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Mortality Impact of Stroke and Major Bleeding across the Ejection Fraction Spectrum in Patients Hospitalized for

Jumpei Yamamoto1,2, Keijiro Nakamura3, Hiromasa Hayama4

  • 1Division of Cardiovascular Medicine, Toho University Medical Center Ohashi Hospital, Tokyo, Japan, 09106y@gmail.com.

Cardiology
|June 26, 2026
PubMed

Insights

In patients with acute heart failure and atrial fibrillation, major bleeding increased mortality risk, while stroke risk was uncertain. Bleeding risk mitigation is advised alongside stroke prevention.

Area of Science:

  • Cardiology
  • Neurology
  • Geriatrics

Background:

  • Investigating differential mortality impacts of ischemic stroke and major bleeding across left ventricular ejection fraction (LVEF) categories in acute heart failure (AHF) patients with atrial fibrillation (AF).
  • Uncertainty exists regarding how stroke and bleeding events affect mortality differently based on heart failure severity (HFrEF, HFmrEF, HFpEF).

Purpose of the Study:

  • To determine if the mortality risk associated with ischemic stroke and major bleeding varies among patients hospitalized for AHF with AF, stratified by LVEF.
  • To analyze the association between post-stroke and post-bleeding states and subsequent all-cause and cardiovascular mortality.

Main Methods:

  • Retrospective analysis of 716 patients hospitalized for AHF with AF.
  • Follow-up for up to 3 years to record stroke, major bleeding, and mortality events.
  • Time-dependent Cox models used to assess mortality associations, stratified by LVEF categories (HFrEF, HFmrEF, HFpEF).

Main Results:

  • Post-major bleeding was linked to increased all-cause mortality (HR 2.00, 95% CI 1.22-3.28).
  • The association between post-stroke status and all-cause mortality was imprecise (HR 1.35, 95% CI 0.67-2.70).
  • Neither stroke nor bleeding reached conventional statistical significance for cardiovascular death; LVEF-stratified results were imprecise.

Conclusions:

  • In AHF patients with AF, developing major bleeding increased subsequent all-cause mortality, while stroke's impact was less clear.
  • Limited event counts and non-significant interaction tests precluded definitive LVEF-stratified conclusions.
  • Mitigating bleeding risk is crucial, but should complement, not replace, ongoing stroke prevention strategies.
Abstract

Keywords:
Acute heart failureAtrial fibrillationEjection fractionMajor bleedingTime-varying exposure

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