-Cognitive symptoms are common in patients with congestive heart failure (CHF) and are usually attributed to low cerebral blood flow. In the present study, we aimed to evaluate global cognitive function (Mini Mental State Exam -MMSE) in relation to both cardiac function (evaluated by echocardiogram) and cere b rovascular hemodynamics (evaluated by transcranial Doppler -TCD) in CHF patients. In 83 patients studied, no correlation was found between echocardiographic parameters and MMSE scores. In contrast, a significant correlation was found between right middle cerebral art e ry (RMCA) mean flow velocity and MMSE score (r=0.231 p=0.039), as well as between RMCA pulsatility index and MMSE score (r s = -0.292 p=0.015). After excluding patients with a previous history of stroke, only RMCA pulsatility index c o rrelated with MMSE score (r s =-0,314 p=0,007). The relationship between high cere b rovascular re s i s t a n c e and worse cognitive scores suggest that microembolism may be responsible for a significant pro p o rtion of cognitive symptoms in CHF patients.KEY WORDS: transcranial Doppler, congestive heart failure, cognitive dysfunction cere b rovascular disord e r s .Disfunção cognitiva na insuficiência cardíaca congestiva: evidência de etiologia micro e m b ó l ica ao Doppler transcraniano RESUMO -Sintomas cognitivos são comuns em pacientes com insuficiência cardíaca congestiva (ICC) e são geralmente atribuídos a um regime de baixo fluxo sanguíneo cerebral. Neste estudo, objetivamos avaliar a função cognitiva global (Mini Exame do Estado Mental -MEEM) em pacientes com ICC e sua relação com o grau de disfunção cardíaca (avaliada pelo ecocardiograma) e a hemodinâmica cerebral (avaliada pelo Doppler transcraniano -DTC). Em 83 pacientes estudados, nenhuma correlação foi encontrada entre a pontuação no MEEM e parâmetros ecocardiográficos. Em contraste, uma correlação significativa foi encontrada entre a velocidade média na artéria cerebral média direita (ACMD) e a pontuação no MEEM (r=0,231 p=0,039), assim como entre o índice de pulsatilidade na ACMD e a pontuação no MEEM (r s =-0,292 p=0,015). Após excluir pacientes com histórico prévio de acidente vascular encefálico, somente o índice de pulsatilidade na ACMD manteve uma correlação com a pontuação no MEEM (r s =-0,314 p=0,007). A relação entre maior resistência vascular cerebral e pior desempenho cognitivo sugere que microembolia pode ser re s p o nsável por uma proporção significativa de sintomas cognitivos em pacientes com ICC. PALAVRAS-CHAVE: Doppler transcraniano, insuficiência cardíaca congestiva, acidente vascular cerebral.
Chagas disease (CD) remains a major cause of cardiomyopathy and stroke in developing countries. Brain involvement in CD has been attributed to left ventricular dysfunction, resulting in chronic brain ischemia due to hypoperfusion and/or embolic infarcts. However, cognitive impairment in CD may occur independently of cardiac disease. Therefore, we aimed to investigate head computed tomography (CT) findings in patients with Chagas disease cardiomyopathy (CDC) in comparison with other cardiomyopathies (OC). We studied 73 patients with CDC (n = 41) or OC (n = 32) matched for age and gender. These patients underwent head CT, rated by an investigator blinded to all clinical information. Head CT was rated for the presence of lacunar or territorial infarcts, as well as for measuring the total volumes of the brain, cerebellum and ventricles. Total brain volume was smaller in CDC as compared to OC patients (1,135 +/- 150 vs. 1,332 +/- 198 cm(3), P < 0.001). Cerebellar and ventricular volumes did not differ between the groups. The prevalence of brain infarcts did not differ significantly between the groups. Chagas disease was the only independent predictor of brain atrophy in the multivariable analysis (OR = 1.38; 95% CI = 1.06-1.79, P = 0.017). Chagas disease is associated with brain atrophy independent of structural cardiac disease related to cardiomyopathy. Brain atrophy, rather than multiple infarcts, may represent the main anatomical substrate of cognitive impairment in Chagas disease.
Chagas disease (CD) remains a major cause of stroke in developing countries, but cognitive repercussion of CD has not been well studied.ObjectiveTo compare the frequency and pattern of cognitive dysfunction in patients with CD cardiomyopathy (CDC) and other cardiomyopathies (OC).MethodsWe studied 37 patients with CDC and 42 patients with OC with similar age, educational level and cardiac systolic function. Cognitive tests were applied to both groups by a single examiner blinded to CD status. Logistic regression multivariable models were constructed to ascertain predictors of cognitive dysfunction for each test.ResultsCognitive dysfunction was detected in 9 (24%) CDC patients and 6 (14%) OC patients by Mini Mental State Exam (MMSE) corrected for educational level. Independent predictors of abnormal MMSE (p<0.05) included stroke history (OR=5.51; 95% CI=1.27–24.01) and digoxin use (OR=0.23, 95% CI=0.06–0.89), while CD showed a trend toward statistical significance (OR=4.63; 95% CI=0.87–24.73, p=0.07). Delayed recall of Rey’s Complex Figure Test was significantly worse in CD patients, where this remained a significant predictor in the multivariable analysis (OR=4.67; 95% CI=1.23–17.68).ConclusionsCognitive dysfunction is frequent in Chagas disease and should be considered as an outcome measure in Chagas disease studies.
Background and Aims: Chagas disease is a common cause of heart failure (HF) and death in developing countries. Although stroke is known to occur in these patients, an accurate estimate of stroke incidence is lacking. We aimed to determine the incidence of stroke and death in patients with HF, comparing Chagas and non-Chagas etiologies. Methods: Cohort of stroke-free patients with HF (Framingham criteria) followed in a university-based outpatient clinic in Brazil. Baseline characteristics included sociodemographic, risk factor assessment, echocardiographic and electrocardiographic findings. Chagas disease was defined by appropriate serologic tests. Cause-specific Cox regression was used to search for predictors of stroke or death as separate outcomes. Results: We studied 565 patients with HF between January 2003 and December 2018, mean age 54.3 ± 12.9 years, 305 (54.0%) female, 271/535 (50.7%) with Chagas disease. Chagas patients were older (55.5 vs 53.1 years), more frequently women (60.5% vs 47.3%), less frequently harbored coronary artery disease (14.5% vs 34.1%) when compared to non-Chagas patients. Echocardiography showed more severe disease among non-Chagas patients [median left ventricle ejection fraction (LVEF) 37.3% vs 47.0%]. Over a mean 42.9 (± 34.4) months, we followed 404 (71.5%) patients, completing 1442 patient-years of follow-up. Stroke incidence was higher in Chagas when compared to non-Chagas patients (20.2 vs 13.9 events per 1000 patient-years), while death rate was similar (41.6 vs 43.1 deaths per 1000 patient-years). In the multivariable analysis for stroke outcome adjusted for LVEF and arrhythmias, cause-specific hazard ratio (CSHR) for Chagas was 2.54 (95% confidence interval 1.01 â 6.42, p=0.048). Chagas disease was also associated with increased risk of death (CSHR 1.83; 95% confidence interval 1.04 â 3.24, p=0.037). Conclusion: Chagas disease is associated with increased risk of stroke and death when compared to other etiologies of HF, independently of HF severity or cardiac arrhythmias, suggesting other factors contribute to increased stroke risk and mortality in Chagas disease. Early prevention and treatment of Chagas disease is imperative to reduce a later risk of stroke in endemic areas.
Objectives: To compare warfarin and dabigatran for thromboembolic event prevention in patients with nonvalvular atrial fibrillation or atrial flutter. Methods: This was a retrospective cohort of participants with nonvalvular atrial fibrillation or atrial flutter using either warfarin or dabigatran in a reference center in Brazil. Results: There were 112 patients (mean age 65.5 years), with 55.3% using warfarin. The median duration of follow-up was 1.9 years for warfarin and 1.6 years for dabigatran (p = 0.167). Warfarin patients had a higher median of medical appointments per year (8.3 [6.8-10.4] vs 3.1 [2.3-4.2], p < 0.001) and the frequency of minor bleeding was more than four times higher (17.7% vs 4.0%, p = 0.035). Among patients with prior stroke, those using warfarin had 2.6 times more medical appointments for person-years of follow-up (8.5 vs 3.3). There was no major bleeding or embolic event during follow-up period. Conclusion: The dabigatran group had a lower frequency of minor bleeding and number of medical appointments than the warfarin group, without more embolic events or major bleeding.
Dear Editor, Defining the underlying mechanism of ischemic stroke is one of the cornerstones of secondary prevention, but up to 42% are classified as embolic stroke of undetermined source (ESUS). 1-4 In this setting, cardiac magnetic resonance imaging (CMRI) has been proposed as a tool to further stratify patients with ESUS. 5-8 However, clinical predictors of these CMRI findings are not well studied, which may help to restrict a costlier investigation to high-risk subjects. We aimed to determine the prevalence of abnormalities found in CMRI in patients with ESUS; and to examine which variables are associated with the occurrence of such abnormalities. Consecutive patients admitted to an outpatient university-based stroke clinic were investigated for stroke etiologies using the Causative Classification of Stroke. Patients with ESUS were further investigated with CMRI, using a previously defined protocol. 9 The study was approved by the IRB and patients signed informed consent.
Introduction: Chagas disease is a major cause of cardiomyopathy and cardioembolic stroke in Latin America. However, stroke has been reported in patients without cardiomyopathy. Hypothesis: We aimed to determine if Chagas is associated with combined events of stroke or death. Methods: Open hospital-based cohort of consecutive stroke-free individuals with suspected heart failure or asymptomatic Chagas (positive serologic test only) followed from February, 2002 to July, 2015. Endpoint was combined events of stroke or death. Potential confounders included age, sex, cerebrovascular risk factors, echocardiographic left ventricular ejection fraction and EKG rhythm, adjusted in a multivariable Cox regression. Results: Participants were 556 individuals, mean age 55 (+/- 12) years, followed for a mean of 2.3 (+/- 1.5) years, leading to 1297 person-years of observation. Chagas was present in 288 (52%) and cardiomyopathy in 444 (80%) individuals at baseline. There were 2.2 strokes and 8.4 stroke or death events per 100 person-years among patients with Chagas, when compared to 1.3 strokes and 6.5 stroke or death events per 100 person-years among non-chagasic patients. In the model adjusted for potential confounders, Chagas remained an independent predictor of stroke or death (hazard ratio = 2.52; 95% confidence interval = 1.29 - 4.95, p=0.007). Conclusions: Chagas disease is associated a 2.5-fold increase in the rate of early stroke or death independently of cardiac disease. Non-cardioembolic mechanisms for stroke should be further investigated in this population.
Chagas disease (CD) is an important cause of cardiomyopathy and stroke in Brazil. Brain infarcts and atrophy seem to occur independently of cardiomyopathy severity and cognitive impairment is understudied.ObjectiveCompare the prevalence of brain magnetic resonance imaging abnormalities between patients with or without CD; determine if inflammatory biomarkers are increased in CD; and determine the efficacy of aspirin in reducing the rate of microembolization in these patients.Methods500 consecutive patients with heart failure will undergo a structured cognitive evaluation, biomarker collection and search for microembolic signals on transcranial Doppler. The first 90 patients are described, evaluated with cognitive tests and brain magnetic resonance imaging to measure N-acetyl aspartate (NAA), choline (Cho), myo-inositol (MI) and creatine (Cr).ResultsMean age was 55±11 years, 51% female, 38 (42%) with CD. Mean NAA/Cr ratio was lower in patients with CD as compared to other cardiomyopathies. Long-term memory and clock-drawing test were also significantly worse in CD patients. In the multivariable analysis correcting for ejection fraction, age, sex and educational level, reduced NAA/Cr (p=0.006) and cognitive dysfunction (long-term memory, p=0.023; clock-drawing test, p=0.015) remained associated with CD.ConclusionIn this preliminary sample, CD was associated with cognitive impairment and decreased NAA/Cr independently of cardiac function or educational level.
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