Systolic blood pressure on discharge after left ventricular assist device insertion is associated with subsequent stroke

Abstract

Background Stroke is a significant complication in patients supported with continuous-flow left ventricular assist devices (CF-LVAD) and hypertension (HTN) is a significant risk factor for stroke, but the association between blood pressure and stroke in LVAD patients is not well characterized. Methods We identified 275 consecutive patients who survived implant hospitalization between 1/2005 and 4/2013. Patients were divided into above and below median SBP (100 mmHg) groups based on their averaged systolic blood pressure (SBP) during the last 48 hours prior to discharge from implantation hospitalization. The groups were compared for the primary outcome of time-to-stroke. Results The above-median SBP (AM-SBP) group had mean SBP=110 mmHg and the below-median SBP (BM-SBP) group had mean SBP=95 mmHg. There were no significant between-group differences in BMI, smoking, vascular disease, HTN, atrial fibrillation, or prior stroke. During a mean follow-up of 16 months, stroke occurred in 16% of the AM-SBP group vs. 7% of the BM-SBP group, HR 2.38 (95% CI 1.11 - 5.11), with a similar proportion of hemorrhagic and ischemic strokes in each group. In Cox proportional hazard models adjusting for age, diabetes, or prior stroke, the HR remained statistically significant. SBP as a continuous variable predictor of stroke had an AUC of 0.64 in an ROC analysis. Conclusion In this large, CF-LVAD cohort, elevated SBP was independently associated with a greater risk of subsequent stroke. These results identify management of HTN as a potential modifiable risk factor for reducing the incidence of stroke in patients supported by CF-LVAD.

Hypertension and Stroke in Patients with Left Ventricular Assist Devices (LVADs)

“…A high blood pressure in this case might rather be an indicator of sustained damage to already fragile cerebral arterioles from chronically elevated blood pressure not only preceding but also following LVAD implantation. Investigators at Washington University have recently reported that a systolic blood pressure above the mean (>100 mmHg) 48 h before discharge from the hospital after implantation was associated with a higher risk of ischemic and hemorrhagic stroke, a mean of 16 months later without a clear difference by device type [25••]. Otherwise, strokes may also reflect a systemic process leading to hemorrhage that is independent of the cerebral vasculature.…”

HeartMate 3—a “Step” in the right direction

“…Additionally, strict blood pressure control is increasingly recognized as a therapeutic goal to reduce the rates of hemorrhagic and embolic stroke (20,21). Will a more focused effort on blood pressure control also improve pulsatility, thereby preventing both GI bleeding and the development of aortic insufficiency?…”

The Rehabilitation of Patients With Advanced Heart Failure After Left Ventricular Assist Device Placement: A Narrative Review

“…Etiology of stroke after LVAD implantation seems equally distributed between embolic and hemorrhagic strokes . Multiple risk factors for stroke occurrence after LVAD implantation have been documented, including history of stroke, pre‐existing atrial fibrillation, diabetes mellitus, suboptimal anticoagulation regimens, hypertension, systemic infection, and aortic cross‐clamping with cardioplegic arrest . Regardless of etiology, postoperative stroke is an important cause of morbidity after LVAD implantation and can be a cause for hospital readmissions .…”