Open Access Research

Clinical characteristics, precipitating

factors, management and outcome of
patients with prior stroke hospitalised
with heart failure: an observational
report from the Middle East
Hadi A R Khafaji,1 Kadhim Sulaiman,2 Rajvir Singh,3 Khalid F AlHabib,4
Nidal Asaad,5 Alawi Alsheikh-Ali,6 Mohammed Al-Jarallah,7 Bassam Bulbanat,7
Wael AlMahmeed,5 Mustafa Ridha,8 Nooshin Bazargani,9 Haitham Amin,10
Ahmed Al-Motarreb,11 Hussam AlFaleh,4 Abdelfatah Elasfar,12,13
Prashanth Panduranga,2 Jassim Al Suwaidi3,14

To cite: Khafaji HAR, ABSTRACT

Sulaiman K, Singh R, et al. Strengths and limitations of this study
Objectives: The purpose of this study is to report the
Clinical characteristics,
prevalence, clinical characteristics, precipitating factors, ▪ This is the first multicentre multinational study in
precipitating factors,
management and outcome of patients with prior stroke the Middle East to provide a report on the preva-
management and outcome of
patients with prior stroke hospitalised with acute heart failure (HF). lence, demographics, management and 1-year
hospitalised with heart Design: Retrospective analysis of prospectively collected outcome of patients hospitalised with HF in
failure: an observational data. relation to a history of stroke that included a rela-
report from the Middle East. Setting: Data were derived from Gulf CARE (Gulf aCute tively large number of patients.
BMJ Open 2015;5:e007148. heArt failuRe rEgistry), a prospective multicentre study of ▪ As an observational study, the possibility for
doi:10.1136/bmjopen-2014- consecutive patients hospitalised with acute HF in 2012 in unmeasured confounding biases exists. The
007148
seven Middle Eastern countries and analysed according to current study has not recorded the cognitive status
the presence or absence of prior stroke; demographics, and the disability status in patients with stroke,
▸ Prepublication for this management and outcomes were compared. which have a major impact on morbidity.
paper is available online. To Participants: A total of 5005 patients with HF. ▪ Furthermore, no information is available regard-
view these files please visit ing the cause of stroke (embolic vs thrombotic),
the journal online
Outcome measures: In-hospital and 1-year outcome.
Results: The prevalence of prior stroke in patients with and future studies need to overcome these
(http://dx.doi.org/10.1136/
bmjopen-2014-007148). HF was 8.1%. Patients with stroke with HF were more limitations.
likely to be admitted under the care of internists rather ▪ Mortality rates at follow-up were only recorded at
Received 10 November 2014 than cardiologists. When compared with patients 1 year without the specification of the exact date
Revised 20 February 2015 without stroke, patients with stroke were more likely to of death of each patient.
Accepted 1 March 2015 be older and to have diabetes mellitus, hypertension,
atrial fibrillation, hyperlipidaemia, chronic kidney
disease, ischaemic heart disease, peripheral arterial Trial registration number: NCT01467973.
disease and left ventricular dysfunction (p=0.001 for
all). Patients with stroke were less likely to be smokers
(0.003). There were no significant differences in terms
of precipitating risk factors for HF hospitalisation INTRODUCTION
between the two groups. Patients with stroke with HF The prevalence and incidence of stroke in
had a longer hospital stay (mean±SD days; 11±14 vs 9 patients with heart failure (HF) and the tem-
±13, p=0.03), higher risk of recurrent strokes and 1-year poral relation of these two diseases in terms of
mortality rates (32.7% vs 23.2%, p=0.001). Multivariate
increasing morbidity and mortality have
logistic regression analysis showed that stroke is an
independent predictor of in-hospital and 1-year
scarcely been reported from around the world
mortality. and never from the Middle East. HF is one
For numbered affiliations see Conclusions: This observational study reports high of the leading causes of hospitalisation, and is a
end of article. prevalence of prior stroke in patients hospitalised with significant factor for morbidity and mortality
HF. Internists rather than cardiologists were the worldwide. Moreover, HF is a major risk factor
Correspondence to predominant caregivers in this high-risk group. Patients for the development of ischaemic stroke with a
Dr Jassim Al Suwaidi; with stroke had higher risk of in-hospital recurrent 2–3-fold increased risk of stroke when com-
jalsuwaidi@hotmail.com strokes and long-term mortality rates. pared with patients without HF.1 Factors that

Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148 1

Open Access

may contribute to the occurrence of stroke in HF include: Patients were excluded from Gulf CARE if: (1) they
atrial fibrillation (AF) or left ventricular (LV) dysfunction were discharged from the emergency room without
that are potential source embolisation.2 3 The hypercoagul- admission. (2) They were transferred from a non-registry
able state and reduced fibrinolysis are a consequence of the hospital. (3) There was a failure to obtain informed
activation of the sympathetic nervous system and the renin- consent. (4) Their final diagnosis was not HF, in which
angiotensin-aldosterone system.4 5 In addition to endothe- case they were also excluded from the final analyses.
lial dysfunction in HF,6 7 hypotension may also be an add- Registry organisation and Data Collection and Validation
itional risk factor for stroke as a result of HF.8 Moreover, are mentioned in Gulf CARE.18
underlying risk factors for the development of HF, such as Definitions of data variables in the chronic renal failure
hypertension and diabetes mellitus,9 can also predispose to (CRF) are based on the ESC guidelines 2008 and the
large-artery atherosclerosis and small-vessel thrombosis and American College of Cardiology clinical data standards
hence stroke.10 2005.19 20 Cardiomyopathy was defined as a myocardial dis-
The prevalence and incidence of prior and acute order in which the heart muscle is structurally and func-
stroke in patients with HF is unclear because of the het- tionally abnormal (in the absence of coronary artery
erogeneous nature of the limited published studies, disease, hypertension, valvular disease or congenital heart
most of which were subset analyses of randomised trials disease) sufficient to cause the observed myocardial abnor-
rather than epidemiological studies.11–17 Furthermore, mality.20 Diastolic HF was defined as the presence of symp-
most of the available data are mainly limited to studies toms and/or signs of HF and a preserved LV ejection
conducted in the western world and data about the fraction (LVEF) >40%.19 Stroke/transient ischaemic attack
prevalence of prior stroke among patients hospitalised (TIA) was defined as a history of cerebrovascular disease,
with HF are lacking. The aim of this study is to define documented by any one of the following: (1) cerebrovascu-
the prevalence, clinical characteristics, precipitating lar ischaemic or haemorrhagic stroke: patient has a history
factors, management and outcome of patients with of stroke (ie, any focal neurological deficit of abrupt onset
stroke hospitalised with HF, using data from Gulf CARE caused by a disturbance in blood supply that did not
(Gulf aCute heArt failuRe rEgistry).18 It is hypothesised resolve within 24 h) confirmed by a standard neurological
that patients with prior stroke when hospitalised with HF examination with or without a positive imaging study, or an
have worse outcomes when compared with patients with event of presumed ischaemic origin that did not resolve
HF and without prior stroke. within 24 h, but the imaging showed a new lesion. (2) TIA:
patient has a history of any sudden new focal neurological
deficit of presumed ischaemic origin as determined by a
PATIENTS AND METHODS standard neurological examination that resolved com-
Registry design pletely within 24 h, with a brain image study not revealing a
Gulf CARE is a prospective multinational multicentre regis- new lesion. (3) Non-invasive/invasive carotid test with
try that recruited patients from February 2012 to occlusion greater than or equal to 75%. (4) Previous
November 2012 who were admitted with the final diagnosis carotid artery surgery. (5) Previous carotid angioplasty.19
of acute HF (AHF) in 47 hospitals in seven Middle Eastern Diabetes mellitus was defined as having a history of dia-
Arab countries in the Gulf.18 Data were collected on epi- betes diagnosed and treated with medication and/or
sodes of hospitalisation beginning with point of initial care, insulin or fasting blood glucose 7.0 mmol/L (126 mg/dL)
with patient’s discharge, transfer out of hospital or or glycated haemoglobin (HbA1c) ≥6.5%. Hypertension
in-hospital death, and for those discharged alive 3 and was defined as having a history of hypertension diagnosed
12 months follow-up was obtained. Patients’ recruitment and treated with medication, blood pressure greater than
was preceded by a pilot phase of 1 month in November 140 mm Hg systolic or 90 mm Hg diastolic on at least two
2011. Institutional or national ethical committee or review occasions or greater than 130 mm Hg systolic or 80 mm Hg
board approval was obtained in each of the seven partici- diastolic on at least two occasions for patients with diabetes
pating countries, and all patients provided informed or chronic kidney disease (CKD). Hyperlipidaemia
consent. Each patient was given a unique identification was defined as a history of dyslipidemia diagnosed and/or
number to prevent double counting. The study is regis- treated by a physician or total cholesterol greater than 5.18
tered at clinicaltrials.gov with the number NCT01467973. mmol/L (200 mg/dL), low-density lipoprotein greater
Patients included in this registry were men and women than or equal to 3.37 mmol/L (130 mg/dL) or high-
aged 18 years and over with AHF who were admitted to density lipoprotein less than 1.04 mmol/L (40 mg/dL).
participating hospitals. AHF was defined based on the Current smoker was defined as a person smoking cigar-
European Society of Cardiology (ESC) definition2 and ettes, a water pipe, a cigar or chewing tobacco within
was further classified as either acute decompensated 1 month of index admission.
chronic HF (ADCHF) or new-onset AHF (de novo AHF) CKD was defined as glomerular filtration rate (GFR)
based on the ESC guidelines. ADCHF was defined as wor- <60 mL/min/ 1.73 m2 for 3 months or more, with or
sening of HF in patients with a previous diagnosis or hos- without kidney damage or on dialysis. If no GFR was
pitalisation for HF. New-onset AHF (de novo AHF) was available, serum creatinine >177 mmol/L or 2 mg/dL
defined as AHF in patients with no history of HF. was marked as CKD. Obesity was defined as body mass

2 Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148

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index greater than 25 kg/m2. In the registry, infection is RESULTS

defined as any systemic infection needing antibiotics.20 Patient demographics
Approximately 8.1% of Gulf CARE patients (total 5005
Statistical analysis patients) had a history of stroke, with no significant
Baseline and outcome data are presented in frequency gender or racial differences between stroke and non-
and percentages for categorical variables and interval stroke groups (tables 1–3). Patients with stroke with HF
variables are presented in mean and SDs or median and were older (66.5 vs 59 years, p=0.001) and more likely to
range as appropriate. In order to establish the associ- have diabetes mellitus, hypertension, AF, coronary artery
ation between stroke and non-stroke groups χ2 tests were disease and LV dysfunction ( p=0.001). Patients with
applied. Student t tests or Wilcoxon rank sum tests were stroke were also more likely to have chronic kidney
used for interval variables between the two groups as disease and to be on renal replacement therapy than
appropriate. Multivariate logistic regression analysis was patients without stroke ( p=0.001) and to have thyroid
performed at in-hospital and 1 year mortality for import- disease (6.2% vs 3.4%, p=0.001) and previous coronary
ant risk factors. Adjusted OR and 95% CI with p values artery bypass grafting (7% vs 10.9%, p=0.004) and less
are presented in table 6. p Value ≤0.05 (two tailed) is likely to be smokers ( p=0.003) or have a history of
considered statistically significant. SPSS V.21.0 Statistical asthma/chronic obstructive pulmonary disease. Patients
package was used for the analysis.21 with stroke were more likely to present with ADCHF

Table 1 Baseline demographic and clinical characteristics (no stroke/TIA vs stroke/TIA)

No stroke/TIA Stroke/TIA
Variable N=4601 (91.9%) N=404 (8.1%) p Value
Acute new-onset heart failure (%) 2150 (46.7) 126 (31.2)
Acute decompensated chronic heart failure (%) 2451 (53.3) 278 (68.8) 0.001
Age (mean ±SD) 59±14.9 66.5±13 0.001
Gender
Male (%) 2892 (62.9) 239 (59.2)
Female (%) 1709 (31.1) 165 (40.8) 0.14
Ethnicity
Arab (%) 4130 (89.8) 386 (95.5)
Asians (%) 455 (9.9) 18 (4.5)
Others (%) 16 (0.3) 0 (0) 0.001
Main caregiver
Cardiologist (%) 3326 (72.3) 249 (61.6)
Internist (%) 1275 (27.7) 155 (38.4) 0.001
Previous CV history
HF previous admission (%)
≤6 months (%) 2439 (53) 278 (68.8) 0.001
Known systolic LV dysfunction (%) 2053 (44.6) 228 (56.4) 0.001
Known CAD (%) 2083 (45.3) 254 (62.9) 0.001
Valvular heart disease (%) 608 (13.2) 67 (16.6) 0.06
PVD (%) 162 (3.5) 61 (15.1) 0.001
Atrial fibrillation (%) 569 (11.1) 98 (24.3) 0.001
Current smoking (%) 1038 (22.6) 65 (16.1) 0.003
Type 1 DM (%) 160 (3.5) 25 (6.2)
Type 2 DM (%) 2052 (44.6) 255 (63.1) 0.001
Known HTN (%) 2718 (59.1) 341 (84.4) 0.001
Known hyperlipidaemia (%) 1572 (34.2) 227 (56.2) 0.001
CKD/dialysis (%) 631 (13.7) 113 (28) 0.001
Sleep apnoea requiring therapy (%) 88 (1.9) 11 (2.7) 0.26
Family history of cardiomyopathy/heart failure (%) 244 (5.3) 15 (3.7) 0.17
Khat (%) 852 (18.5) 39 (9.7) 0.001
Alcohol (%) 165 (3.6) 11 (2.7) 0.63
Peripartum (at present) (%) 76 (1.7) 2 (0.5) 0.07
Radiation (%) 19 (0.4) 0 (0) 0.20
Chemotherapy (%) 29 (0.6) 3 (0.7) 0.79
Thyroid disease (%) 156 (3.4) 25 (6.2) 0.001
Asthma/COPD (%) 446 (9.7) 55 (13.6) 0.01
CAD, coronary artery disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CV, cardiovascular; DM, diabetes
mellitus; HTN, hypertension; LV, left ventricular; PVD, peripheral vascular disease; TIA, transient ischaemic attack.

Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148 3

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Table 2 Clinical presentation (symptoms, signs; stroke/TIA vs no stroke/TIA)

No stroke/TIA Stroke/TIA,
Variable N=4601 (91.9%) N=404 (8.1%) p Value
Clinical symptoms
Cardiac arrest (%) 138 (3) 19 (4.7) 0.06
NYHA I (%) 124 (2.7) 5 (1.2)
NYHA II (%) 933 (20.3) 72 (17.8)
NYHA III (%) 1973 (42.9) 188 (46.5)
NYHA IV (%) 1471 (32) 132 (32.7) 0.22
Orthopnoea (%) 3618 (78.6) 324 (80.2) 0.46
Paroxysmal nocturnal dyspnoea (%) 2942 (63.9) 274 (67.8) 0.12
Abdominal/lower limb swelling (%) 2055 (44.7) 187 (46.3) 0.53
Weight gain (yes) (%) 1207 (26.2) 100 (24.8) 0.52
Chest pain (%) 2034 (44.2) 166 (41.1) 0.23
Palpitation (%) 1413 (30.7) 107 (26.5) 0.08
Easy fatigability (%) 2604 (56.6) 230 (56.9) 0.89
Syncope in the last 1 year (%) 218 (4.7) 45 (11.1) 0.001
Clinical signs
Heart rate (mean±SD) 97±23 95±22.9 0
BP (mm Hg) (mean±SD)
Systolic 137±34 142±33 0.01
Diastolic 81±20 80±19.5 0.37
RR (mean±SD) 24.6±5.9 24.9±5.8 0.32
Weight (kg) (mean±SD) 74±17 76±17.6 0.02
Height (cm) (mean±SD) 162±8.6 163±9 0.56
Waist circumference (cm) (mean±SD) 92±15 93±16.7 0.84
BMI (kg/m2) (mean±SD) 28±6 29±6.3 0.03
Raised JVP>6 cm (%) 2323 (56.5) 203 (50.2) 0.93
Peripheral oedema (%) 2496 (54.2) 231 (57.2) 0.26
Ascites (%) 658 (14.3) 65 (16.1) 0.33
Enlarged tender liver (%) 1260 (27.4) 78 (19.3) 0.001
Gallop (%) 1747 (38) 129 (31.9) 0.02
Basal lung crepitation (%) 4214 (91.6) 383 (94.8) 0.02
Signs of pleural effusion (%) 847 (18.4) 77 (19.1) 0.75
BMI, body mass index; BP, blood pressure; JVP, jugular venous pressure; NYHA, New York Heart Association; RR, respiratory rate;
TIA, transient ischaemic attack.

with more frequent recent (≤6 months) HF hospitalisa- Precipitating factors, hospitalisation course and outcomes
tions ( p=0.001), and more likely to be admitted under There were no significant differences in terms of pre-
the care of internists rather than cardiologists when cipitating factors for HF hospitalisation between the two
compared with patients without stroke. groups (tables 5 and 6).
Patients with stroke were more likely to require inva-
Investigations during hospitalisation sive and non-invasive ventilations (12.4% vs 8.1%,
Patients with stroke were more likely to be admitted with p=0.003), (15.3% vs 8.9%, p=0.001), respectively, and
AF when compared with patients without stroke; atrial were also more likely to require inotropic support
fibrillation/flutter (12.7% vs 24.9%, p=0.001; table 4). (21.8% vs 15.1%, p=0.001), AF therapy (11.4% vs 5.8%,
Patients with stroke were also more likely to have con- p=0.001%), renal replacement therapy (2.5% vs 4.5%,
centric LV hypertrophy (26.8% vs 32.7%, p=0.02), and p=0.02) and blood transfusions (9.2% vs 4.7%, p=0.001)
less likely to have mitral regurgitation (30.4% vs 22.5%, when compared with patients without stroke. Patients
p=0.001) with no differences in the mean EF on echo- with stroke were also more likely to suffer recurrent
cardiographic assessment between the two groups. strokes and have systemic infections that require anti-
Patients with stroke were more likely to have a lower biotic treatment (34.9% vs 23.2%, p=0.001) during the
GFR (mean±SD; 58±36.6 vs 69±35.7, p=0.001 and, as a same hospitalisation when compared with patients
result, higher serum creatinine (mean±SD; 146±111 without stroke (table 5). The clinical workup of patients
vs129±117 mg/dL, p=0.003) and blood urea (mean±SD: with stroke showed that they were more likely to have
12.8±9 vs 11±8.4 mg/dL, p=0.002). Patients with stroke ischaemic heart disease (59.2% vs 42.7%, p=0.01) and
were also more likely to have lower admission haemoglo- less likely to have other types of cardiomyopathies
bin levels (mean±SD; 11.9±2.3 vs 12.7±2.4 mg/dL, (13.1% vs 18.7% p=0.005), including idiopathic cardio-
p=0.001). myopathy (9.2% vs 13.1%, p=0.02; table 5).

4 Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148

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Table 3 Medications and interventions (stroke/TIA vs no stroke/TIA)

Before admission On discharge
No stroke/TIA Stroke/TIA No stroke/TIA Stroke/TIA
Variable N=4601 (91.9%) N=404 (8.1%) p Value N=4601 (91.9%) N=404 (8.1%) p Value
Digoxin 758 (16.5) 92 (22.8) 0.001 1112 (24.2) 95 (23.5) 0.77
Oral nitrates 1151 (25) 154 (38.1) 0.001 1636 (35.6) 186 (46) 0.001
Hydralazine 187 (4.1) 34 (8.4) 0.001 299 (6.5) 54 (13.4 0.001
Aspirin 2781 (60.4) 308 (76.2) 0.001 3538 (76.9) 313 (77.5) 0.80
Clopidogrel 849 (18.5) 117 (29) 0.001 1631 (35.5) 167 (41.3) 0.02
Oral anticoagulants (%) 537 (11.7) 81 (20) 0.001 806 (17.5) 91 (22.5) 0.01
Statin 2269 (49.3) 286 (70.8) 0.001 311 (67.7) 319 (79) 0.001
Allopurinol 121 (2.6) 14 (3.5) 0.32 219 (4.8) 20 (5) 0.86
Ivabradine (%) 107 (2.3) 8 (2.0) 0.66 227 (4.9) 17 (4.2) 0.52
Antiarrhythmic (%) 116 (2.5) 10 (2.5) 0.96 208 (4.5) 15 (3.7) 0.45
Antidepressants (%) 57 (1.2) 9 (2.2) 0.10 82 (1.8) 10 (2.5) 0.32
BB
Carvedilol 992 (49.6) 105 (50.2) 0.87 1600 (51.6) 140 (53.8) 0.48
Metoprolol 197 (9.9) 26 (12.4) 0.24 295 (9.5) 32 (12.3) 0.14
Bisoprolol 648 (32.4) 59 (28.2) 0.22 1151 (37.1) 80 (30.8) 0.04
ACE inhibitors 1968 (42.8) 164 (40.6) 0.40 2694 (58.6) 188 (46.5) 0.001
ARBs 563 (12.2) 84 (20.8) 0.001 725 (15.8) 77 (19.1) 0.08
Aldosterone antagonists 778 (16.9) 62 (15.3) 0.42 1921 (41.8) 135 (33.4) 0.001
Cardiac procedures
PCI 484 (10.5) 55 (13.6) 0.05 2861 (6.2) 13 (3.2) 0.02
CABG 322 (7) 44 (10.9) 0.004 65 (1.4) 4 (1.0) 0.49
Device therapy (yes) (%)
CRT-P 4 (0.1) 1 (0.2) 2 (0) 0 (0)
CRT-D 52 (1.1) 4 (1.0) 26 (0.6) 3 (0.7)
ICD 80 (1.7) 12 (3) 0.37 45 (1.0) 8 (2.0) 0.10
Valve repair/replacement (yes) (%) 148 (3.2) 19 (4.7) 0.11 88 (1.9) 6 (1.5) 0.54
ARBs, angiotensin receptors blockers; BB, B blockers; CABG, coronary artery bypass grafting; CRT, cardiac resynchronization therapy; ICD,
International Classification of Diseases; PCI, percutaneous coronary intervention; TIA, transient ischaemic attack.

Patients with stroke were more likely to be discharged 38.1%, p=0.007) and with less incidence of recurrent
on oral nitrates, hydralazine, statin, ACE inhibitors stroke (2% vs11%, p=0.001), less major bleeding (0% vs
(ACEIs), aldosterone antagonists ( p=0.001), oral antic- 1.9%, p=0.03) and the need for blood transfusion
oagulants ( p=0.02) and clopidogrel ( p=0.01) when com- (6.4% vs 13.5%, p=0.02) when compared with patients
pared with patients without stroke (table 3). In with prior stroke hospitalised under the care of inter-
comparison with stroke patients non-stroke patients had nists. Patients with prior stroke with systemic infection
percutaneous coronary intervention during hospitalisa- requiring antibiotics were more likely to be admitted
tion ( p=0.02). under internal medicine care (46.5% vs 27.7%, p=0.001)
Patients with stroke had a longer hospital stay (mean with higher in-hospital mortality (13.5% vs 5.2%,
±SD days; 11±14 vs 9±13, p=0.03) as well as a higher but p=0.009) with no significant differences in the
statistically non-significant in-hospital (8.4% vs 6.1%, duration of hospital stay (11±17 vs 10±10 (days), p=0.33)
p=0.06) and a significantly higher 1-year mortality rate when compared with those admitted under cardiologist
(32.7% vs 23.2%, p=0.001; table 5). On multivariate care. One year follow-up showed non-significant
logistic regression analysis, stroke was an independent marginally higher rehospitalisation for patients
mortality predictor for in-hospital and 1-year follow-up under internist care (19.3% vs 24.5%, p=0.07) with
(table 6). Age, hypertension, peripheral vascular disease significantly higher mortality when compared with
and AF were independent risk factors for stroke in patients under cardiologist care (69.9% vs 63.2%,
patients with HF (table 6). p=0.002; table 7).

Cardiologist vs internist care

Subanalysis of patients with prior stroke according to DISCUSSION
whether the primary care provider is a cardiologist The current registry of patients hospitalised for HF
versus internist showed the following: patients admitted demonstrates the following: (1) stroke history is relatively
to cardiologists were more likely to be prescribed clopi- common among Middle Eastern patients. (2) Patients
dogrel (48.2% vs 30.3%, p=0.001) and ACEI (51.8 vs with stroke had a higher risk of recurrent in-hospital

Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148 5

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Table 4 Investigations during hospitalisation (stroke/TIA vs no stroke/TIA)

No stroke/TIA Stroke/TIA
Variable N=4601 (91.9%) N=404 (8.1%) p Value
Pulse oximetry saturation (mean±SD) 93±6.9 93±6.2 0.86
Troponin, ng/mL
Elevated (%) 1726 (37.5) 176 (43.6)
Normal (%) 2453 (53.3) 198 (49)
Not performed (%) 422 (9.2) 30 (7.4) 0.05
First BNP or NT-Pro BNP, pg/mL 780 (17) 70 (17.3) 0.85
HbA1c (mean±SD) (%) 7.2±2.2 7.6±2.0 0.03
Total cholesterol (mean±SD) mmol/L 4.8±2.3 4.5±2.2 0.02
First haemoglobin (mean±SD) g/dL 12.7±2.4 11.9±2.3 0.001
First WCC (mean±SD) cells/mL 10.4±8 10±7 0.89
First urea (mean±SD) mmol/L 11±8.4 12.8±9 0.002
First creatinine (mean±SD) mmol/L 129±117 146±111 0.003
E-GFR (mean±SD) mL/min 69±35.7 58±36.6 0.001
First serum potassium (mean±SD) mmol/L 4.3±0.7 4.3±0.69 0.06
First ALT (mean±SD) mmol/L 94±218 71±192 0.02
ECG rhythm
Sinus (%) 3803 (83.2) 288 (71.8) 0.01
AF/flutter (%) 579 (12.7) 100 (24.9) 0.001
Paced (%) 69 (1.5) 10 (2.5) 0.13
Others (%) 62 (1.4) 1 (0.2) 0.05
LVH (%) 1377 (29.9) 144 (35.6) 0.02
STEMI (%) 495 (10.8) 31 (7.7) 0.05
AF 509 (11.1) 98 (24.3) 0.001
CHB 56 (1.2) 2 (0.5) 0.20
Pathological Q waves (old MI) 1072 (23.3) 106 (16.2) 0.18
QRS duration ≥0.12 ms –
LBBB 596 (13) 61 (15.1) 0.22
RBBB 203 (4.4) 19 (4.7) 0.79
IVCD 142 (3.1) 17 (4.2) 0.22
Echocardiography (available) (%) 4207 (91.4) 370 (91.6) 0.92
Left atrial enlargement (yes) (%) 2658 (63.2) 239 (64.6) 0.59
LVEF (mean±SD) 37±14 36.5±13 0.57
EF≤35% 1847 (43.9) 165 (44.6) 0.80
EF>35% 2360 (56.1) 205 (55.4) 0.80
Concentric LVH 1129 (26.8) 121 (32.7) 0.02
Moderate-to-severe valve disease
MS 127 (2.8) 8 (2) 0.35
MR 1400 (30.4) 91 (22.5) 0.001
AS 115 (2.5) 8 (2.0) 0.52
AR 177 (3.8) 12 (3.0) 0.38
TR 646 (14) 49 (12.1) 0.29
PA systolic pressure (mean±SD) 55.7±16 53±11 0.03
Coronary angiogram (within 1 year) (%) 1017 (22.1) 74 (18.3) 0.08
SVD 183 (4) 10 (2.5) 0.13
DVD 204 (4.4) 10 (2.5) 0.06
TVD 313 (6.8) 30 (7.4) 0.64
LMSD 16 (0.3) 0 (0) 0.24
Blocked stent/graft 23 (0.5) 6 (1.5) 0.01
AF, atrial fibrillation; ALT, alanine transaminase; AR, aortic regurgitation; AS, aortic stenosis; BNP, brain natriuretic peptide; CHB, complete
heart block; DVD, double vessel disease; EF, ejection fraction; GFR, glomerular filtration rate; HbA1c, glycated haemoglobin; IVCD, intra-
ventricular conduction delay; LBBB, left bundle branch block; LMSD, left main disease; LVH, left ventricular hypertrophy; LVEF, left ventricular
ejection fraction; MI, myocardial infarction; MR, mitral regurgitation; MS, mitral stenosis; NT-Pro BNP, N-terminal Pro brain natriuretic peptide;
PA, pulmonary artery; RBBB, right bundle branch block; STEMI, ST elevation myocardial infarction; SVD, single vessel disease; TIA, transient
ischaemic attack; TR, tricuspid regurgitation; TVD, tripe vessel disease, WCC, white cell count.

strokes and higher long-term mortality rates. (3) Prior with HF were more likely to be admitted under internist
stroke was an independent predictor of in-hospital and care rather than cardiologist care with less use of
1-year mortality. (4) Patients with stroke hospitalised evidence-based medications.

6 Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148

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Table 5 Course in the hospital and in-hospital and 1-year outcome (stroke/TIA vs no stroke/TIA)
No stroke/TIA Stroke/TIA
Variable N=4601 (91.9%) N=404 (8.1%) p Value
Precipitating factors for HF
Medications non-compliance (%) 878 (19.1) 86 (21.3) 0.28
Non-compliance with diet (%) 129 (2.8) 7 (1.7) 0.20
Salt retaining drugs (%) 26 (0.6) 0 (0) 0.13
Acute coronary syndrome (%) 1259 (27.4) 106 (26.2) 0.63
Uncontrolled hypertension (%) 374 (8.1) 36 (8.9) 0.58
Uncontrolled arrhythmia (%) 271 (5.9) 30 (7.4) 0.21
Anaemia (%) 138 (3) 16 (4) 0.28
Infection (%) 667 (14.5) 641 (15.8) 0.46
Unknown (%) 651 (14.1) 35 (8.7) 0.002
Worsening of renal failure 197 (4.3) 24 (5.9) 0.12
NIV 411 (8.9) 62 (15.3) 0.001
Intubation/ventilation 374 (8.1) 50 (12.4) 0.003
Inotropes 695 (15.1) 88 (21.8) 0.001
IABP 76 (1.7) 6 (1.5) 0.80
Acute dialysis/ultrafiltration 117 (2.5) 18 (4.5) 0.02
VT/VF requiring therapy (%) 202 (4. 4) 20 (5.0) 0.60
AF requiring therapy (%) 265 (5.8) 46 (11.4) 0.001
Major bleeding (%) 37 (0.8) 3 (0.7) 0.90
Blood transfusion (%) 217 (4.7) 37 (9.2) 0.001
In-hospital new stroke (%) 46 (1) 22 (5.4) 0.001
Systemic infection requiring antibiotics (%) 1067 (23.2) 141 (34.9) 0.001
HHD 725 (15.8) 77 (19.1) 0.08
IHD 2424 (42.7) 239 (59.2) 0.01
Primary VHD 432 (9.4) 29 (7.2) 0.14
Viral myocarditis (%) 17 (0.4) 0 (0.0) 0.22
Cardiomyopathy (total) 862 (18.7) 53 (13.1) 0.005
CM subtype
HCM 19 (0.4) 3 (0.7) 0.34
Infiltrative CM 12 (0.3) 1 (0.2) 0.96
Toxic CM 36 (0.8) 3 (0.7) 0.93
Pregnancy-related CM 63 (1.4) 2 (0.5) 0.14
Thyroid disease-related CM 10 (0.2) 0 (0) 0.35
Familial CM 9 (0.2) 0 (0) 0.37
Tachycardia-induced CM 30 (0.7) 1 (0.2) 0.32
Idiopathic DCM 605 (13.1) 37 (9.2) 0.02
Discharge home 4104 (89.2) 350 (86.6) 0.30
Transfer to another hospital 80 (1.7) 8 (2.0) 0.30
Death 279 (6.1) 34 (8.4) 0.06
Hospital stay (days) (mean±SD) 9±13 11±14 0.03
Alive (yes) 3532 (76.8) 272 (67.3) 0.001
HF rehospitalisation (yes) (%) 989 (28) 86 (31.6) 0.20
Cardiac intervention needed
ICD 33 (0.7) 1 (0.2) 0.27
CRTD/P 12 (0.2) 2 (0.5) 0.33
PCI/CABG 358 (10.1) 22 (8.1) 0.28
AF, atrial fibrillation; CABG, coronary artery bypass grafting; CRTD, cardiac resynchronisation therapy, defibrillator; CRT, Cardiac
resynchronization therapy; CM, cardiomyopathy; DCM, dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; HHD, hypertensive heart
disease; IABP, intra-aortic balloon pump insertion; ICD, International Classification of Diseases; IHD, ischaemic heart disease;
NIV, non-invasive ventilation; PCI, percutaneous coronary intervention; VF, ventricular fibrillation; VHD, valvular heart disease;
VT, ventricular tachycardia.

HF is a common disease and is a major risk factor for prevalence and outcome of stroke in patients hospita-
ischaemic stroke. Stroke-related morbidity and mortality lised for HF are very sparse and mainly conducted in
are considerably higher in patients with HF compared the western world. To the best of our knowledge, this is
with patients with stroke without HF.22 Data on the the first study from the Middle East and the developing

Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148 7

Open Access

Prevalence of stroke in patients with HF

Table 6 Multivariate logistic regression analysis for
The reported prevalence of stroke in patients with HF is
in-hospital mortality
variable because of the heterogeneous and limited
Variable Adjusted OR 95% CI p Value
number of published studies (table 8).25–31 The initial
Age 0.99 0.98 to 1.03 0.16 risk of ischaemic stroke during the first year after diag-
Male gender 0.78 0.59 to 1.04 0.09 nosis of HF was reported to be 1.8%; this compares with
DM II 1.06 0.79 to 1.41 0.70 subsequent risk of nearly 5% at 5 years post-diagnosis.25
CKD 1.31 0.91 to 1.89 0.15 Data from the Framingham Study11 and a recent cohort
COPD/asthma 0.64 0.37 to 1.10 0.11
study12 indicated that the risk of ischaemic stroke is 2–3
STEMI 2.25 1.57 to 3.23 0.001
LVEF≥35% 0.77 0.59 to 1.01 0.06
times higher for patients with HF than it is for those
LVEF<35 1.30 0.99 to 1.70 0.06 without HF. According to epidemiological data, cohort
VHD 1.59 1.12 to 2.25 0.009 studies and case series, ≈10% to 24% of all patients
Stroke 1.71 1.13 to 2.60 0.01 with stroke have HF, whereas HF is thought to be the
PVD 1.52 0.89 to 2.62 0.13 likely cause of stroke in ≈9% of all patients.13–17
Multivariate logistic regression analysis for 1-year mortality A meta-analysis including 15 clinical studies and 11
Age 1.04 1.03 to 1.05 0.001 cohort studies published before 200625 reported a stroke
Male gender 1.12 0.90 to 1.40 0.31 rate of 1.8% and 4.7% within 1 and 5 years, respectively.
DM II 1.18 0.95 to 1.46 0.13 A recent report from the population-based, prospective
CKD 1.53 1.19 to 1.96 0.001 Rotterdam Scan Study revealed that stroke risk is highest
COPD/asthma 1.22 0.91 to 1.65 0.19
within 1 month after the diagnosis of HF that normal-
STEMI 0.89 0.62 to 1.29 0.55
LVEF≥35 0.74 0.60 to 0.91 0.005
ised within 6 months.32
LVEF<35 1.35 1.10 to 1.67 0.005 This study complements previous reports by showing
VHD 1.46 1.10 to 1.93 0.009 high prevalence of prior stroke among patients hospita-
Stroke 1.34 0.98 to 1.84 0.07 lised with HF in the Middle East. Moreover, patients with a
PVD 1.20 0.79 to 1.82 0.41 prior stroke had a higher risk of recurrent strokes during
Risk factors for stroke in heart failure the index hospitalisation. This high prevalence may be
Age 1.02 1.01 to 1.03 0.001 due to associated risk factors for stroke such as severe LV
Gender 1.02 0.81 to 1.28 0.88 systolic dysfunction (44.6% had EF <35%) and AF (25%),
DM 1.30 1.01 to 1.69 0.045 even though there was a relatively high prevalence of asso-
HTN 2.10 1.50 to 2.80 0.001 ciated risk factors, including LV dysfunction and AF, while
Systolic BP 1.0 0.99 to 1.01 0.51
the use of anticoagulants and antiplatelet agents was low
Diastolic BP 1.0 0.99 to 1.01 0.65
In this study, we reported the use of anticoagulants (20–
NYHA I 0.64 0.19 to 2.14 0.33
NYHA II 0.98 0.42 to 2.25 0.46 22%) and antiplatelets (29–41%) during hospitalisation at
NYHA III 1.24 0.55 to 2.80 0.95 discharge, respectively, in patients with prior stroke; this
NYHA IV 1.24 0.54 to 2.81 0.61 rate may be much lower than has been reported in a
Hyperlipidaemia 1.30 1.02 to 1.65 0.03 EUROASPIRE III survey where antiplatelet drugs or oral
CKD 1.31 1.05 to 1.75 0.045 anticoagulants were used by 87.2%, of patients with
Systolic LV 1.08 0.85 to 1.37 0.52 stroke.33 This lower use of anticoagulants and antiplatelets
dysfunction in this study may have contributed to their increased risk
Known CAD 1.14 0.89 to 1.47 0.30 of recurrent strokes and higher mortality rates.
PVD (%) 2.97 2.06 to 4.12 0.001
AF 2.20 1.67 to 2.89 0.001
Risk factors for stroke in patients with HF and outcome
Thyroid disease 0.91 0.56 to 1.49 0.71
Present facts concerning other risk factors for stroke in
AF, atrial fibrillation; BP, blood pressure; CAD, coronary artery
disease; CKD, chronic kidney disease; COPD, chronic obstructive HF (apart from AF as the major factor) are primarily
pulmonary disease; DM, diabetes mellitus; HTN, hypertension; grounded on retrospective studies, cohort studies or
LV, left ventricular; LVEF, left ventricular ejection fraction; NYHA, post-hoc analyses of large clinical trials with significant
New York Heart Association; PVD, peripheral vascular disease;
TIA, transient ischaemic attack; VHD, valvular heart disease. inconsistencies.34 This study reported age, diabetes mel-
litus, hypertension, hyperlipidaemia, peripheral vascular
disease and AF to be independently associated with
recurrent stroke risk in patients with HF. The Olmsted
world that explores this issue. We had previously County cohort demonstrated that prior stroke, advanced
reported a low prevalence of prior stroke in patients hos- age and diabetes were relevant stroke risk factors in 630
pitalised with acute coronary syndrome (ACS) in the patients with HF,12 whereas a history of AF or hyperten-
Middle East.23 24 On the other hand, this study reports a sion did not reach statistical significance according to
relatively higher prevalence of stroke in patients hospita- multivariable analysis. On the other side, a retrospective
lised with HF in seven Middle Eastern countries, suggest- analysis of the prospective Survival and Ventricular
ing that prior stroke is more prevalent among patients Enlargement (SAVE) study also reported no significant
hospitalised with HF rather than ACS in this region. impact of hypertension (and diabetes) in 2231 patients

8 Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148

 Open Access

Table 7 Patient with HF with stroke/TIA as per care provider

Variable Cardiologist care 249 (61.6%) Internist care 155 (38.4%) p Value
Acute new-onset HF (%) 83 (33.3) 43 (27.7)
Acute decompensated chronic HF (%) 166 (66.7) 112 (72.3) 0.24
Age (mean±SD) 66±13 67±12 0.36
Male (%) 158 (63.5) 81 (52.3) 0.03
Previous admission for HF (%) 10 (4) 5 (3.2) 0.68
AF 60 (24.1) 38 (24.5) 0.92
CKD/dialysis (%) 71 (28.5) 42 (27.1) 0.76
PVD 44 (17.7) 17 (11) 0.07
CAD 164 (65.9) 90 (58.1) 0.12
NYHA III 106 (42.6) 82 (52.9) 0.04
NYHA IV 83 (33.3) 49 (31.6) 0.72
Clopidogrel 120 (48.2) 47 (30.3) 0.001
Oral anticoagulants (%) 60 (24.1) 31 (20) 0.34
ACE inhibitors 129 (51.8) 59 (38.1) 0.007
ARBs 43 (17.3) 34 (21.9) 0.25
Aldosterone antagonists 88 (35.3) 47 (30.3) 0.30
LVEF (mean±SD) 35±12.6 39±14 0.01
NIV 37 (14.9) 25 (16.1) 0.73
Intubation/ventilation 33 (13.3) 17 (11) 0.50
Inotropes 48 (19.3) 40 (25.8) 0.12
IABP 5 (2) 1 (0.6) 0.27
Acute dialysis/ultrafiltration 11 (4.4) 7 (4.5) 0.96
VT/VF requiring therapy (%) 14 (5.6) 6 (3.9) 0.43
AF requiring therapy (%) 27 (10.8) 19 (12.3) 0.66
Major bleeding (%) 0 (0) 3 (1.9) 0.03
Blood transfusion (%) 16 (6.4) 21 (13.5) 0.02
In-hospital stroke (%) 5 (2) 17 (11) 0.001
Systemic infection requiring antibiotics (%) 69 (27.7) 72 (46.5) 0.001
Death in-hospital 13 (5.2) 21 (13.5) 0.009
Hospital stay (days) (mean±SD) 11±17 10±10 0.33
1-year follow-up
Alive (yes) 174 (69.9) 98 (63.2) 0.002
HF hospitalisation (yes) (%) 48 (19.3) 38 (24.5) 0.07
ICD 0 (0) 1 (0.6) 0.20
CRTD 2 (0.8) 0 (0) 0.26
PCI/CABG 13 (7.5) 9 (9.2) 0.62
AF, atrial fibrillation; ARBs, angiotensin receptors blockers; CABG, coronary artery bypass grafting; CAD, coronary artery disease;
CKD, chronic kidney disease; CRTD, Cardiac resynchronization therapy, defibrillator; HF, heart failure; IABP, intra-aortic balloon pump
insertion; ICD, International Classification of Diseases; LVEF, left ventricular ejection fraction; NIV, non-invasive ventilation; NYHA, New York
Heart Association; PCI, percutaneous coronary intervention; PVD, peripheral vascular disease; TIA, transient ischaemic attack, VF, ventricular
fibrillation; VT, ventricular tachycardia.

with HF.35 In contrast to these reports, the SCD-HeFT- result of the Framingham Study that indicated that
study revealed an HR of 1.9 (95% CI 1.1 to 3.1) for advanced age does not account for the increased risk of
stroke when hypertension was present at randomisation stroke in patients with HF3 37
of 2144 patients with HF without AF.9 In addition, a This study has shown that patients with HF with stroke
medical history of hypertension was associated with an had higher in-hospital mortality with longer hospital stay
increased risk of hospitalisation for stroke (HR 1.4; 95% and that they are less likely to stay alive at 1-year
CI 1.01 to 1.8) in 7788 patients with HF of the Digitalis follow-up, probably explained by the multiple comorbid-
Investigation Group trial.36 Furthermore, our result is ities in this patient population. Many retrospective data-
compatible from the age point of view with the Olmsted base analyses have shown that stroke increases the
County data that revealed a significant but modest asso- disability and mortality of patients with HF through the
ciation between stroke risk and advanced age (relative alteration in neuropsychological status, like decreased
risk 1.04; 95% CI 1.02 to 1.06).12 An exploratory analysis attention and concentration, memory loss, diminished
of the SAVE study also showed similar results (relative psychomotor speed and decreased executive function,
risk of stroke 1.18; 95% CI 1.05 to 1.3, for each increase and this ranged from approximately 25–80% of all
of 5 years in age),9 while these results contradict the patients with chronic HF.38–41

Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148 9

Open Access

Cardiologist vs internist care of patients with

F/U* (days)
HF with prior stroke
Cardiologists when compared with internists may

1230

360
1011

1110

1131

1197

1740
provide more evidence-based therapies for the treatment
of patients with HF.42 43 This is supported by this study,
where patients under the care of cardiologists had a
lower risk of recurrent in-hospital stroke, major bleed-
Strokes (%)

ing, the need for blood transfusion and lower in-hospital

and 1-year mortality rates when compared with patients
managed by internists. This suggests that patients with

3.4
3.8

4.2

1.4

3.5

4.7
8.1
prior stroke are a higher risk group which may benefit
from specialised care. On the other hand, the observa-
tional nature of this study does not adjust for the possi-
Female sex (%)

bility of selection bias in that patients with “lower” risk

stroke were “preferentially” admitted under the care of
cardiologists rather than internists.
4.4

21.3

0.2
31.9

24.7

31.6

40.8

STUDY LIMITATIONS
This study is a subanalysis of an observational study, which
Mean age (years)

is like any observational study, where the possibility for

unmeasured confounding variables exists. In addition, not
all hospitals in each country participated; hence, the
results cannot be generalised. This study did not record
the cognitive status and the disability status in patients with
66.5

63.9

66.5

stroke, which obviously have a major impact on morbidity

64
66

60

62

and mortality and only 1-year mortality. Mortality rates at

follow-up were only recorded at 1 year without the specifi-
Table 8 Prevalence of stroke in patients with HF/studies from different parts of the world
Patient (n)

cation of the exact date of death of each patient, and

hence the Kaplan-Meier curves could not have been done.
2548
2028

7788

7599

6378

3029
5005

Finally, no information was available regarding the cause

of stroke (embolic vs thrombotic). Future studies need to
overcome these limitations.
CHARM-Overall programme 1999–2001

CONCLUSION
This observational study reports a high prevalence of prior
CHARM-Alternative trial 1999–2001

stroke in Middle Eastern patients with HF. There was

underuse of anticoagulation therapy in patients with stroke
and HF with AF. Patients with stroke hospitalised with HF
CHARM-Added trial 1999

COMET trial 1996–1999

were more likely to be admitted under the care of internists

SOLVD trial 1986–1989

rather than cardiologists, resulting in less use of evidence-

DIG trial 1991–1993

based medications and worse outcome. Patients with stroke

had a higher risk of in-hospital recurrent strokes and
Study period

higher long-term mortality rates. History of stroke was an

2012–2013
Gulf CARE

Gulf CARE, Gulf aCute heArt failuRe rEgistry.

independent predictor of in-hospital and 1-year mortality

rates in patients hospitalised with HF. Future studies are
*Included studies in the follow-up period.

needed to evaluate whether aggressive evidence based ther-

apies to this high-risk group will improve outcome.
Khafaji et al current study

Author affiliations
Study name (reference)

26 countries worldwide

1
Department of Cardiology, Saint Michael’s Hospital, Toronto University,
Remme et al31 Europe
North America Europe

North America Europe

Canada
2
Department of Cardiology, Royal Hospital, Muscat, Oman
McMurray et al30

3
Biostatistics Section, Cardiovascular Research, Heart Hospital, Hamad
Granger et al26

Mathew et al27
North America

North America
Pfeffer et al28

Medical Corporation, Doha, Qatar

Dries et al29

Middle East

4
Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud
University, Riyadh, Saudi Arabia
5
Adult Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
6
Department of Cardiology, Sheikh Khalifa Medical City, Abu Dhabi, UAE
7
Department of Cardiology, Sabah Al-Ahmed Cardiac Center, Kuwait

10 Khafaji HAR, et al. BMJ Open 2015;5:e007148. doi:10.1136/bmjopen-2014-007148

 Open Access
8
Department of Cardiology, Adan Hospital, Kuwait, Kuwait 15. Hays AG, Sacco RL, Rundek T, et al. Left ventricular systolic
9 dysfunction and the risk of ischemic stroke in a multiethnic
Department of Cardiology, Dubai hospital, Dubai, UAE
10
Department of Cardiology, Mohammed Bin Khalifa Cardiac Center, population. Stroke 2006;37:1715–19.
16. Ois A, Gomis M, Cuadrado-Godia E, et al. Heart failure in acute
Manamah, Bahrain ischemic stroke. J Neurol 2008;255:385–9.
11
Department of Cardiology, Faculty of Medicine, Sana’a University, Sana’a, 17. Pullicino P, Homma S. Stroke in heart failure: atrial fibrillation
Yemen revisited? J Stroke Cerebrovasc Dis 2010;19:1–2.
12 18. Sulaiman KJ, Panduranga P, Al-Zakwani I, et al. Rationale, Design,
Department of Cardiology, Prince Salman Heart Center, King Fahad Medical
City, Saudi Arabia Methodology and Hospital Characteristics of the First Gulf Acute
13 Heart Failure Registry (Gulf CARE). Heart Views 2014;15:6–12.
Department or Cardiology, Tanta University, Tanta, Egypt
14 19. Radford MJ, Arnold JM, Bennett SJ, et al; American College of
Qatar Cardiovascular Research Center and Adult Cardiology, Heart Hospital, Cardiology; American Heart Association Task Force on Clinical Data
Hamad Medical Corporation, Doha, Qatar Standards; American College of Chest Physicians, et al;. ACC/AHA
key data elements and definitions for measuring the clinical
Acknowledgements We thank Hani Altaradi and Kazi Nur Asfina for research management and outcomes of patients with chronic heart failure: a
report of the American College of Cardiology/American Heart
coordination.
Association Task Force on Clinical Data Standards (Writing
Contributors KS, KFA, NA, AA-A, MA-J, BB, WA, MR, NB, HA, AA-M, HA, AE, Committee to Develop Heart Failure Clinical Data Standards):
PP and JA were involved in the design of the Gulf CARE registry and patient developed in collaboration with the American College of Chest
Physicians and the International Society for Heart and Lung
enrolment and ensuring quality control of the study. RS carried out the Transplantation: endorsed by the Heart Failure Society of America.
statistical analyses. All authors contributed to the drafting of the article and Circulation 2005;112:1888–916.
approved the final version of the manuscript. 20. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for
the diagnosis and treatment of acute and chronic heart failure 2008:
Funding Gulf CARE is an investigator-initiated study conducted under the the Task Force for the Diagnosis and Treatment of Acute and
auspices of the Gulf Heart Association and funded by Servier, Paris, France; Chronic Heart Failures 2008 of the European Society of Cardiology.
and (for centres in Saudi Arabia) by the Saudi Heart Association. Developed in collaboration with the Heart Failure Association of the
ESC (HFA) and endorsed by the European Society of Intensive
Competing interests None. Care Medicine (ECSIM). Eur Heart J 2008;29:2388–442.
21. Hosmer DW Jr, Lemeshow S, Sturdivant RX. Introduction to the
Provenance and peer review Not commissioned; externally peer reviewed. Logistic Regression Model, in Applied Logistic Regression. 3rd edn.
Data sharing statement No additional data are available. Hoboken, NJ, USA: John Wiley & Sons, Inc., 2013.
22. Haeusler KG, Laufs U, Endres M. Chronic heart failure and ischemic
Open Access This is an Open Access article distributed in accordance with stroke. Stroke 2011;42:2977–82.
the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, 23. Al Suwaidi J, Al Habib K, Asaad N, et al. Immediate and one-year
outcome of patients presenting with acute coronary syndrome
which permits others to distribute, remix, adapt, build upon this work non-
complicated by stroke: findings from the 2nd Gulf Registry of Acute
commercially, and license their derivative works on different terms, provided Coronary Events (Gulf RACE-2). BMC Cardiovasc Disord 2012;12:64.
the original work is properly cited and the use is non-commercial. See: http:// 24. Albaker O, Zubaid M, Alsheikh-Ali AA, et al. Gulf RACE
creativecommons.org/licenses/by-nc/4.0/ Investigators. Early stroke following acute myocardial infarction:
incidence, predictors and outcome in six Middle-Eastern countries.
Cerebrovasc Dis 2011;32:471–82.
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