Heart failure and the risk of ischemic stroke recurrence: A systematic review and meta-analysis

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.