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(Stroke. 2005;36:2015.)
© 2005 American Heart Association, Inc.
Research Reports |
From the Cardiomyopathy Clinic, Hospital Universitário Professor Edgard Santos, Federal University of Bahia, Brazil.
Correspondence to Jamary Oliveira-Filho, MD, PhD, Rua Prof. Sabino Silva, 282, Apartment 701, Jd. Apipema, Salvador, BA 40155-250, Brazil. E-mail jamaryof{at}ufba.br
| Abstract |
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Methods We screened 305 consecutive cardiopathy patients. Significant predictors of stroke in univariable analyses were included in a multivariable model.
Results Stroke was more frequent in CD (15.0%) compared with other cardiopathies (6.3%; P=0.015). Other predictors of stroke in univariable analyses were previous diabetes or cardioversion and use of amiodarone, antiplatelet agents, and warfarin. In multivariable analysis, remaining predictors of stroke were CD (odds ratio [OR], 1.09; 95% CI, 1.02 to 1.17), cardioversion (OR, 1.07; 95% CI, 1.02 to 1.13), and diabetes (OR, 1.12; 95% CI, 1.01 to 1.24).
Conclusions In conclusion, CD is a risk factor for stroke, independent of systolic dysfunction or presence of cardiac arrhythmias.
Key Words: cerebrovascular disorders stroke trypanosomiasis
| Introduction |
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Recently, an association between various infectious agents and stroke has been described.4,5 In CD, stroke has been identified in patients without clinical signs of cardiopathy,6 raising the possibility of other operative mechanisms. In the present study, we aimed to describe predictors of stroke in patients with various cardiopathies, in a region where CD is endemic.
| Patients and Methods |
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For univariable analyses, Student t test was used for continuous variables, and Fisher exact test for categorical variables, with P<0.05 considered significant. Logistic regression was used for multivariable analysis, including variables with a possible association (P<0.1).
| Results |
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50%), stroke was present in 6 of 39 (15.4%) patients with CD and only 1 (4.8%) patient with other cardiopathies (P=0.404). Patients with CD had a similar frequency of atrial fibrillation and history of cardioversion as non-CD patients. Apical aneurysm with thrombus was only present in patients with CD. Variables associated with stroke in univariable analyses (Table 1) were history of diabetes, CD, or cardioversion, and use of amiodarone, antiplatelet agents, and warfarin. Echocardiographic findings did not differ between patients with or without stroke.
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In multivariable analysis (Table 2), remaining predictors of stroke were CD (odds ratio [OR], 1.09), cardioversion (OR, 1.07), and diabetes (OR, 1.12). Because medication use was probably consequence and not a cause of stroke in this population, we did not include these in the final analysis. If we excluded patients with concomitant CD and either hypertension or diabetes from the analysis (n=48), CD still showed a trend as a significant predictor of stroke (OR, 1.07; 95% CI, 0.99 to 1.15; P=0.068).
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| Discussion |
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The main finding of our study was an independent association between CD and stroke. Previously, neurological manifestations of the chronic form of CD have been attributed to embolic phenomenon.8 However, case series have reported stroke in patients with CD without clinical evidence of cardiopathy.6 A case-control study also established CD as an independent risk factor for stroke but did not correct for presence or severity of cardiac disease.9 In our patients, stroke was frequently present in patients without evidence of systolic dysfunction by echocardiogram, and the relationship between CD and stroke was independent of cardiac disease severity. When excluding important confounders for stroke risk such as hypertension and diabetes, CD still showed marginal significance (P=0.068) as an independent predictor for stroke, a hypothesis that should be confirmed in future studies.
The reason for an association between CD and stroke is speculative. Associations between chronic infections and stroke have been attributed to activation of inflammatory and coagulation cascade, endothelial dysfunction, and atherogenesis.4,5 In CD, a chronic activation of the immune system occurs, with persistent lymphomonocytic myocarditis and fibrosis.10 In experimental CD, microvascular damage,11,12 endothelial cell changes,13 and hyperviscosity14 have been demonstrated. We hypothesize that such chronic inflammation may explain, at least in part, our findings of stroke in patients without criteria for cardiomyopathy. However, we cannot fully exclude that CD patients with stroke could have intermittent cardiac arrhythmias undetected on clinical examination, history or EKG, or intracardiac thrombus undetected by transthoracic echocardiogram.
There are limitations to our study. First, our population is selected, including only patients with clinical signs of cardiomyopathy. Thus, no patients with latent, arrhythmic or gastrointestinal forms of CD were studied. Second, no data were collected regarding stroke subtypes, which might differ according to the cardiomyopathy etiology. In the present cohort, we are currently collecting data on carotid duplex sonography and neuroimaging, which will allow for a more complete classification.
| Acknowledgments |
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fico e Tecnológico (CNPq) grant 304094/2002-1, and by National Institutes of Health grant R21TW006679-01. Received January 30, 2005; revision received June 7, 2005; accepted June 14, 2005.
| References |
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