillation, a previous diagnosis of PAD was associated with a significantly higher rate of the ischemic stroke and all-cause death compared to patients with no vascular disease or prior MI. Prevention strategies may be particularly relevant among HF patients with PAD.

【背景】此前针对伴不同类型血管疾病病史的心力衰竭患者的卒中与死亡风险相关研究尚少。本研究开展一项观察性研究，旨在评估未确诊心房颤动、且合并外周动脉疾病（PAD）或有心肌梗死（MI）病史的心力衰竭患者的卒中与死亡风险。
【研究方法】本研究为基于人群的队列研究，研究对象为2000-2012年期间确诊为新发心力衰竭且未合并心房颤动的患者，通过丹麦全国登记系统的记录关联进行筛选。本研究以随访1年后的缺血性卒中与全因死亡的风险比为指标，对比以下三组患者：确诊PAD组、有MI病史组，以及无血管疾病组。
【研究结果】本研究共纳入39357例心力衰竭患者。与无血管疾病的心力衰竭患者相比，合并PAD的患者1年缺血性卒中发生率更高（校正后风险比[HR]：1.34，95%置信区间[CI]：1.08~1.65），全因死亡率也更高（校正后HR：1.47，95%CI：1.35~1.59）；而有MI病史的患者则无上述差异（缺血性卒中与全因死亡的校正后HR分别为1.00，95%CI：0.86~1.15和0.94，95%CI：0.89~1.00）。将PAD组与MI病史组对比后发现，PAD组的两项结局发生率均更高。
【研究结论】在未确诊心房颤动的新发心力衰竭患者中，既往确诊PAD的患者，其缺血性卒中与全因死亡发生率显著高于无血管疾病或有MI病史的患者。因此，针对合并PAD的心力衰竭患者，制定针对性的预防策略或具有重要临床价值。