American Journal of Medical Case Reports
ISSN (Print): 2374-2151 ISSN (Online): 2374-216X Website: Editor-in-chief: Samy, I. McFarlane
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American Journal of Medical Case Reports. 2020, 8(1), 22-25
DOI: 10.12691/ajmcr-8-1-6
Open AccessReview Article

Acute Systolic Heart Failure as the only Risk Factor for Cardioembolic Cerebrovascular Accident in the Setting of Nonischemic Cardiomyopathy and Normal Sinus Rhythm: A Case Report with Literature Review

Bader Madoukh1, , Ayman Battisha2, Henry Ukwu1, Mohammed Al-Sadawi3 and Shakil Shaikh3

1Overland Park Regional Medical Center-HCA Midwest Health, United States

2University of Massachusetts Medical School-Baystate, United States

3Department of Medicine, State University of New York, Downstate Medical Center, United States

Pub. Date: November 24, 2019

Cite this paper:
Bader Madoukh, Ayman Battisha, Henry Ukwu, Mohammed Al-Sadawi and Shakil Shaikh. Acute Systolic Heart Failure as the only Risk Factor for Cardioembolic Cerebrovascular Accident in the Setting of Nonischemic Cardiomyopathy and Normal Sinus Rhythm: A Case Report with Literature Review. American Journal of Medical Case Reports. 2020; 8(1):22-25. doi: 10.12691/ajmcr-8-1-6


The association between atrial fibrillation and stroke is well-known by use of the CHA2DS2VASc risk assessment. However, little is known about the thromboembolic risk in patients who have isolated systolic heart failure (HF) with sinus rhythm. Despite growing literature which shows how HF in the setting of normal sinus rhythm is a risk factor for thromboembolic disease, the recommendation for use of anticoagulation, whether warfarin or direct oral anticoagulation (DOAC) in this setting, is not yet reflected in cardiology guidelines. To reduce the risk of thromboembolism, anticoagulation trials have been done but have not conclusively shown benefit over risk. We present a case of left middle cerebral artery (MCA) stroke after de novo HF in a patient with sinus rhythm, who was previously not on anticoagulation. Case: A 57-year-old male presented to our hospital with worsening shortness of breath for 3 days. He had signs of hypervolemia consistent with an acute heart failure exacerbation. Pertinent physical exam findings included lower extremity edema, rales, and jugular venous distension. He also had fatigue and exertional dyspnea. During his hospital course, he underwent imaging studies that revealed cardiomegaly, absence of pulmonary embolism, and a severely reduced ejection fraction. During his acute heart failure admission, he developed a left MCA stroke suspected to be of cardioembolic etiology and was successfully treated with tissue plasminogen activator (tPA). Conclusion: According to the most recent AHA/ACC cardiovascular disease guidelines, anticoagulation is not indicated in systolic heart failure patients with sinus rhythm. However, our case is rare because the patient had no underlying risk factors for thromboembolism and significant past medical history. He developed new-onset nonischemic cardiomyopathy complicated by a stroke. Therefore, we suggest the need for prophylactic anticoagulation should be assessed on an individual basis, with the assistance of shared decision making, especially when the ejection fraction is acutely and severely reduced.

heart failure normal sinus rhythm atrial fibrillation cardioembolic stroke

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[1]  Zeitler, E. P., & Eapen, Z. J. (2015). Anticoagulation in Heart Failure: a Review. J Atr Fibrillation, 8(1), 1250.
[2]  Sivri, N., Yetkin, E., Tekin, G. O., Yalta, K., & Waltenberger, J. (2014). Anticoagulation in patients with left ventricular systolic dysfunction and sinus rhythm: when? Clin Appl Thromb Hemost, 20(7), 729-734.
[3]  Schumacher, K., Kornej, J., Shantsila, E., & Lip, G. (2018). Heart Failure and Stroke. Current heart failure reports, 15(5), 287-296.
[4]  Siliste, R. N., Antohi, E. L., Pepoyan, S., Nakou, E., & Vardas, P. (2018). Anticoagulation in heart failure without atrial fibrillation: gaps and dilemmas in current clinical practice. Eur J Heart Fail, 20(6), 978-988.
[5]  Beggs, S.A., Rorth, R., Gardner, R.S., &McMurray, J. J. (2019). Anticoagulation therapy in heart failure and sinus rhythm: a systematic review and meta-analysis. Heart, heartjnl-2018.
[6]  Berger, J. S., Peterson, E., Laliberte, F., Germain, G., Lejeune, D., Schein, J., . . . Weir, M. R. (2019). Risk of Ischemic Stroke in Patients Newly Diagnosed With Heart Failure: Focus on Patients Without Atrial Fibrillation. J Card Fail, 25(6), 436-447.
[7]  Abdul-Rahim, A. H., Perez, A. C., Fulton, R. L., Jhund, P. S., Latini, R., Tognoni, G., . . . Investigators, G.-H. F. G.-H. C. a. (2015). Risk of Stroke in Chronic Heart Failure Patients Without Atrial Fibrillation: Analysis of the Controlled Rosuvastatin in Multinational Trial Heart Failure (CORONA) and the Gruppo Italiano per lo Studio della Sopravvivenza nell'Insufficienza Cardiaca-Heart Failure (GISSI-HF) Trials. Circulation, 131(17), 1486-1494; discussion 1494.
[8]  Hai, J. J., Chan, P. H., Chan, Y. H., Fong, C. H., Huang, D., Li, W. H., . . . Siu, C. W. (2016). Prediction of Thromboembolic Events in Heart Failure Patients in Sinus Rhythm: The Hong Kong Heart Failure Registry. PLoS One, 11(12), e0169095.
[9]  Melgaard, L., Gorst-Rasmussen, A., Lane, D. A., Rasmussen, L. H., Larsen, T. B., & Lip, G. Y. (2015). Assessment of the CHA2DS2-VASc Score in Predicting Ischemic Stroke, Thromboembolism, and Death in Patients With Heart Failure With and Without Atrial Fibrillation. JAMA, 314(10), 1030-1038.
[10]  Avellana, P., Segovia, J., Ferrero, A., Vazquez, R., Brugada, J., Borras, X., . . . Cinca, J. (2012). Anticoagulation therapy in patients with heart failure due to systolic dysfunction and sinus rhythm: analysis of REDINSCOR registry. Rev Esp Cardiol (Engl Ed), 65(8), 705-712. doi:10.1016/j.recesp.2011.11.012
[11]  Kang, S. H., Kim, J., Park, J. J., Oh, I. Y., Yoon, C. H., Kim, H. J., . . . Choi, D. J. (2017). Risk of stroke in congestive heart failure with and without atrial fibrillation. Int J Cardiol, 248, 182-187.
[12]  Vaduganathan, M., Patel, R. B., & Yancy, C. W. (2016). Stroke prevention in heart failure and sinus rhythm: where do we go from here? Eur J Heart Fail, 18(10), 1267-1269.
[13]  Ferreira, J. P., Girerd, N., Gregson, J., Latar, I., Sharma, A., Pfeffer, M. A., . . . Initiative, H.-R. M. I. D. (2018). Stroke Risk in Patients With Reduced Ejection Fraction After Myocardial Infarction Without Atrial Fibrillation. J Am Coll Cardiol, 71(7), 727-735.
[14]  Kim, W., & Kim, E. J. (2018). Heart Failure as a Risk Factor for Stroke. J Stroke, 20(1), 33-45.
[15]  Hung, W. W. (2015). CHA 2 DS 2-VASc Score Modestly Predicts Ischemic Stroke, Thromboembolic Events, and Death in Patients with Heart Failure Without Atrial Fibrillation. Journal of Clinical Outcomes Management, 22(11).
[16]  Nair A, Sealove B, Halperin JL, Webber G, Fuster V. Anticoagulation in patients with heart failure: who, when, and why? Eur Hear J Suppl. 2006; 8(suppl_E):E32-E38.
[17]  Greenberg, B., Neaton, J. D., Anker, S. D., Byra, W. M., Cleland, J. G. F., Deng, H., . . . Zannad, F. (2019). Association of Rivaroxaban With Thromboembolic Events in Patients With Heart Failure, Coronary Disease, and Sinus Rhythm: A Post Hoc Analysis of the COMMANDER HF Trial. JAMA Cardiol, 4(6), 515-523.
[18]  Haeusler, K. G., Endres, M., & Doehner, W. (2017). Relevance of heart failure in prevention, treatment and prognosis of ischemic stroke. Neurology International Open, 1(02), E61-E64.