LOW INCIDENCE OF STROKE IN AMBULATORY PATIENTS WITH HEART-FAILURE - A PROSPECTIVE-STUDY

The current study was undertaken to determine prospectively the risk of cerebral thromboembolism and the prognostic significance of left ventricular thrombus in ambulatory patients with chronic congestive heart failure. A total of 264 ambulatory patients (mean age 62 years, mean left ventricular ejection fraction 27%) were followed prospectively for 24 +/- 9 months to determine the incidence of nonhemorrhagic stroke, transient ischemic attack, and mortality. Two-dimensional echocardiographic studies, performed for clinical indications other than previous systemic thromboembolism in 109 patients, were analyzed to relate the presence of left ventricular thrombus to subsequent outcome. Nine cerebral thromboembolic events occurred in 264 patients during the two-year mean follow-up period, yielding a rate of 1.7 thromboembolic events per 100 patient-years of follow-up. Known risk factors for stroke (hypertension, diabetes mellitus, and/or atrial fibrillation) were present in all nine patients with cerebral thromboembolic events. The 109 patients with echocardiographic studies had more severe heart failure than patients without echocardiographic studies (functional class 2.6 vs 2.1, p < 0.01), greater risk of a thromboembolic event (2.4 vs 1.4 events/100 patient-years of follow-up, p < 0.01), and higher mortality (21.3 vs 5.5 deaths/100 patient-years, p < 0.01). Left ventricular thrombus, detected in 54 (50%) of these patients, was associated with a greater risk of thromboembolism in a univariate model (p = 0.03) and was an independent predictor of mortality in a Cox analysis (relative risk 2.2, p = 0.03). Thromboembolic stroke and transient ischemic attack occurred infrequently in ambulatory patients with heart failure during a 2-year follow-up period. In selected patients with echocardiographic studies, left ventricular thrombus was associated with increased mortality. A controlled trial of oral anticoagulation therapy is warranted.