Pulmonary hypertension: An unexplored risk factor for stroke in patients with atrial fibrillation

Georges Khattar; Ahmad Mustafa; Fasih Sami Siddiqui; Khalil El Gharib; Wei Chapman; Saif Abu Baker; Saud Bin Abdul Sattar; Dany Elsayegh; Halim El-Hage; Suzanne El Sayegh; Michel Chalhoub

doi:10.1016/j.jstrokecerebrovasdis.2023.107247

Pulmonary hypertension: An unexplored risk factor for stroke in patients with atrial fibrillation

J Stroke Cerebrovasc Dis. 2023 Sep;32(9):107247. doi: 10.1016/j.jstrokecerebrovasdis.2023.107247. Epub 2023 Jul 29.

Affiliations

¹ Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA. Electronic address: geokhattar22@gmail.com.
² Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA.
³ Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, New York, USA.
⁴ Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, New York 10305, USA; Department of Nephrology, Staten Island University Hospital/Northwell Health, Staten Island, New York, USA.

PMID: 37523879
DOI: 10.1016/j.jstrokecerebrovasdis.2023.107247

Abstract

Background: Atrial fibrillation (Afib) is one of the most common and significant risk factors for stroke, with the CHADsVAsc score used as the tool for stroke risk assessment. Pulmonary hypertension (PH) has not been studied as an independent risk factor for stroke in individuals with Afib.

Methods: In this retrospective case-control study, National Inpatient Sample Database was used to sample individuals with atrial fibrillation, and baseline demographics and comorbidities were collected using ICD-10 codes. Patients with missing data, age under 18, history of thromboembolic diseases, or stroke were excluded. Greedy propensity matching using R was performed to match patients with and without PH on age, race, gender, and 19 other comorbidities, including anticoagulation use. Binary logistic regression was performed after matching to assess whether PH was an independent risk factor for stroke. A p-value of <0.05 was considered statistically significant.

Results: Of the 2,421,545 patients included in the study, 158,545 (6.5%) had PH. PH patients were more likely to be elderly, females, and smokers. Comorbidities were more common in the PH group. Patients with PH were more likely to have an ischemic stroke (3.6% vs. 2.9%, p<0.001), hemorrhagic stroke (2.2% vs. 0.7%, p<0.001), and transient ischemic attack (TIA) (2.3% vs. 0.7%, p<0.001). After matching, the presence of PH was associated with increased ischemic stroke (OR: 1.2 [1.1-1.2]; p<0.001), hemorrhagic stroke (OR: 2.4 [2.1-2.6]; p<0.001) and TIA (OR: 2.2 [2.0-2.4]; p<0.001). PH patients also had increased length of stay (β = 0.8; p<0.001) mortality (OR: 1.1 [1.0-1.2]; p<0.001).

Conclusion: Apart from demonstrating the deleterious effect of PH on mortality and length of hospital stay, this study is the first to report on such a large scale that PH independently increases the incidence of all types of strokes in patients with Afib.

Keywords: Anticoagulation; Atrial Fibrillation; Hemorrhagic Stroke; Ischemic Stroke; Pulmonary Hypertension; Transient Ischemic Attack.

MeSH terms

Aged
Atrial Fibrillation* / complications
Atrial Fibrillation* / diagnosis
Atrial Fibrillation* / epidemiology
Case-Control Studies
Female
Hemorrhagic Stroke* / complications
Humans
Hypertension, Pulmonary* / diagnosis
Hypertension, Pulmonary* / epidemiology
Ischemic Attack, Transient* / etiology
Ischemic Stroke* / complications
Retrospective Studies
Risk Factors
Stroke* / diagnosis
Stroke* / epidemiology
Stroke* / etiology