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 Madoukh^1, , 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

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

Abstract

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.

Keywords

heart failure, normal sinus rhythm, atrial fibrillation, cardioembolic stroke

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

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