Ischemic stroke (IS) and Chagas disease are strongly related. Nevertheless, little attention has been paid to this association and its natural history. The current guidelines concerning the management and secondary prevention of IS are largely based on the incomplete information or extrapolation of knowledge from other stroke etiologies. We performed a retrospective study which compared stroke etiologies among a cohort of hospitalized patients with IS and Chagas disease. The Instituto de Pesquisa Evandro Chagas/Fundação Oswaldo Cruz (IPEC/FIOCRUZ) embolic score was also used to identify and evaluate the risk of embolism in this population. A total of 86 patients were included in the analysis. The mean age of the study population was 58 years, and 60 % were men. According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) Classification, 45 % of the strokes were of undetermined etiology and 45 % of cardioembolic origin, while the Stop Stroke Study/Causative Classification System (SSS/CCS) TOAST indicated that 34 % were undetermined and 50 % cardioembolic (p < 0.01); 44 % of these patients were classified as having a high embolic risk according to the IPEC/FIOCRUZ score. Among the undetermined causes, 83.3 % fulfilled the criteria for embolic stroke of undetermined source (ESUS). The SSS/CCS TOAST etiological classification system was superior to the classical TOAST criteria in identifying a cardioembolic etiology in patients with ischemic stroke and Chagas disease. The IPEC/FIOCRUZ score did not correlate with the number of patients who were determined to have cardioembolic stroke etiologies. The current guidelines for stroke prevention should be reviewed in this population.

Results: After multivariate analysis, the association between PFO x cryptogenic IS was still statistically significant with odds ratio (adjusted association with cryptogenic IS (adjusted met all the causality criteria. Conclusion:The causal relation between PFO and cryptogenic IS in the young population is highly probable. This fact should be considered in the therapeutic decision.

Background: Chagas disease is related to ischemic stroke (IS), although few epidemiological studies have evaluated the associated mortality and recurrence. Our objective is to determine factors associated with mortality and recurrence of IS in patients with IS and Chagas disease. Methods: We retrospectively studied data obtained from electronic medical records of patients admitted at SARAH Hospitals across Brazil between 2009 and 2013. Using Cox regression analysis for mortality and logistic regression for recurrence, we assessed primary population characteristics and statistical associations between risk factors and outcomes. Results: We analyzed 279 patients who were followed up until 2016. The mean age at stroke onset was 61 with a 10% frequency of death. Multivariate analysis assessing mortality demonstrated that the associated factors were age at stroke (hazard ratio [HR] 1.04), initial modified Rankin Scale (mRS; HR 20.91), bladder dysfunction (HR 2.51), diabetes mellitus (DM; HR 3.64), and alcoholism (HR 3.37). Multivariate analysis assessing recurrence demonstrated that the associated factors were age at ictus (OR 0.96), cognitive deficit (OR 0.44), initial mRS (OR 1.84), cardioembolic etiology (OR 2.47), and female sex (OR 2.73). Conclusions: Cardiac conditions did not correlate with mortality or recurrence. Age was a protective factor against recurrence, probably due to cumulative risk of IS over time, while initial mRS was associated with both outcomes. Treating diseases such as DM and bladder dysfunction, and early treatment to reduce the initial mRS could potentially prevent both outcomes; also, establishing a correct etiological diagnosis is important.

Resumo Fundamento O acidente vascular encefálico isquêmico (AVEi) e a doença arterial coronariana (DAC) coexistem frequentemente e compartilham fatores de risco para doença aterosclerótica. Segundo a American Heart Association , os subtipos de AVEi podem ser considerados equivalentes de risco para DAC, mas a evidência para o AVEi não-aterosclerótico não está bem definida. Além disso, o escore de cálcio coronário (CAC) é um marcador preciso para estimar o risco de DAC. Entretanto, a distribuição do CAC pelos subtipos de AVEi ainda não foi bem caracterizada. Objetivos Comparar o CAC entre os grupos de AVEi ateroscleróticos e não ateroscleróticos, e determinar quais covariáveis estão associadas a CAC alto no AVEi Métodos Em um estudo transversal, incluímos todos os pacientes com AVEi, com idades entre 45 a 70 anos no momento do acidente vascular, consecutivamente admitidos em um hospital de reabilitação entre agosto de 2014 e dezembro de 2016, sem DAC prevalente. Todos os pacientes passaram por tomografia computadorizada (TC), para medir o CAC. CAC≥100 foi considerado alto risco de DAC. O nível de significância foi p<0,05. Resultados Dos 244 pacientes estudados (média de idade de 58,4±6,8 anos; 49% do sexo feminino), 164 (67%) apresentavam etiologia não-aterosclerótica. As proporções de CAC≥100 foram semelhantes entre os grupos ateroscleróticos e não-ateroscleróticos (33% [n=26] x 29% [n=47]; p= 0,54). Entre todos os pacientes com AVEi, apenas os de idade ≥60 anos foram associados independentemente a CAC≥100 (RC 3,5; 95% IC 1,7-7,1), ajustado para hipertensão, dislipidemia, diabetes, sedentarismo, e histórico familiar de DAC. Conclusão O AVEi aterosclerótico não apresentou risco maior de DAC quando comparado ao AVEi não-aterosclerótico de acordo com o CAC. Apenas a faixa etária ≥60 anos – mas não a etiologia - foi associada independentemente a CAC≥100. (Arq Bras Cardiol. 2020; 115(6):1144-1151)

AVCI criptogênico e FOP (razão de chance de 4,3; IC95% 1,7 -10,7). Foram diagnosticados apenas 5 casos de aneurisma do septo interatrial entre aqueles com FOP, todos classificados como AVCI criptogênico. Ta n t o a sensibilidade, especificidade e os valores preditivos positivo e negativo exibiram valores superiores a 85%, semelhantes, pelo menos com base nos intervalos de confiança. Conclusão: Constatamos, pela primeira vez em nosso meio, forte associação entre AVCI criptogênico e FOP. O DTC é importante re c u r s o diagnóstico nesse contexto, já que sua validade foi considerada muito boa, podendo ser útil no rastre a m e n t o de fontes emboligênicas, part i c u l a rmente alterações do septo atrial. Uma investigação minuciosa desses casos se impõe, notadamente pela perspectiva de fechamento do shunt intracardíaco.PA L AV R A S -C H AVE: forame oval, defeitos do septo interatrial, acidente cere b ro v a s c u l a r, ecocard i o g r a f i a transesofagiana, ultra-sonografia doppler transcraniana. Abnormalities of interatrial septum and ischemic stroke in young people ABSTRACT -O b j e c t i v e :To verify the frequency of patent foramen ovale (PFO) among patients with ischemic s t roke (cryptogenic or with a known cause) investigated by transcranial doppler (TCD) and transesophageal e c h o c a rd i o g r a p h y. Secondarily, to determine the diagnostic validity of the form e r, compared with the later m e t h o d . Method: R e t ro s p e c t i v e l y, 124 patients (<51 years old) with ischemic stroke were submitted to TCD and or transesophageal echocardiography. The patients were classified as cryptogenic stroke or not. Results: We could found an important association between cryptogenic ischemic stroke and PFO (odds ratio 4.3 -CI 95% 1.7 -10.7). Only five cases of interatrial septal aneurysm were diagnosed among patients with PFO. Sensitivity, specificity and positive and negative predictive values exhibited values upper of 85%, equivalents, at least based on confidence interv a l s . Conclusion: We could determine, for the first time in our c o u n t ry, a strong association between cryptogenic ischemic stroke and PFO. The TCD is a valuable diagnostic re s o u rce in this context since its validity was considered excellent. A detailed investigation in these cases should always be done due to the possibility of FOP closure.KEY WORDS: patent foramen ovale, atrial heart septal defects, stroke, transesophageal echocard i o g r a p h y, transcranial doppler.

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