Fibrilación auricular una arritmia y un sindrome / Atrial fibrillation, an arrhythmia and a syndrome

Atrial Fibrillation (AF) is the most common sustained arrhythmia and is highly prevalent in elderly patients. It confers a higher risk for ischemic stroke, heart failure and death. The diagnosis and treatment of AF has been extensively studied and remain under constant revision. This article reviews the recent European guidelines and the advances observed with the introduction of direct oral anticoagulants in the last ten years. This new family of drugs has clear benefits in terms of efficacy and safety compared with traditional vitamin K antagonists. Treatment of most common comorbidities in patients with AF such as advanced age, heart failure, diabetes, renal failure, and others are also analyzed. New therapies for AF will be shortly available.

Development and validation of ischemic heart disease and stroke prognostic models using large-scale real-world data from Japan

BACKGROUND@#Previous cardiovascular risk prediction models in Japan have utilized prospective cohort studies with concise data. As the health information including health check-up records and administrative claims becomes digitalized and publicly available, application of large datasets based on such real-world data can achieve prediction accuracy and support social implementation of cardiovascular disease risk prediction models in preventive and clinical practice. In this study, classical regression and machine learning methods were explored to develop ischemic heart disease (IHD) and stroke prognostic models using real-world data.@*METHODS@#IQVIA Japan Claims Database was searched to include 691,160 individuals (predominantly corporate employees and their families working in secondary and tertiary industries) with at least one annual health check-up record during the identification period (April 2013-December 2018). The primary outcome of the study was the first recorded IHD or stroke event. Predictors were annual health check-up records at the index year-month, comprising demographic characteristics, laboratory tests, and questionnaire features. Four prediction models (Cox, Elnet-Cox, XGBoost, and Ensemble) were assessed in the present study to develop a cardiovascular disease risk prediction model for Japan.@*RESULTS@#The analysis cohort consisted of 572,971 invididuals. All prediction models showed similarly good performance. The Harrell's C-index was close to 0.9 for all IHD models, and above 0.7 for stroke models. In IHD models, age, sex, high-density lipoprotein, low-density lipoprotein, cholesterol, and systolic blood pressure had higher importance, while in stroke models systolic blood pressure and age had higher importance.@*CONCLUSION@#Our study analyzed classical regression and machine learning algorithms to develop cardiovascular disease risk prediction models for IHD and stroke in Japan that can be applied to practical use in a large population with predictive accuracy.

Impact of Smoke-Free Legislation on Acute Myocardial Infarction and Subtypes of Stroke Incidence in Shenzhen, China, 2012-2016: An Interrupted Time Series Analysis / 生物医学与环境科学（英文）

OBJECTIVE@#This study assesses the impact of smoke-free legislation on the incidence rate for acute myocardial infarction (AMI) and stroke in Shenzhen.@*METHODS@#Data on ischemic ( n = 72,945) and hemorrhagic ( n = 18,659) stroke and AMI ( n = 17,431) incidence covering about 12 million people in Shenzhen from 2012 to 2016 were used. Immediate and gradual changes in incidence rates were analyzed using segmented Poisson regression.@*RESULTS@#Following the smoke-free legislation, a 9% (95% CI: 3%-15%) immediate reduction was observed in AMI incidence, especially in men (8%, 95% CI: 1%-14%) and in those aged 65 years and older (17%, 95% CI: 9%-25%). The gradual annual benefits were observed only in hemorrhagic and ischemic stroke incidence, with a 7% (95% CI: 2%-11%) and 6% (95% CI: 4%-8%) decrease per year, respectively. This health effect extended gradually to the 50-64 age group. In addition, neither the immediate nor gradual decrease in stroke and AMI incidence rates did not show statistical significance among the 35-49 age group ( P > 0.05).@*CONCLUSION@#Smoke-free legislation was enforced well in Shenzhen, which would generate good experiences for other cities to enact and enforce smoke-free laws. This study also provided more evidence of the health benefits of smoke-free laws on stroke and AMI.

Lower Baseline LDL Cholesterol Affects All-cause Mortality in Patients with First Percutaneous Coronary Intervention / 生物医学与环境科学（英文）

OBJECTIVE@#Foreign studies have reported that coronary artery disease (CAD) patients with high baseline low-density lipoprotein cholesterol (LDL-C) may have a good prognosis, which is called the "cholesterol paradox". This study aimed to examine whether the "cholesterol paradox" also exists in the Chinese population.@*METHODS@#A total of 2,056 patients who underwent the first percutaneous coronary intervention (PCI) between 2014 and 2016 were enrolled in this retrospective cohort study and classified into two groups based on baseline LDL-C = 2.6 mmol/L (100 mg/dL). The outcomes of interest included major adverse cardiovascular events (MACE), all-cause mortality, recurrent nonfatal myocardial infarction, unexpected coronary revascularization, or any nonfatal stroke.@*RESULTS@#All-cause mortality occurred in 8 patients (0.7%) from the low-LDL-C group and 12 patients (2.4%) in the high-LDL-C group, with a significant difference between the two groups (adjusted hazard ratio: 4.030, 95% confidence interval: 1.088-14.934; P = 0.037). However, no significant differences existed for the risk of MACE or other secondary endpoints, such as unexpected revascularization, nor any nonfatal stroke in the two groups.@*CONCLUSION@#In this study, a high baseline LDL-C was not associated with a low risk of clinical outcomes in CAD patients undergoing first PCI, which suggested that the "cholesterol paradox" may be inapplicable to Chinese populations.

Manejo avanzado del infarto cerebral en un hospital público chileno: trombectomía mecánica en el Hospital Barros Luco Trudeau / Mechanical thrombectomy in a Chilean public hospital. Experience in 149 patients

BACKGROUND: Mechanical thrombectomy is the accepted treatment for acute ischemic stroke in Large Vessel Occlusion. The Barros Luco Trudeau hospital developed endovenous thrombolysis in 2010, and since 2012, implemented endovascular management, becoming the neurovascular center in the southern area of the metropolitan region. AIM: To describe endovascular management of acute ischemic stroke in a Chilean public hospital. Material and Methods: Analysis of patients with acute ischemic stroke that were treated with mechanical throm-bectomy from 2012 to 2019 in the Barros Luco Hospital. RESULTS: In the study period, a mechanical thrombectomy was carried out in 149 patients aged 61 ± 15 years (46% females). The average National institute of Health Stroke Scale (NIHSS) at presentation was 19 ± 4-5. Anterior or posterior circulation involvement was present in 89.9 and 10.1 % of patients. Twenty-five percent of patients were referred from other public centers. The mean lapse between onset of symptoms and thrombectomy was 266 ± 178 in. Ninety days after the procedure, 58% of patients had minimal or absent disability (Modified Ranson score of 0-2), and 19,2% died. CONCLUSIONS: Mechanical thrombectomy, according to this experience, has favorable clinical outcomes in patients with high NIHSS scores at entry.

Correlation analysis of Trial of Org 10172 in acute stroke treatment classification and National Institutes of Health Stroke Scale score in acute cerebral infarction with risk factors

SUMMARY OBJECTIVE: The aim of this study was to investigate the correlation between the Trial of Org 10172 in acute stroke treatment classification and the National Institutes of Health Stroke Scale score of acute cerebral infarction as well as acute cerebral infarction's risk factors. METHODS: The clinical data of 3,996 patients with acute cerebral infarction hospitalized in Hebei Renqiu Kangjixintu Hospital from January 2014 to November 2018 were analyzed retrospectively. According to Trial of Org 10172 in acute stroke treatment, they were divided into five groups: arteriosclerosis, cardio cerebral embolism, arterial occlusion, other causes, and unknown causes. Through questionnaire design, routine physical examination, and physical and chemical analysis of fasting venous blood samples, the risk factors were evaluated, and the correlation between Trial of Org 10172 in acute stroke treatment classification and National Institutes of Health Stroke Scale classification was analyzed using multivariate logistic regression. In addition, the relationship between National Institutes of Health Stroke Scale score and risk factors in different groups was compared, and the correlation between Trial of Org 10172 in acute stroke treatment classification and National Institutes of Health Stroke Scale score was analyzed. RESULTS: Multivariate logistic regression analysis showed that diabetes, atrial fibrillation or stroke history, age, and education level were related to Trial of Org 10172 in acute stroke treatment classification. In the National Institutes of Health Stroke Scale comparison, the scores of the cardio cerebral embolism group were significantly higher than those of the other four groups, and patients with diabetes, atrial fibrillation, or stroke history had a high share, especially atrial fibrillation (33.06%). CONCLUSIONS: The nerve function defect is more serious after acute cerebral infarction with cardiogenic cerebral embolism, indicating a poor prognosis.

La inflamación como el nexo entre la enfermedad periodontal y la enfermedad cardiovascular / Inflammation as a link between periodontal disease and cardiovascular disease

La periodontitis es una enfermedad no transmisible, con una alta prevalencia, que oscila entre el 45% y el 50% de la población mundial, ocupando el sexto lugar entre las enfermedades más frecuentes de la huma-nidad. Existe suficiente evidencia que avala la relación entre la enfermedad periodontal y la enfermedad car-diovascular, responsable de aproximadamente el 45% de las muertes en países desarrollados, compren-diendo en su causalidad al infarto de miocardio, el accidente cerebrovascular, la insuficiencia cardíaca y las arritmias, que causan alrededor del 95 % de las muertes relacionadas con la enfermedad cardiovas-cular. Ambas patologías presentan factores de riesgo comunes ampliamente reconocidos, como la diabetes y el tabaquismo, pero además manifiestan caracte-rísticas genéticas y epigenéticas que avalan distintos mecanismos etiopatológicos. Más allá de los factores de riesgo comunes, se han propuesto dos mecanis-mos para explicar la relación entre la enfermedad periodontal y las cardiovasculares. Uno de ellos, constituye la invasión directa de patógenos periodontales en las células endoteliales. El otro mecanismo sugerido (vía indirecta), ocasionado por la respuesta inflamatoria sistémica que resulta en niveles cróni-camente elevados de diferentes citoquinas, también relacionadas con la enfermedad vascular aterosclerotica como IL-1ß, IL-6, IL-8, TNF-α, PCR y la proteína quimioatrayente de monocitos, podría estar mediado por productos bacterianos, como los lipopolisacári-dos que alcanzarían la circulación induciendo una potente respuesta inmunitaria. Estos mecanismos pueden actuar inflamando las células endoteliales, modulando el metabolismo de los lípidos y aumentan-do el estrés oxidativo, favoreciendo la aterosclerosis, conformando la expresión de un fenotipo arterial in-flamatorio, generando el nexo entre la enfermedad periodontal y las patologías cardiovasculares (AU))

Periodontitis is a non-communicable disease which is highly prevalent worldwide. It was reported to range from 45% to 50% around the world and it was the sixth most prevalent condition of humanity. Consistent body of evidence explains the relationship between periodontal disease and other common systemic conditions such as cardiovascular disease. Periodontitis is likely to cause a 45% of deaths in developed countries, including myocardial infarction, stroke, heart failure and arrhythmias that cause about a 95% of deaths related to cardiovascular disease.Both diseases share many risk factors, such as diabetes and smoking; but also, genetic, and epigenetic characteristics support several etiopathological mechanisms. Beyond the common risk factors, two mechanisms have been proposed to elucidate the relationship between the periodontal disease and cardiovascular diseases. One of them supports the concept that periodontal pathogens are capable of the direct invasion of endothelial cells. The other mechanism suggested (indirect pathway), caused by the disease resulting in chronically elevation of CRP, inflammatory cytokines, the monocyte chemoattractant protein, could be mediated by bacterial products, such as lipopolysaccharides, wich induce a potent immune response and can accelerate endothelial dysfunction. These mechanisms may act by inflaming endothelial cells, modulating lipid metabolism and increasing oxidative stress, favoring atherosclerosis, determining the expression of an inflammatory arterial phenotype, generating the link between periodontal disease and cardiovascular pathologies (AU)

Research progress in atrial fibrillation with cerebral small vessel disease / 中南大学学报(医学版)

Non-valvular atrial fibrillation is a common arrhythmia and a major risk factor for cardioembolic stroke. Small cerebral vascular disease is a syndrome of clinical, cognitive, imaging, and pathological manifestations caused by intracranial small vascular lesions. The imaging findings on cranial magnetic resonance usually shows recent subcortical small infarction, vascularised lacunae, white matter hypersignal, perivascular space enlargement, cerebral microhemorrhage, and brain atrophy. It is a major cause of neurological loss and cognitive function decline in the elderly. Current studies suggest that atrial fibrillation may increase the imaging load of cerebral small vessel disease through a series of mechanisms such as microembolization, hypoperfusion, inflammation, endothelial dysfunction, and lymphoid system dysfunction. The imaging of cerebral small vessel disease with atrial fibrillation has a potential relationship with cognitive function decline and is related to the occurrence and prognosis of stroke, even more has a potential role in suggesting the etiology and secondary prevention strategies of ischemic stroke.

Risk factors of postoperative stroke in elderly patients with hip fracture / 中国骨伤

OBJECTIVE@#To study the risk factors of stroke after of elderly patients with hip fracture after operation.@*METHODS@#From March 2012 to June 2017, 500 elderly patients with hip fracture who underwent hip replacement were selected, including 286 males and 214 females, aged from 60 to 76 years old with an average of (68.49±11.85) years. They were divided into stroke group with 30 cases and control group with 470 cases according to the occurrence of acute stroke within two weeks after operation. The general data and serum contents of cytokines IL-1, IL-6, IL-10 and TNF-α were compared between the two groups. The overall survival of the two groups were followed up.@*RESULTS@#There was no significant difference in sex, age, anesthesia method, operation time, intraoperative blood loss, preoperative IL-1, IL-6, IL-10 and TNF-α contenta between stroke group and control group(P>0.05). The prevalence of hypertension, diabetes mellitus, atrial fibrillation, intraoperative hypotension, IL-1, IL-6, IL-10 and TNF-α contenta 1 day and 3 days after operation of stroke group were significantly higher than control group(P<0.05);up to the date of follow-up, the cumulative survival rate of stroke patients were significantly lower than those of the control group(P<0.05). Logistic regression analysis showed that intraoperative hypotension, elevated contents of serum IL-1 and TNF-α at 1 and 3 days after operation were risk factors for acute stroke.@*CONCLUSION@#Postoperative stroke in elderly patients with hip fracture affects the prognosis of the disease. The increase of inflammatory cytokines IL-1 and TNF-α after operation is an independent risk factor for stroke.

Incidence and risk factors of ischemic stroke in patients with type 2 diabetes among urban workers in Beijing, China / 北京大学学报(医学版)

OBJECTIVE@#To explore the incidence of ischemic stroke after the onset of type 2 diabetes, and further analyze the risk factors, so as to provide a basis for further research.@*METHODS@#The data were obtained from the database of the Beijing Urban Employee Basic Medical Insurance Database. The study used a prospective design to describe the incidence of ischemic stroke in patients with type 2 diabetes. In our study, these patients were followed up for seven years. Multivariate Logistic regression models were used to analyze the risk factors of ischemic stroke in patients with type 2 diabetes.@*RESULTS@#A total of 185 813 newly diagnosed type 2 diabetes patients were enrolled, with an average age of (58.5±13.2) years, and 49.0% of them were males. A total of 10 393 patients with newly diagnosed ischemic stroke occurred in 7 years, with a cumulative incidence of 5.6% and an incidence density of 8.1/1 000 person-years. Ischemic stroke occurred in all age groups in patients with type 2 diabetes. The cumulative incidence was 1.5% (95%CI: 1.3%-1.6%) in group ≤44 years old, 3.6% (95%CI: 3.4%-3.7%) in group 45-54 years old, 5.4% (95%CI: 5.2%-5.5%) in group 55-64 years old, and 9.2% (95%CI: 9.0%-9.4%) in group ≥65 years old, and the cumulative incidence increased with age (P < 0.05). Cumulative incidence rate of the males (6.8%, 95%CI: 6.7%-7.0%) was higher than the females (4.4%, 95%CI: 4.3%-4.6%). Among the patients < 80 years old, the cumulative incidence rate of the males was higher than that of the females in all the age groups. In the patients ≥80 years of age, the cumulative incidence was higher in the females (9.2%) than in the males (7.9%). Further analysis revealed that complications, such as coronary heart disease (OR=3.18, 95%CI: 2.72-3.72), heart failure (OR=1.53, 95%CI: 1.32-1.79) and kidney failure (OR=1.45, 95%CI: 1.20-1.75) were associated with ischemic stroke in the patients with type 2 diabetes.@*CONCLUSION@#The incidence level of ischemic stroke in patients with type 2 diabetes is high. It is necessary to strengthen the management of risk factors in elderly patients, screen the complications of type 2 diabetes as early as possible, and take active preventive and control measures.

Evaluación de los factores de riesgo vasculares convencionales en pacientes con ataque cerebrovascular isquémico en un hospital de Uruguay / Evaluation of conventional vascular risk factors in patients with ischemic cerebrovascular attack in a hospital in Uruguay

Resumen El ataque cerebrovascular es la segunda causa de muerte en adultos en el mundo occidental. Con el objetivo de conocer el estado actual de los factoresde riesgo vasculares convencionales (FRC) para el ataque cerebrovascularisquémico (ACVi) -hipertensión arterial (HTA), dislipemia, diabetes mellitus (DM), tabaquismo, arritmias, antecedentes de ataque cerebrovascular (ACV),edad y sexo- y de valorar el cumplimiento de las medidas de prevención, se analizó la distribución de éstos según etiología y topografía en un hospital público de Montevideo, Uruguay. Se estudiaron 114 pacientes de 25-97 años con ACVi. Se aplicó un protocolo para recolectar variables afines a la investigación utilizando criterios del Trial of Org 10172 in Acute Stroke Treatment y Oxfordshire Community Stroke Project para la clasificación etiológica y topográfica respectivamente. Se consideró la presencia de HTA y DM según criterios dela Organización Mundial de la Salud, de dislipemia según el Adult Treatment Panel III, de tabaquismo por haber fumado como mínimo un cigarrillo/día en el último trimestre y de arritmia a la alteración de la frecuencia cardíaca. Se observó un aumento de la frecuencia de ACVi con la edad, mayor proporción del sexo masculino respecto a la población general hasta los 64 años y frecuencia relativa etiológica y topográfica similar a la descripta en la bibliografía. La HTA fue el FRC de mayor frecuencia, tanto único como en concomitancia con otros,seguida de dislipemia y DM. Estos fueron superiores respecto de publicaciones nacionales previas. Se corroboró la implicancia de los FRC en el ACVi y la inadecuada prevención de los factores de riesgo modificables.

Abstract Stroke is the second leading cause of death in adults in the western world. Inorder to know the current status of conventional risk factors (CRF) for ischs emic stroke (IS) hypertension (HBP), dyslipidemia, diabetes mellitus, smoking, arrhythmias, history of stroke,age and sex- and to assess compliance with prevention measures, their distribution was analysed according toetiology and topography in a public hospital in Montevideo, Uruguay. One hundred fourteen IS patients aged 25-97 years were studied. A protocol was applied to collect variables related to the research using the Trial of Org 10172 in Acute Stroke Treatment and Oxfordshire Community Stroke Project criteria for etiological andtopographic classification, respectively. The presence of hypertension (HBP) and diabetes according to World Health Organization criteria, dyslipidemia according to the criteria of the Adult Treatment Panel III, smoking having smoked at least one cigarette/day in the last trimester and arrhythmia according to the alterationof the heart rate were considered. An increased in the frequency of stroke with age, a higher proportionin men compared to the general population up to 64 years of age and relative etiological and topographic frequency like bibliography were obserbed. HBP was the most frequent CRF, both alone and in concomitance with others, followed by dyslipidemia and diabetes, these being higher to than previous national publications.The implication of CRFs in stroke and the inadequate prevention of modifiable risk factors were corroborated.

Resumo O acidente vascular-cerebral é a segunda causa de morte em adultos no mundo ocidental. Para conhecer ostatus atual dos fatores de risco vasculares convencionais (FRC) para acidente vascular-cerebral isquêmico(ACVi) -hipertensão arterial (HTA), dislipidemia, diabetes mellitus (DM), tabagismo, arritmias, antecedentesde ACVi, idade e sexo- e para avaliar o cumprimento das medidas de prevenção, sua distribuição foi analisadade acordo com a etiologia e a topografia em um hospital público de Montevidéu, Uruguai. Foram estudados114 pacientes com ACVi com idades entre 25 e 97 anos. Um protocolo foi aplicado para coletar variáveis vinculadas à pesquisa usando os critérios do Trial of Org 10172 in Acute Stroke Treatment e Oxfordshire Community Stroke Project para classificação etiológica e topográfica, respectivamente. Considerou-se apresença de HTA e DM de acordo com os critérios da Organização Mundial da Saúde, dislipidemia de acordocom o Adult Treatment Panel III, tabagismo tendo fumado pelo menos um cigarro/dia no último trimestree arritmia conforme a alteração da frequência cardíaca. Observa-se aumento da frequência de AVCi com aidade, maior proporção de homens em relação à população geral até 64 anos e frequência relativa etiológicae topográfica semelhante à bibliografia. A HTA foi o FRC mais frequente, tanto única quanto em concomitância com outras, seguida de dislipidemia e DM. Eles foram superiores às publicações prévias. O envolvimentodos FRCs no ACVi e a prevenção inadequada dos fatores de risco modificáveis foram confirmadas.

Risk score elaboration for stroke in cardiac surgery

Abstract Introduction: Stroke is a complication that causes considerable morbidity and mortality during the heart surgery postoperative period (incidence: 1.3 to 5%; mortality: 13 to 41%). Models for assessing the risk of stroke after heart surgery have been proposed, but most of them do not evaluate postoperative morbidity. The aim of this study was to develop a risk score for postoperative stroke in patients who undergo heart surgery with cardiopulmonary bypass. Methods: A cohort study was conducted with data from 4,862 patients who underwent surgery from 1996 to 2016. Logistic regression was used to assess relationships between risk factors and stroke. Data from 3,258 patients were used to construct the model. The model's performance was then validated using data from the remainder of the patients (n=1,604). The model's accuracy was tested using the area under the receiver operating characteristic (ROC) curve. Results: The prevalence of stroke during the postoperative period was 3% (n=149); 59% of the patients who exhibited this outcome were male, 51% were aged ≥ 66 years, and 31.5% of the patients died. The variables that remained as independent predictors of the outcome after multivariate analysis were advanced age, urgent/emergency surgery, peripheral arterial occlusive disease, history of cerebrovascular disease, and cardiopulmonary bypass time ≥ 110 minutes. The area under the ROC curve was 0.71 (95% confidence interval 0.66 - 0.75). Conclusion: We were able to develop a risk score for stroke after heart surgery. This score classifies patients as low, medium, high, or very high risk of a surgery-related stroke.

ABO blood group system and occurrence of ischemic stroke / Sistema ABO de grupos sanguíneos e ocorrência de acidente vascular cerebral isquêmico

ABSTRACT Background: Ischemic stroke (IS) is a multifactorial disease that presents high rates of morbimortality in Brazil. Several studies proved that there is a link between the ABO blood group system and the occurrence of thrombotic events. Nonetheless, its association with IS is not well established. Objective: For that reason, the purpose hereof was to investigate the relation between the ABO blood groups and the occurrence of IS in a Brazilian cohort of cerebrovascular diseases. Methods: Five hundred and twenty-nine subjects were included over 12 months, from which 275 presented an IS episode and 254 composed the control group. Blood samples were drawn for direct and reverse serotyping. The control and IS groups were compared regarding the traditional risk factors and the distribution of the ABO blood groups. Results: The IS group presented a higher prevalence of systemic arterial hypertension (SAH), diabetes mellitus, smoking habits, family history, cardiopathy, and sedentary lifestyle in comparison with the control group. The AB blood type prevailed among the patients (5.1 vs. 1.6%; p<0.05) and this group had more SAH cases in comparison with the O type group (92.9 vs. 67.3%; p<0.05). Conclusions: Our results suggest that the occurrence of IS is more frequent among patients of the AB blood type.

RESUMO Antecedentes: O acidente vascular cerebral isquêmico (AVCI) é uma doença multifatorial que apresenta altas taxas de morbimortalidade no Brasil. Vários estudos provaram que existe uma ligação entre o sistema ABO de grupos sanguíneos e a ocorrência de eventos trombóticos. No entanto, sua associação com AVCI não está bem estabelecida. Objetivo: Por essa razão, o objetivo deste trabalho foi investigar a relação entre os grupos sanguíneos ABO e a ocorrência de AVCI em uma coorte brasileira de doenças cerebrovasculares. Métodos: Ao longo de 12 meses foram incluídos 529 indivíduos, dos quais 275 apresentaram um episódio de AVCI e 254 compuseram o grupo controle. Amostras de sangue foram coletadas para sorotipagem direta e reversa. Os grupos controle e AVCI foram comparados em relação aos fatores de risco tradicionais e à distribuição dos grupos sanguíneos ABO. Resultados: O grupo AVCI apresentou maior prevalência de hipertensão arterial sistêmica (HAS), diabetes mellitus, tabagismo, história familiar, cardiopatia e estilo de vida sedentário em comparação ao grupo controle. O tipo sanguíneo AB prevaleceu entre os pacientes (5,1 vs. 1,6%; p<0,05) e apresentou mais casos de HAS em comparação ao tipo O (92,9 vs. 67,3%; p<0,05). Conclusões: Nossos resultados sugerem que a ocorrência de AVCI é mais frequente entre os pacientes do tipo sanguíneo AB.

Comparison of right-to-left shunt characteristics in cryptogenic embolic ischemic stroke and non-cardioembolic ischemic stroke / Comparação das características do shunt direita-esquerda em pacientes com AVC isquêmico criptogênio e AVC não cardioembólico

Abstract Background: Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin. Objective: The aim of the present study was to identify the features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke. Methods: A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver. Results: Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). According to the moment of the cardiac cycle, 75 patients (78.1%) in the UES group had a positive test at rest compared to 42 (58.3%) in the NCES group (p=0.007). Conclusions: The current study demonstrated that almost 70% of patients with undetermined embolic stroke and PFO presented a large RLS and more than 75% had RLS at rest. These findings suggest that the size of the shunt should be taken into account when evaluating whether PFO could be a possible mechanism underlying cryptogenic stroke.

RESUMO Antecedentes: Uma das potenciais fontes embólicas no acidente vascular cerebral (AVC) de origem indeterminada é o forame oval patente (FOP). Objetivo: O objetivo do presente estudo foi identificar as características do shunt direita-esquerda em paciente com AVC de etiologia indeterminada, presumidamente embólica, e comparar tais características com pacientes apresentando AVC por outras causas não embólicas. Métodos: Trata-se de um estudo retrospectivo com 168 pacientes com AVC e forame oval patente, separados em dois grupos: AVC embólico de etiologia indeterminada e AVC por outras causas não embólicas. Todos os pacientes foram submetidos a Doppler transcraniano, para avaliar a presença de shunt direita-esquerda por meio do teste de embolia paradoxal. Além da quantificação de microbolhas, também foi avaliada a presença de shunt em repouso e sob manobra de Valsalva. Resultado: Do total, 96 pacientes foram incluídos no primeiro grupo (AVC indeterminado) e 72, no segundo grupo (AVC não embólico). No primeiro grupo, 65 pacientes exibiram shunt com passagem de mais de 10 microbolhas (67,5%), enquanto no segundo grupo isso aconteceu em 51,4% (p=0,038) dos casos. Além disso, 75 pacientes (78,1%) do primeiro grupo tiveram teste positivo ao repouso, comparados com 42 pacientes (58,3%) no segundo grupo (p=0,007). Conclusão: O presente estudo demonstrou que até 70% dos pacientes com AVC de etiologia indeterminada e forame oval apresentaram shunts maiores; em mais de 75%, houve passagem de microbolhas ao repouso. Esses achados sugerem que as características do shunt, como quantidade de microbolhas e passagem ao repouso, devem ser levadas em consideração na avaliação do FOP como possível mecanismo subjacente ao AVC.

Embolic Stroke of Undetermined Source (ESUS) and Stroke in Atrial Fibrillation Patients: not so Different after all?

Abstract Background: Stroke related to atrial fibrillation (AF) is associated with high recurrence and mortality rates. Embolic Stroke of Undetermined Source (ESUS) is associated with fewer vascular risk factors, less disability, and a high recurrence rate. Objective: To compare risk factors, functional outcomes and the occurrence of primary endpoint (a composite of recurrent stroke, cardiovascular death, and myocardial infarction) between AF stroke and ESUS patients. Method: A retrospective analysis was conducted including all consecutive patients with first-ever ischemic stroke admitted to the Hospital de Clinicas (Clinical Hospital) of the Federal University of Paraná from October 2012 to January 2017 (n=554). There were 61 patients with stroke due to AF and 43 due to ESUS. Both groups were compared for demographic characteristics and vascular risk factors. Logistic regression models were performed to assess the impact of each variable on the primary endpoint in a 12-month follow-up. Statistical significance was considered for p-values < 0.05. Results: ESUS patients, as compared to AF patients, were younger and more likely to be smokers. ESUS patients presented a mean CHADS2VASc score of 4, while the AF group presented a score of 5 (p <0.001). The primary endpoint was observed in 9 (20.9%) ESUS and 11 (18.0%) AF patients over a 12-month period (p=0.802). Higher glucose levels upon hospital admission (p=0.020) and a higher modified Rankin Scale upon hospital discharge (p=0.020) were predictors of the primary endpoint occurrence. Conclusion: AF and ESUS stroke patients presented very similar independence rates upon hospital discharge and outcomes after 12 months, despite some baseline differences, including stroke recurrence, vascular death, and myocardial infarction.

Caracterización clínica e imagenológica de una serie de pacientes con disección de arterias cervicales e intracraneales / Cervicocranial arterial dissection: experience in 57 patients

Background: Cervicocranial arterial dissection (CIAD) is an important cause of stroke. Aim: To describe the clinical and imaging characteristics of patients with CIAD. Material and Methods: An anonymous registry was made including all patients admitted to a private hospital with a diagnosis of CIAD. Patients were subdivided as having an anterior or posterior circulation dissection (ACD or PCD, respectively). Results: Fifty-seven patients aged 40 ± 8 years (60% women) were included in the study, 39 with PCD and 18 with ACD. Cervical pain was the most common symptom. CIAD was diagnosed with no clinical or imaging signs of stroke in 49% of patients. Fifty one percent of patients had focal neurological deficits and 72% had a NIH stroke score below five. No significant differences between patients with ACD or PCD were found. Fifty patients received antiplatelet therapy (simple or dual), seven patients were anticoagulated and 13 were subjected to stenting due to progression of stenosis with hemodynamic involvement or bilateral dissection with scarce collaterals. The lesion was located in V3 segment in 27 patients and cervical segment of the internal carotid in 16 cases. A favorable Modified Rankin Scale (0-2) was achieved in 85.9%, with a trend towards achieving better functional prognosis in PCD. Conclusions: Due to the greater availability of non-invasive imaging methods, 50% of these patients with CIAD did not have a stroke. Thus, an earlier and more timely management is feasible.

AISYF: first national, prospective, multicenter study of young patients with stroke in Argentina / AISYF: primer estudio nacional, prospectivo y multicéntrico de pacientes jóvenes con ataque cerebral en Argentina

Abstract Up to 15% of all strokes affect young patients and the incidence of ischemic stroke in this population is rising. Nevertheless, there is limited information of cerebrovascular events in this population both in our country and in Latin America. The aim of our study was to evaluate the clinical characteristics and risk factors of young adults with stroke in Argentina. This is a prospective, multicenter study of stroke in young adults (18 - 55 years) in Argentina. Patients presenting with a cerebrovascular event within 180 days were included. Stroke subtypes were classified according to TOAST criteria. A total number of 311 patients were enrolled (men 53.9%, mean age: 43.3 years). Ischemic strokes occurred in 91.8% (brain infarcts 82.6%, transient ischemic attack 9.2%) and hemorrhagic strokes in 8.2%. The most frequent vascular risk factors (including ischemic and hemorrhagic strokes) were: hypertension 120 (41%), smoking 92 (31.4%), dyslipidemia 81 (27.6%) and, over weight/obesity: 74 (25.3%). Stroke subtypes were: large artery disease 12.3%, cardioembolism 7.5, small artery occlusion 11.5%, other defined etiology 27.1%, and undetermined etiology 41.6%. Our study demonstrates that vascular risk factors are very frequent in young adults with stroke. Our findings underline that urgent strategies are required for primary and secondary stroke prevention in this group of patients.

Resumen Aproximadamente un 15% de todos los ataques cerebrovasculares afectan a pacientes jóvenes y su incidencia estaría en aumento. Existe escasa información sobre el ataque cerebral en esta población tanto en nuestro país como en Latinoamérica. El objetivo de nuestro estudio fue evaluar las características clínicas y los factores de riesgo de los adultos jóvenes con ictus en Argentina. Realizamos un estudio prospectivo y multicéntrico en adultos jóvenes (18-55 años) en Argentina, que presentaron un evento cerebrovascular dentro de los 180 días previos. Los subtipos de ictus se clasificaron según los criterios de TOAST. Se incluyeron un total de 311 pacientes (hombres 53.9%, edad media: 43,3 años). Los ataques cerebrovasculares isquémicos ocurrieron en el 91.8% (infartos cerebrales 82.6%, ataque isquémico transitorio 9.2%) y los eventos hemorrágicos correspondieron al 8.2%. Los factores de riesgo vascular más frecuentes (incluyendo los eventos isquémicos y hemorrágicos) fueron: hipertensión 120 (41%), tabaquismo 92 (31.4%), dislipidemia 81 (27.6%) y sobrepeso/obesidad: 74 (25.3%). Los subtipos de ictus isquémicos fueron: arteriopatía de gran vaso 12.3%, cardioembolismo 7.5%, oclusión de pequeña arteria 11.5%, otra etiología definida 27.1% y etiología indeterminada 41.6%. Los factores de riesgo vascular son muy frecuentes en los adultos jóvenes con ictus. Nuestros hallazgos subrayan que se requieren estrategias urgentes para la prevención primaria y secundaria del ictus en este grupo particular de pacientes en nuestro país.

Clinical Characteristics and Therapeutic Adherence of Women in a Referral Outpatient Clinic for Severe Hypertension

Abstract Background Cardiovascular disease is the main cause of death worldwide. There is a lack of studies addressing this issue in women and its risk factors, such as hypertension. Objective To evaluate the clinical and therapeutic profile of women with hypertension and to determine which factors are related to treatment adherence and blood pressure control. Methods Cross-sectional study of 181 hypertensive women treated at an outpatient referral clinic. Data were obtained from medical records, face-to-face interviews, and physical examination, using a standardized form. Statistical analysis was performed with prevalence ratio, chi-square and Student's t test. Significance was accepted at p<0.05. Results Most patients were mixed-race or black (91.7%) and the mean age was 66.09 years. Only 44.2% of patients had controlled blood pressure. The prevalence of stroke was 14.9%, whereas the prevalence of coronary artery disease was 19.3%. The mean number of oral antihypertensive drugs prescribed to each individual was 3.41. A history of stroke was more often found in patients with uncontrolled blood pressure (p=0.013) and in those using three or more antihypertensives (p=0.023). Eighty patients (44.2%) had high treatment adherence. Depression was more frequently reported by patients with poorer adherence to treatment (p=0.026). Conclusion Women with hypertension presented a high prevalence of cardiovascular risk factors and cardiovascular events, including a significantly higher prevalence of stroke in those with uncontrolled hypertension. Self-reported depression may help identify patients at risk of nonadherence to treatment.

Comportamiento de la enfermedad cerebrovascular aguda en una zona rural / Behavior of acute cerebrovascular disease in a rural área / Comportamento da doença cerebrovascular aguda em área rural

RESUMEN Introducción: Las enfermedades cerebrovasculares agudas se consideran una epidemia vascular y un problema socio-sanitario de primer orden. Objetivo: Describir el comportamiento de la enfermedad cerebrovascular en pacientes de una zona rural perteneciente al Policlínico Comunitario "Juan Bruno Zayas"de Cifuentes, provincia Villa Clara, durante el año 2019. Método: Se realizó un estudio observacional de tipo descriptivo transversal. La muestra estuvo constituida por 32 pacientes que cumplieron los criterios de inclusión y exclusión. Se aplicó un cuestionario a pacientes y familiares cercanos, además, de la revisión de historias clínicas individuales y familiares con el propósito de identificar la etiopatogenia, mes en que ocurrió el evento cerebrovascular, factores de riesgo asociados, tipo de enfermedad cerebrovascular, variante, y forma de presentación clínica. Resultados: Predominó el grupo de edades de 60-69 años, sexo masculino y color de la piel negro. Los factores de riesgo más frecuentes fueron: hipertensión arterial sistémica, tabaquismo y dislipidemia. Marzo fue el mes donde hubo mayor número de casos diagnosticados como enfermedad cerebrovascular. Prevaleció el infarto cerebral como variante más frecuente. Conclusiones: La enfermedad cerebrovascular aguda siempre está asociada a los factores de riesgo clásicos. Existe predominio del ictus de origen isquémico sobre el hemorrágico. Más de la mitad de los pacientes tiene cifras elevadas de tensión arterial durante el evento cerebral. Se evidencia mayor frecuencia de casos durante los meses de menores temperaturas.

ABSTRACT Introduction: Acute cerebrovascular diseases are considered a vascular epidemic and a first-order social and health problem. Objective: To describe the behavior of cerebrovascular disease in patients who residing in a rural area associated to the Policlínico Comunitario "Juan Bruno Zayas" in Cifuentes, Villa Clara, period time 2019. Method: A cross-sectional, descriptive observational study was carried out. The sample selected envolved 32 patients who met the inclusion and exclusion criteria. A questionnaire was administered to patients and close relatives, and individual and family medical records were reviewed to identify the etiopathogenesis, month in which the cerebrovascular event occurred, associated risk factors, type of cerebrovascular disease, variant, and form of clinical presentation. Results: Group age 60 to 69 and male black patients, were predominant. Most common risk factors were: systemic arterial hypertension, smoking and dyslipidemia. March was the month with the highest number of cases diagnosed with cerebrovascular disease. Cerebral infarction prevailed as the most frequent variant. Conclusions: Acute cerebrovascular disease is always associated with classical risk factors. Ischemic stroke predominates over hemorrhagic stroke. More than half of patients have elevated blood pressure during the cerebral event. Arising cases were higher during the months with lower temperatures.

RESUMO Introdução: As doenças cerebrovasculares agudas são consideradas uma epidemia vascular e um problema sócio-sanitário de primeira ordem. Objetivo: descrever o comportamento da doença cerebrovascular em pacientes de uma área rural pertencente à Policlínico Comunitario "Juan Bruno Zayas", de Cifuentes, província de Villa Clara, durante o ano de 2019. Método: Foi realizado um estudo observacional descritivo transversal. A amostra foi composta por 32 pacientes que atenderam aos critérios de inclusão e exclusão. Foi aplicado questionário aos pacientes e familiares próximos, além da revisão dos prontuários individuais e familiares para identificação da etiopatogenia, mês em que ocorreu o evento cerebrovascular, fatores de risco associados, tipo de doença cerebrovascular, variante e forma de apresentação clínica. Resultados: Predominou a faixa etária de 60 a 69 anos, sexo masculino e cor da pele negra. Os fatores de risco mais frequentes foram: hipertensão arterial sistêmica, tabagismo e dislipidemia. Março foi o mês com maior número de casos diagnosticados como doença cerebrovascular. O infarto cerebral prevaleceu como a variante mais frequente. Conclusões: A doença cerebrovascular aguda está sempre associada a fatores de risco clássicos. Há predomínio do AVC de origem isquêmica sobre o hemorrágico. Mais da metade dos pacientes apresentam níveis elevados de pressão arterial durante o evento cerebral. Há maior frequência de casos nos meses de menor temperatura.