• Nicholas Robert Jones, Margaret Smith, Sarah Lay-Flurrie, Yaling Yang, Fd Richard Hobbs, and Clare Taylor.
• University of Oxford Department of Primary Care Health Sciences, Oxford, United Kingdom nicholas.jones2@phc.ox.ac.uk.
• Br J Gen Pract. 2025 Jan 8.

BackgroundHeart failure (HF) is a risk factor for stroke among people with atrial fibrillation (AF). Prognosis following a HF diagnosis is often poor, but this is not accounted for in existing stroke risk scores.AimTo examine stroke incidence in people with HF and AF compared to AF alone, considering the competing risk of death.Design And SettingPopulation-based cohort study.MethodsWe identified 2,381,941 people aged ≥45 years in the Clinical Practice Research Datalink (2000-2018). HF and AF were included as time-varying covariates; 69,575 had HF and AF, 141,562 had AF alone and 91,852 had HF alone. We report hazard ratios for first stroke using Cox and Fine and Gray models.ResultsOver median follow-up of 6.62 years, 93,665 people (3.9%) had a first stroke and 314,042 (13.2%) died. Over half (51.3%) of those with HF and AF died. In the fully-adjusted Cox model, relative stroke risk was highest among people with AF alone (HR 2.43, 95%CI: 2.38-2.48) than HF and AF (HR 2.20, 95%CI: 2.14-2.26). In a Fine and Gray model accounting for all-cause mortality, the relative risk of stroke was similar for people with AF alone (HR 2.38, 95%CI: 2.33-2.43), but there was significant attenuation among those with HF and AF (HR 1.48, 95%CI: 1.44-1.53).ConclusionHF is an aetiological risk factor for stroke yet its prognostic significance is reduced by the high incidence of death. Use of the CHA2DS2VASc score may over-estimate stroke incidence in some people with HF, particularly those with a poor prognosis.Copyright © 2024, The Authors.

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