Risk of stroke and bleeding in patients with heart failure and chronic kidney disease: a nationwide cohort study

Abstract

Aims: The aim of this study was to assess the prognostic value of chronic kidney disease (CKD) in relation to ischaemic stroke, intracranial haemorrhage, major bleeding, and all-cause death in heart failure patients without atrial fibrillation.

Methods and results: In this observational cohort study, heart failure patients without atrial fibrillation were identified using Danish nationwide registries. Risk of stroke, major haemorrhage, and death were calculated after 1 and 5 years to compare patients with and without CKD, ±dialysis [dialysis: CKD with renal replacement therapy (CKD-RRT); no dialysis: CKD-no RRT]. A total of 43 199 heart failure patients were included, among which 0.8% had CKD-RRT and 5.9% had CKD-no RRT. When compared with heart failure patients without CKD, both CKD-RRT and CKD-no RRT were associated with a higher 5 year rate of major bleeding (CKD-RRT: adjusted hazard ratio (aHR): 2.91, 95% confidence interval (CI): 2.29 to 3.70; CKD-no RRT: aHR: 1.28, 95% CI: 1.13 to 1.45) and all-cause death (CKD-RRT: aHR: 2.40, 95% CI: 2.07 to 2.77; CKD-no RRT: aHR: 1.63, 95% CI: 1.55 to 1.73). For the endpoints of ischaemic stroke and intracranial bleeding, only CKD-no RRT was associated with significantly higher 5 year rates (ischaemic stroke: aHR: 1.31, 95% CI: 1.13 to 1.52; intracranial haemorrhage: aHR: 1.66, 95% CI: 1.04 to 2.65).

Conclusions: Compared with patients without CKD, among incident heart failure patients without atrial fibrillation, CKD both with and without dialysis was associated with a higher rate of major bleeding and all-cause death. Only CKD-no RRT was associated with a higher rate of ischaemic stroke and intracranial bleeding.

Keywords: Bleeding; Chronic kidney disease; Heart failure; Mortality; Stroke.

Figure 1

Flowchart of patients included in the final study population.

Figure 2

Crude cumulative incidence of all endpoints according to chronic kidney disease status (note the varying range of the y‐axes). Abbreviations: CKD, chronic kidney disease; CKD‐RRT, chronic kidney disease with dialysis; CKD‐no RRT, chronic kidney disease without dialysis; HF, heart failure.

Figure 3

Hazard rate ratios of all endpoints after 1 and 5 years of follow‐up, according to chronic kidney disease status (reference group: patients without chronic kidney disease). Abbreviations: 95% CI, 95% confidence interval; FUP, follow‐up. Analysis adjusted for sex (binary), age (continuous), hypertension (binary), diabetes (binary), prior stroke/transient ischaemic attack (binary), vascular disease (binary), and antiplatelet therapy (binary).