Acute Decompensated Heart Failure Complicated by Ischemic Stroke and Its Association With Hemoglobin Levels

Ischemic stroke (IS) is a serious but underexplored complication of acute decompensated heart failure (ADHF). We assessed the incidence, subtypes, and phase-specific association between hemoglobin and IS risk.

The West Tokyo Heart Failure Registry-2 is a prospective multicenter cohort enrolling consecutive patients hospitalized for ADHF at 11 tertiary hospitals in Tokyo (2018-2024). Board-certified neurologists confirmed IS and classified subtypes using the TOAST criteria. IS incidence and subtypes were evaluated during the early (≤30 days) and late (>30 days) phases after hospitalization relative to hemoglobin levels (anemic/non-anemic). Among 5,106 patients (median age 79 years; 58% male; median left ventricular ejection fraction 45%), 115 (2.3%; 3.6% per person-year) developed IS during a median 13-month follow-up. IS incidence peaked in the early phase, with a median onset of 7 days (interquartile range 3-12 days; P_trend=0.002). Cardioembolic stroke (61.7%) predominated across both phases. Early-phase IS patients were younger, had less prior anticoagulant use, and had higher hemoglobin levels. In multivariable Fine-Gray models accounting for competing risk of death, non-anemia was independently associated with increased early-phase IS risk (subdistributional hazard ratio 2.04; 95% confidence interval 1.09-3.82; P=0.03), but not with late-phase IS.

IS occurred most frequently within 30 days after ADHF hospitalization, and was predominantly cardioembolic. Non-anemia identified patients at higher risk of IS in the early phase, suggesting its potential value for early risk stratification.