Incidence and functional outcome of atrial fibrillation and non-atrial fibrillation- related cardioembolic stroke in Joinville, Brazil: a population-based study

Abstract

Among ischemic strokes, cardioembolic (CE) stroke has the worst outcome. We measured the incidence of atrial fibrillation (AF) and non-AF related CE strokes, previous anticoagulant use, and the 90-day functional outcome. Using multiple overlapping sources, we included all CE strokes that occurred in 2015 in Joinville, Brazil. Of the 374 ischemic strokes, 23% (84) were CE. The CE age-adjusted incidence, per 1,000 person-years, was 0.14 (0.11-0.17). Of the 26 patients with known prior AF, 73% (19) were not anticoagulated, 77% (20) had a CHA 2 DS 2 VASc score ≥ 3 and 81% (21) had a HAS-BLED score < 3. After three months, approximately one third of those 26 patients died or became disabled. The incidence of CE stroke in our sample was lower than in other population-based studies. The opportunity for anticoagulation was missed in one third of cases.Keywords: stroke; incidence; prognosis; population studies in public health. RESUMOEntre todos os subtipos de AVC isquêmico, os eventos cardioembólicos (CE) apresentam os piores prognósticos. Determinamos a incidência de AVC isquêmico CE, associada ou não à fibrilação atrial (FA), o uso prévio de anticoagulantes e os desfechos funcionais em Joinville, Brasil. Utilizando múltiplas e sobrepostas fontes de informação, registramos todos os primeiros eventos CE ocorridos em 2015. Entre 374 eventos isquêmicos, 23% (84) foram CE. A incidência ajustada, para qualquer fonte cardioembólica, foi 0.14 (0.11-0.17) por 1000 pessoas-ano. Entre 26 pacientes com FA previamente conhecida, 73% (19) não estavam anticoagulados, 77% (20) tinham ≥ 3 pontos na escala CHA 2 DS 2 VASc e 81 % (21) < 3 pontos na escala HAS-BLED. Após 3 meses, um terço destes 26 pacientes morreram ou ficaram dependentes. A incidência de AVC I CE em Joinville é menor do que em outros estudos de base populacional. Um terço dos casos de AVC I CE com FA previamente conhecida perderam a oportunidade de anticoagulação.Palavras-chave: acidente cerebral vascular; incidência; prognóstico; estudos populacionais em saúde pública.Worldwide, ischemic stroke is the most common major pathological type of stroke 1 . Among all ischemic stroke subtypes, cardioembolic (CE) stroke is particularly worrisome for two main reasons. The first one is demographic: as age is a risk factor for both atrial fibrillation (AF) and stroke, the aging of the population will progressively increase the burden of CE stroke in many countries.1,2 The second reason involves outcomes: in a population-based study in Oxfordshire, UK, 2,555 ischemic stroke subtypes were followed up from 2002 to 2014. After six months, two thirds were dependent. After one year, 42% had died. These outcomes are significantly higher than those reported for other ischemic stroke subtypes 2 . Therefore, knowing the incidence of CE stroke is crucial for primary and secondary prevention policies 1,2,3 .

Seguimento de pessoas acometidas por doenças cerebrovasculares em um hospital regional amazônico: uma metodologia WHO STEP Stroke

“…Estudos mais recentes revelaram em Joinville/SC uma letalidade entre 22,5% e 26,5% em pacientes com AVC isquêmico, 17 e em São Paulo/SP uma proporção de 12,8%, ambos em 30 dias de seguimento. 19 Portanto, proporções acima de 30% de óbito em casos de AVC ainda no primeiro mês -Step 1 de Coari -confere letalidade acima daquelas notificadas em outras regiões e hospitais do Brasil.…”

“…Estudos realizados na região nordeste do Brasil tiveram média de 13 pontos na NIHSS em até 90 dias após o evento 15,16. Enquanto estudos na região sul do Brasil demonstram pontuação na internação hospitalar de 5 a 8 pontos, e na alta hospitalar (cerca de 12 dias após internação) fica entre 2 e 6 pontos 17,18. Fernandes TG, Baptista PPA, Costa JG, Lotufo PA, Campos TF Seguimento de pessoas acometidas por doenças cerebrovasculares em um hospital regional amazônico ............................................................................................................................................................................................................................................................................. Perfil dos casos de AVC coletados no Step 1 na cidade de Coari, Amazonas, quanto a aspectos relativos à evolução clínico-funcional…”

Alarming lack of knowledge about antithrombotic therapy among patients with atrial fibrillation

“…Of the patients who were on anticoagulation, only 25.9% identified stroke as a risk of nonadherence to AF anticoagulant treatment. This alarming number shows us why patients with AF continue to frequently be seen in stroke units, even in the face of a well-known primary risk 21,22 . The crucial role of anticoagulation and adherence to therapy in AF should be as evident for patients as it is to physicians.…”

Norberto Luiz Cabral, MD, PhD - (1963‒2019)

“…Always restless and inquisitor, Cabral, as he was called, published 52 articles and six book chapters on stroke and related problems. Fifteen articles were published by Archives of Neuro Neuropsychiatry 1,4,5,6,7,8,9,10,11,12 , including his publication debut, as many Brazilian researchers, in 1997 13 . In 2008 he received from the Brazilian Academy of Neurology the Award of Best Thesis of the Year, and in 2011 he received an International Scholarship by the British Association and the Brazilian Academy of Neurology.…”