The cardiovascular system is markedly affected by stress after stroke. There is a complex interaction between the brain and heart, and the understanding of the mutual effects has increased in recent decades. Stroke is accompanied by pathological disturbances leading to autonomic dysfunction and systemic inflammation, which leads to changes in cardiomyocyte metabolism. Cardiac injury after stroke may lead to serious complications and long-term cardiac problems. Evidence suggests that blood biomarkers and electrocardiogram analyses can be valuable for estimating the severity, prognosis, and therapy strategy in patients after stroke. It is necessary to distinguish whether these abnormalities presenting in stroke patients are caused by coexisting ischemic heart disease or are caused by brain injury directly. Distinguishing the origin can have a great impact on the treatment of patients after acute stroke. In this article, we focus on epidemiology, pathophysiological mechanisms, and the presentation of cardiac changes in patients after stroke.

Department of Cardiology 3rd Faculty of Medicine University Hospital Královské Vinohrady Charles University 100 34 Prague Czech Republic

See more in PubMed

Lanas F., Seron P. Facing the stroke burden worldwide. Lancet Glob. Health. 2021;9:e235–e236. doi: 10.1016/S2214-109X(20)30520-9. PubMed DOI

Samuels M.A. The Brain–Heart Connection. Circulation. 2007;116:77–84. doi: 10.1161/CIRCULATIONAHA.106.678995. PubMed DOI

Agewall S., Giannitsis E., Jernberg T., Katus H. Troponin elevation in coronary vs. non-coronary disease. Eur. Heart J. 2011;32:404–411. doi: 10.1093/eurheartj/ehq456. PubMed DOI

Iadecola C., Anrather J. The immunology of stroke: From mechanisms to translation. Nat. Med. 2011;17:796–808. doi: 10.1038/nm.2399. PubMed DOI PMC

Nagatomo Y., Tang W.H.W. Intersections Between Microbiome and Heart Failure: Revisiting the Gut Hypothesis. J. Card. Fail. 2015;21:973–980. doi: 10.1016/j.cardfail.2015.09.017. PubMed DOI PMC

Levy A.G. Sudden Death under Light Chloroform Anæsthesia. Proc. R. Soc. Med. 1914;7:57–84. doi: 10.1177/003591571400701421. PubMed DOI PMC

Burch G.E., Meyers R., Abildskov J.A. A New Electrocardiographic Pattern Observed in Cerebrovascular Accidents. Circulation. 1954;9:719–723. doi: 10.1161/01.CIR.9.5.719. PubMed DOI

Beattie J., Brow G.R., Long C.N.H. Physiological and anatomical evidence for the existence of nerve tracts connecting the hypothalamus with spinal sympathetic centres. R. Soc. 1930;106:253–275. doi: 10.1098/rspb.1930.0027. DOI

Dimant J., Grob D. Electrocardiographic changes and myocardial damage in patients with acute cerebrovascular accidents. Stroke. 1977;8:448–455. doi: 10.1161/01.STR.8.4.448. PubMed DOI

Christensen H., Christensen A.F., Boysen G. Abnormalities on ECG and telemetry predict stroke outcome at 3 months. J. Neurol. Sci. 2005;234:99–103. doi: 10.1016/j.jns.2005.03.039. PubMed DOI

Frontera J.A., Parra A., Shimbo D., Fernandez A., Schmidt J.M., Peter P., Claassen J., Wartenberg K.E., Rincon F., Badjatia N., et al. Cardiac Arrhythmias after Subarachnoid Hemorrhage: Risk Factors and Impact on Outcome. Cerebrovasc. Dis. 2008;26:71–78. doi: 10.1159/000135711. PubMed DOI PMC

Stead L.G., Gilmore R.M., Bellolio M.F., Vaidyanathan L., Weaver A.L., Decker W.W., Brown R.D. Prolonged QTc as a Predictor of Mortality in Acute Ischemic Stroke. J. Stroke Cerebrovasc. Dis. 2009;18:469–474. doi: 10.1016/j.jstrokecerebrovasdis.2009.02.006. PubMed DOI

Wolf P.A., Abbott R.D., Kannel W.B. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke. 1991;22:983–988. doi: 10.1161/01.STR.22.8.983. PubMed DOI

Johnson C.O., Nguyen M., Roth G.A., Nichols E., Alam T., Abate D., Abd-Allah F., Abdelalim A., Abraha H.N., Abu-Rmeileh N.M., et al. Global, regional, and national burden of stroke, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18:439–458. doi: 10.1016/S1474-4422(19)30034-1. PubMed DOI PMC

Gunnoo T., Hasan N., Khan M.S., Slark J., Bentley P., Sharma P. Quantifying the risk of heart disease following acute ischaemic stroke: A meta-analysis of over 50,000 participants. BMJ Open. 2016;6:e009535. doi: 10.1136/bmjopen-2015-009535. PubMed DOI PMC

Sörös P., Hachinski V. Cardiovascular and neurological causes of sudden death after ischaemic stroke. Lancet Neurol. 2012;11:179–188. doi: 10.1016/S1474-4422(11)70291-5. PubMed DOI

Li Y., Fitzgibbons T.P., McManus D.D., Goddeau R.P., Jr., Silver B., Henninger N. Left Ventricular Ejection Fraction and Clinically Defined Heart Failure to Predict 90-Day Functional Outcome After Ischemic Stroke. J. Stroke Cerebrovasc. Dis. 2019;28:371–380. doi: 10.1016/j.jstrokecerebrovasdis.2018.10.002. PubMed DOI PMC

Prosser J., MacGregor L., Lees K.R., Diener H.-C., Hacke W., Davis S. Predictors of Early Cardiac Morbidity and Mortality After Ischemic Stroke. Stroke. 2007;38:2295–2302. doi: 10.1161/STROKEAHA.106.471813. PubMed DOI

Junttila E., Vaara M., Koskenkari J., Ohtonen P., Karttunen A., Raatikainen P., Ala-Kokko T. Repolarization Abnormalities in Patients with Subarachnoid and Intracerebral Hemorrhage: Predisposing factors and association with outcome. Anesth. Analg. 2013;116:190–197. doi: 10.1213/ANE.0b013e318270034a. PubMed DOI

Christensen H., Boysen G., Christensen A.F., Johannesen H.H. Insular lesions, ECG abnormalities, and outcome in acute stroke. J. Neurol. Neurosurg. Psychiatry. 2005;76:269–271. doi: 10.1136/jnnp.2004.037531. PubMed DOI PMC

Oppenheimer S. Cerebrogenic cardiac arrhythmias: Cortical lateralization and clinical significance. Clin. Auton. Res. 2006;16:6–11. doi: 10.1007/s10286-006-0276-0. PubMed DOI PMC

Silvani A., Calandra-Buonaura G., Dampney R.A.L., Cortelli P. Brain–heart interactions: Physiology and clinical implications. Philos. Trans. R. Soc. A Math. Phys. Eng. Sci. 2016;374:20150181. doi: 10.1098/rsta.2015.0181. PubMed DOI

Dhar R., Diringer M. The Burden of the Systemic Inflammatory Response Predicts Vasospasm and Outcome after Subarachnoid Hemorrhage. Neurocrit. Care. 2008;8:404–412. doi: 10.1007/s12028-008-9054-2. PubMed DOI PMC

Vahidy F.S., Parsha K.N., Rahbar M.H., Lee M., Bui T.-T., Nguyen C., Barreto A.D., Bambhroliya A.B., Sahota P., Yang B. Acute splenic responses in patients with ischemic stroke and intracerebral hemorrhage. J. Cereb. Blood Flow Metab. 2016;36:1012–1021. doi: 10.1177/0271678X15607880. PubMed DOI PMC

Tay A., Tamam Y., Yokus B., Ustundag M., Orak M. Serum myeloperoxidase levels in predicting the severity of stroke and mortality in acute ischemic stroke patients. Eur. Rev. Med. Pharmacol. Sci. 2015;19:1983–1988. PubMed

Chen Z., Venkat P., Seyfried D., Chopp M., Yan T., Chen J. Brain-Heart Interaction: Cardiac Complications After Stroke. Circ. Res. 2017;121:451–468. doi: 10.1161/CIRCRESAHA.117.311170. PubMed DOI PMC

Lekawanvijit S., Adrahtas A., Kelly D.J., Kompa A.R., Wang B.H., Krum H. Does indoxyl sulfate, a uraemic toxin, have direct effects on cardiac fibroblasts and myocytes? Eur. Heart J. 2010;31:1771–1779. doi: 10.1093/eurheartj/ehp574. PubMed DOI

Zhu W., Gregory J.C., Org E., Buffa J.A., Gupta N., Wang Z., Li L., Fu X., Wu Y., Mehrabian M., et al. Gut Microbial Metabolite TMAO Enhances Platelet Hyperreactivity and Thrombosis Risk. Cell. 2016;165:111–124. doi: 10.1016/j.cell.2016.02.011. PubMed DOI PMC

Palma J.-A., Benarroch E.E. Neural control of the heart: Recent concepts and clinical correlations. Neurology. 2014;83:261–271. doi: 10.1212/WNL.0000000000000605. PubMed DOI

Cechetto D.F. Experimental cerebral ischemic lesions and autonomic and cardiac effects in cats and rats. Stroke. 1993;24((Suppl. 12)):I6–I9. PubMed

Hachinski V.C., Oppenheimer S.M., Wilson J.X., Guiraudon C., Cechetto D.F. Asymmetry of Sympathetic Consequences of Experimental Stroke. Arch. Neurol. 1992;49:697–702. doi: 10.1001/archneur.1992.00530310039010. PubMed DOI

Oppenheimer S., Cechetto D. The Insular Cortex and the Regulation of Cardiac Function. Compr. Physiol. 2016;6:1081–1133. doi: 10.1002/cphy.c140076. PubMed DOI

Oppenheimer S. The anatomy and physiology of cortical mechanisms of cardiac control. Stroke. 1993;24((Suppl. 12)):I3–I5. PubMed

Cechetto D.F., Chen S.J. Subcortical sites mediating sympathetic responses from insular cortex in rats. Am. J. Physiol. Integr. Comp. Physiol. 1990;258:R245–R255. doi: 10.1152/ajpregu.1990.258.1.R245. PubMed DOI

Tokgoçzoglu S.L., Batur M.K., Topçuoglu M.A., Saribas O., Kes S., Oto A. Effects of Stroke Localization on Cardiac Autonomic Balance and Sudden Death. Stroke. 1999;30:1307–1311. doi: 10.1161/01.STR.30.7.1307. PubMed DOI

Iltumur K., Karabulut A., Apak I., Aluclu U., Ariturk Z., Toprak N. Elevated plasma N-terminal pro–brain natriuretic peptide levels in acute ischemic stroke. Am. Heart J. 2006;151:1115–1122. doi: 10.1016/j.ahj.2005.05.022. PubMed DOI

Bunevicius A., Kazlauskas H., Raskauskiene N., Mickuviene N., Ndreu R., Corsano E., Bunevicius R. Role of N-Terminal Pro-B-Type Natriuretic Peptide, High-Sensitivity C-Reactive Protein, and Inteleukin-6 in Predicting a Poor Outcome after a Stroke. Neuroimmunomodulation. 2015;22:365–372. doi: 10.1159/000381218. PubMed DOI

Oppenheimer S.M., Kedem G., Martin W.M. Left-insular cortex lesions perturb cardiac autonomic tone in humans. Clin. Auton. Res. 1996;6:131–140. doi: 10.1007/BF02281899. PubMed DOI

Oppenheimer S.M., Cechetto D.F. Cardiac chronotropic organization of the rat insular cortex. Brain Res. 1990;533:66–72. doi: 10.1016/0006-8993(90)91796-J. PubMed DOI

Chouchou F., Mauguière F., Vallayer O., Catenoix H., Isnard J., Montavont A., Jung J., Pichot V., Rheims S., Mazzola L. How the insula speaks to the heart: Cardiac responses to insular stimulation in humans. Hum. Brain Mapp. 2019;40:2611–2622. doi: 10.1002/hbm.24548. PubMed DOI PMC

Friberg L., Rosenqvist M., Lindgren A., Terént A., Norrving B., Asplund K. High Prevalence of Atrial Fibrillation Among Patients With Ischemic Stroke. Stroke. 2014;45:2599–2605. doi: 10.1161/STROKEAHA.114.006070. PubMed DOI

Potpara T.S., Lip G.Y. Ischemic stroke and atrial fibrillation-a deadly serious combination. Cerebrovasc. Dis. 2011;32:461–462. doi: 10.1159/000332030. PubMed DOI

Sander D., Winbeck K., Klingelhofer J., Etgen T., Conrad B. Prognostic relevance of pathological sympathetic activation after acute thromboembolic stroke. Neurology. 2001;57:833–838. doi: 10.1212/WNL.57.5.833. PubMed DOI

Yang H.-J., Liu X., Qu C., Shi S.-B., Yang B. Usefulness of upright T wave in lead aVR for predicting short-term prognosis of patients with ischemic stroke. Chronic Dis. Transl. Med. 2018;4:192–198. doi: 10.1016/j.cdtm.2018.01.004. PubMed DOI PMC

Fure B., Wyller T.B., Thommessen B. Electrocardiographic and troponin T changes in acute ischaemic stroke. J. Intern. Med. 2006;259:592–597. doi: 10.1111/j.1365-2796.2006.01639.x. PubMed DOI

Di Pasquale G., Pinelli G., Andreoli A., Manini G., Grazi P., Tognetti F. Holter detection of cardiac arrhythmias in intracranial subarachnoid hemorrhage. Am. J. Cardiol. 1987;59:596–600. doi: 10.1016/0002-9149(87)91176-3. PubMed DOI

Schuiling W.J., Algra A., De Weerd A.W., Leemans P., Rinkel G.J.E. ECG abnormalities in predicting secondary cerebral ischemia after subarachnoid haemorrhage. Acta Neurochir. 2006;148:853–858. doi: 10.1007/s00701-006-0808-3. PubMed DOI

Frangiskakis J.M., Hravnak M., Crago E.A., Tanabe M., Kip K.E., Gorcsan J., Horowitz M.B., Kassam A.B., London B. Ventricular Arrhythmia Risk After Subarachnoid Hemorrhage. Neurocrit. Care. 2009;10:287–294. doi: 10.1007/s12028-009-9188-x. PubMed DOI PMC

Takeuchi S., Nagatani K., Otani N., Wada K., Mori K. Electrocardiograph abnormalities in intracerebral hemorrhage. J. Clin. Neurosci. 2015;22:1959–1962. doi: 10.1016/j.jocn.2015.04.028. PubMed DOI

Van Bree M.D.R., Roos Y.B.W.E.M., Van Der Bilt I.A.C., Wilde A.A.M., Sprengers M.E.S., De Gans K., Vergouwen M.D.I. Prevalence and Characterization of ECG Abnormalities After Intracerebral Hemorrhage. Neurocrit. Care. 2010;12:50–55. doi: 10.1007/s12028-009-9283-z. PubMed DOI

Banki N.M., Kopelnik A., Dae M.W., Miss J., Tung P., Lawton M.T., Drew B.J., Foster E., Smith W., Parmley W.W., et al. Acute Neurocardiogenic Injury After Subarachnoid Hemorrhage. Circulation. 2005;112:3314–3319. doi: 10.1161/CIRCULATIONAHA.105.558239. PubMed DOI

Montaner J., García-Berrocoso T., Mendioroz M., Palacios M., Perea-Gainza M., Delgado P., Rosell A., Slevin M., Ribo M., Molina C., et al. Brain Natriuretic Peptide Is Associated with Worsening and Mortality in Acute Stroke Patients but Adds No Prognostic Value to Clinical Predictors of Outcome. Cerebrovasc. Dis. 2012;34:240–245. doi: 10.1159/000341858. PubMed DOI

Etgen T., Baum H., Sander K., Sander D. Cardiac Troponins and N-Terminal Pro-Brain Natriuretic Peptide in Acute Ischemic Stroke Do Not Relate to Clinical Prognosis. Stroke. 2005;36:270–275. doi: 10.1161/01.STR.0000151364.19066.a1. PubMed DOI

Yip H.-K., Sun C.-K., Chang L.-T., Chen M.-C., Liou C.-W. Time Course and Prognostic Value of Plasma Levels of N-Terminal Pro-Brain Natriuretic Peptide in Patients after Ischemic Stroke. Circ. J. 2006;70:447–452. doi: 10.1253/circj.70.447. PubMed DOI

Chen X., Zhan X., Chen M., Lei H., Wang Y., Wei D., Jiang X. The Prognostic Value of Combined NT-pro-BNP Levels and NIHSS Scores in Patients with Acute Ischemic Stroke. Intern. Med. 2012;51:2887–2892. doi: 10.2169/internalmedicine.51.8027. PubMed DOI

Shibazaki K., Kimura K., Sakai K., Fujii S., Aoki J., Saji N. Brain Natriuretic Peptide on Admission as a Biological Marker of Long-Term Mortality in Ischemic Stroke Survivors. Eur. Neurol. 2013;70:218–224. doi: 10.1159/000351777. PubMed DOI

Rost N.S., Biffi A., Cloonan L., Chorba J., Kelly P., Greer D., Ellinor P., Furie K.L. Brain Natriuretic Peptide Predicts Functional Outcome in Ischemic Stroke. Stroke. 2012;43:441–445. doi: 10.1161/STROKEAHA.111.629212. PubMed DOI PMC

Llombart V., Antolin-Fontes A., Bustamante A., Giralt D., Rost N.S., Furie K., Shibazaki K., Biteker M., Castillo J., Rodríguez-Yáñez M., et al. B-Type Natriuretic Peptides Help in Cardioembolic Stroke Diagnosis. Stroke. 2015;46:1187–1195. doi: 10.1161/STROKEAHA.114.008311. PubMed DOI

Chaudhuri J.R., Sharma V., Mridula K.R., Balaraju B., Bandaru V.C.S.S. Association of Plasma Brain Natriuretic Peptide Levels in Acute Ischemic Stroke Subtypes and Outcome. J. Stroke Cerebrovasc. Dis. 2015;24:485–491. doi: 10.1016/j.jstrokecerebrovasdis.2014.09.025. PubMed DOI

Giannakoulas G., Hatzitolios A., Karvounis H., Koliakos G., Charitandi A., Dimitroulas T., Savopoulos C., Tsirogianni E., Louridas G. N-Terminal Pro-Brain Natriuretic Peptide Levels Are Elevated in Patients with Acute Ischemic Stroke. Angiology. 2005;56:723–730. doi: 10.1177/000331970505600610. PubMed DOI

Park K.C., Gaze D.C., Collinson P.O., Marber M.S. Cardiac troponins: From myocardial infarction to chronic disease. Cardiovasc. Res. 2017;113:1708–1718. doi: 10.1093/cvr/cvx183. PubMed DOI PMC

Mochmann H.-C., Scheitz J., Petzold G.C., Haeusler K.G., Audebert H.J., Laufs U., Schneider C., Landmesser U., Werner N., Endres M., et al. Coronary Angiographic Findings in Acute Ischemic Stroke Patients With Elevated Cardiac Troponin. Circulation. 2016;133:1264–1271. doi: 10.1161/CIRCULATIONAHA.115.018547. PubMed DOI

Di Angelantonio E., Fiorelli M., Toni D., Sacchetti M.L., Lorenzano S., Falcou A., Ciarla M.V., Suppa M., Bonanni L., Bertazzoni G., et al. Prognostic significance of admission levels of troponin I in patients with acute ischaemic stroke. J. Neurol. Neurosurg. Psychiatry. 2005;76:76–81. doi: 10.1136/jnnp.2004.041491. PubMed DOI PMC

Bugnicourt J.-M., Rogez V., Guillaumont M.-P., Rogez J.-C., Canaple S., Godefroy O. Troponin Levels Help Predict New-Onset Atrial Fibrillation in Ischaemic Stroke Patients: A Retrospective Study. Eur. Neurol. 2010;63:24–28. doi: 10.1159/000258679. PubMed DOI

Zhang L., Wang Z., Qi S. Cardiac Troponin Elevation and Outcome after Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis. J. Stroke Cerebrovasc. Dis. 2015;24:2375–2384. doi: 10.1016/j.jstrokecerebrovasdis.2015.06.030. PubMed DOI

Oras J., Grivans C., Bartley A., Rydenhag B., Ricksten S.-E., Seeman-Lodding H. Elevated high-sensitive troponin T on admission is an indicator of poor long-term outcome in patients with subarachnoid haemorrhage: A prospective observational study. Crit. Care. 2016;20:11. doi: 10.1186/s13054-015-1181-5. PubMed DOI PMC

Ahmadian A., Mizzi A., Banasiak M., Downes K., Camporesi E.M., Sullebarger J.T., Vasan R., Mangar D., Van Loveren H.R., Agazzi S. Cardiac manifestations of subarachnoid hemorrhage. Heart Lung Vessel. 2013;5:168–178. PubMed PMC

Kumar S., Selim M.H., Caplan L.R. Medical complications after stroke. Lancet Neurol. 2010;9:105–118. doi: 10.1016/S1474-4422(09)70266-2. PubMed DOI

Biso S., Wongrakpanich S., Agrawal A., Yadlapati S., Kishlyansky M., Figueredo V. A Review of Neurogenic Stunned Myocardium. Cardiovasc. Psychiatry Neurol. 2017;2017:5842182. doi: 10.1155/2017/5842182. PubMed DOI PMC

Frangieh A.H., Obeid S., Ghadri J., Imori Y., D’Ascenzo F., Kovac M., Ruschitzka F., Lüscher T.F., Duru F., Templin C., et al. ECG Criteria to Differentiate Between Takotsubo (Stress) Cardiomyopathy and Myocardial Infarction. J. Am. Heart Assoc. 2016;5:e003418. doi: 10.1161/JAHA.116.003418. PubMed DOI PMC

Ibánez B., James S., Agewall S., Antunes M.J., Bucciarelli-Ducci C., Bueno H., Caforio A.L., Crea F., Goudevenos J.A., Halvorsen S., et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Rev. Esp. Cardiol. 2017;70:1082. doi: 10.1016/j.rec.2017.11.010. PubMed DOI

Thygesen K., Alpert J.S., Jaffe A.S., Chaitman B.R., Bax J.J., Morrow D.A., White H.D., The Executive Group on behalf of the Joint European Society of Cardiology (ESC) American College of Cardiology (ACC) American Heart Association (AHA) et al. Fourth Universal Definition of Myocardial Infarction. Circulation. 2018;138:e618–e651. doi: 10.1161/CIR.0000000000000617. PubMed DOI

Prevalence of myocardial injury in patients after acute ischaemic stroke according to standard criteria