Jones Nicholas R, Smith Margaret, Lay-Flurrie Sarah, Yang Yaling, Hobbs Richard, Taylor Clare J
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford; NIHR Oxford Biomedical Research Centre, Oxford.
Br J Gen Pract. 2025 Mar 27;75(753):e258-e265. doi: 10.3399/BJGP.2024.0470. Print 2025 Apr.
Heart failure (HF) is a risk factor for stroke among people with atrial fibrillation (AF). Prognosis following an HF diagnosis is often poor, but this is not accounted for in existing stroke risk scores.
To examine stroke incidence in people with HF and AF compared with AF alone, considering the competing risk of death.
A population-based retrospective cohort study in English primary care, linked to secondary care Hospital Episode Statistics data.
In total, 2 381 941 people aged ≥45 years were identified in the Clinical Practice Research Datalink from 2000 to 2018. HF and AF were included as time-varying covariates; 69 575 had HF and AF, 141 562 had AF alone, and 91 852 had HF alone. Hazard ratios (HRs) for first stroke are reported using the Cox model and the Fine-Gray model.
Over median follow-up of 6.62 years, 93 665 people (3.9%) had a first stroke and 314 042 (13.2%) died. Over half (51.3%) of those with HF, with or without AF, died. In the fully adjusted Cox model, relative stroke risk was highest among people with AF alone (HR 2.43, 95% confidence interval [CI] = 2.38 to 2.48), followed by HF and AF (HR 2.20, 95% CI = 2.14 to 2.26). The cumulative incidence function of stroke was also highest among those with AF only once accounting for the competing risk of all-cause mortality. In a Fine-Gray model, the relative risk of stroke was similar for people with AF alone (HR 2.38, 95% CI = 2.33 to 2.43), but there was significant attenuation among those with HF and AF (HR 1.48, 95% CI = 1.44 to 1.53).
HF is an aetiological risk factor for stroke, yet its prognostic significance is reduced by the high incidence of death. Use of the CHADS-VASc score may overestimate stroke incidence in some people with HF, particularly those with a poor prognosis.
心力衰竭（HF）是心房颤动（AF）患者发生中风的危险因素。HF诊断后的预后通常较差，但现有中风风险评分未考虑这一点。
在考虑死亡竞争风险的情况下，比较HF合并AF患者与单纯AF患者的中风发病率。
一项基于人群的回顾性队列研究，数据来源于英国初级医疗，并与二级医疗的医院事件统计数据相关联。
2000年至2018年期间，在临床实践研究数据链中总共识别出2381941名年龄≥45岁的人。HF和AF被视为随时间变化的协变量；69575人患有HF和AF，141562人仅患有AF，91852人仅患有HF。使用Cox模型和Fine-Gray模型报告首次中风的风险比（HRs）。
在中位随访6.62年期间，93665人（3.9%）发生了首次中风，314042人（13.2%）死亡。无论有无AF，超过一半（51.3%）的HF患者死亡。在完全调整的Cox模型中，单纯AF患者的相对中风风险最高（HR 2.43，95%置信区间[CI]=2.38至2.48），其次是HF合并AF患者（HR 2.20，95%CI=2.14至2.26）。仅考虑全因死亡率的竞争风险时，中风的累积发病率函数在仅患有AF的患者中也最高。在Fine-Gray模型中，单纯AF患者的中风相对风险相似（HR 2.38，95%CI=2.33至2.43），但HF合并AF患者的风险显著降低（HR 1.48，95%CI=1.44至1.53）。
HF是中风的病因性危险因素，但其预后意义因高死亡率而降低。CHADS-VASc评分的使用可能会高估一些HF患者的中风发病率，尤其是那些预后较差的患者。
