Stroke Correlates in Chagasic and Non-Chagasic Cardiomyopathies

PLOS ONE, Dec 2019

Background Aging and migration have brought changes to the epidemiology and stroke has been shown to be independently associated with Chagas disease. We studied stroke correlates in cardiomyopathy patients with focus on the chagasic etiology. Methodology/Principal Findings We performed a cross-sectional review of medical records of 790 patients with a cardiomyopathy. Patients with chagasic (329) and non-chagasic (461) cardiomyopathies were compared. There were 108 stroke cases, significantly more frequent in the Chagas group (17.3% versus 11.1%; p<0.01). Chagasic etiology (odds ratio [OR], 1.79), pacemaker (OR, 2.49), atrial fibrillation (OR, 3.03) and coronary artery disease (OR, 1.92) were stroke predictors in a multivariable analysis of the entire cohort. In a second step, the population was split into those with or without a Chagas-related cardiomyopathy. Univariable post-stratification stroke predictors in the Chagas cohort were pacemaker (OR, 2.73), and coronary artery disease (CAD) (OR, 2.58); while atrial fibrillation (OR, 2.98), age over 55 (OR, 2.92), hypertension (OR, 2.62) and coronary artery disease (OR, 1.94) did so in the non-Chagas cohort. Chagasic stroke patients presented a very high frequency of individuals without any vascular risk factors (40.4%; OR, 4.8). In a post-stratification logistic regression model, stroke remained associated with pacemaker (OR, 2.72) and coronary artery disease (OR, 2.60) in 322 chagasic patients, and with age over 55 (OR, 2.38), atrial fibrillation (OR 3.25) and hypertension (OR 2.12; p = 0.052) in 444 non-chagasic patients. Conclusions/Significance Chagas cardiomyopathy presented both a higher frequency of stroke and an independent association with it. There was a high frequency of strokes without any vascular risk factors in the Chagas as opposed to the non-Chagas cohort. Pacemaker rhythm and CAD were independently associated with stroke in the Chagas group while age over 55 years, hypertension and atrial fibrillation did so in the non-Chagas cardiomyopathies.

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Stroke Correlates in Chagasic and Non-Chagasic Cardiomyopathies

Citation: Matta JAMd, Aras R Jr, Macedo CRBd, Cruz CGd, Netto EM ( Stroke Correlates in Chagasic and Non-Chagasic Cardiomyopathies Jose Alberto Martins da Matta 0 Roque Aras 0 Jr. 0 Cristiano Ricardo Bastos de Macedo 0 Cristiano 0 Gonc alves da Cruz 0 Eduardo Martins Netto 0 Valdur Saks, Universite Joseph Fourier, France 0 1 Hospital Universita rio Professor Edgard Santos, Universidade Federal da Bahia , Salvador, Bahia , Brazil , 2 Hospital Ana Nery, Universidade Federal da Bahia , Salvador, Bahia , Brazil , 3 Hospital Universita rio Professor Edgard Santos, Universidade Federal da Bahia , Salvador, Bahia , Brazil Background: Aging and migration have brought changes to the epidemiology and stroke has been shown to be independently associated with Chagas disease. We studied stroke correlates in cardiomyopathy patients with focus on the chagasic etiology. Methodology/Principal Findings: We performed a cross-sectional review of medical records of 790 patients with a cardiomyopathy. Patients with chagasic (329) and non-chagasic (461) cardiomyopathies were compared. There were 108 stroke cases, significantly more frequent in the Chagas group (17.3% versus 11.1%; p,0.01). Chagasic etiology (odds ratio [OR], 1.79), pacemaker (OR, 2.49), atrial fibrillation (OR, 3.03) and coronary artery disease (OR, 1.92) were stroke predictors in a multivariable analysis of the entire cohort. In a second step, the population was split into those with or without a Chagasrelated cardiomyopathy. Univariable post-stratification stroke predictors in the Chagas cohort were pacemaker (OR, 2.73), and coronary artery disease (CAD) (OR, 2.58); while atrial fibrillation (OR, 2.98), age over 55 (OR, 2.92), hypertension (OR, 2.62) and coronary artery disease (OR, 1.94) did so in the non-Chagas cohort. Chagasic stroke patients presented a very high frequency of individuals without any vascular risk factors (40.4%; OR, 4.8). In a post-stratification logistic regression model, stroke remained associated with pacemaker (OR, 2.72) and coronary artery disease (OR, 2.60) in 322 chagasic patients, and with age over 55 (OR, 2.38), atrial fibrillation (OR 3.25) and hypertension (OR 2.12; p = 0.052) in 444 non-chagasic patients. Conclusions/Significance: Chagas cardiomyopathy presented both a higher frequency of stroke and an independent association with it. There was a high frequency of strokes without any vascular risk factors in the Chagas as opposed to the non-Chagas cohort. Pacemaker rhythm and CAD were independently associated with stroke in the Chagas group while age over 55 years, hypertension and atrial fibrillation did so in the non-Chagas cardiomyopathies. - Chagas disease (CD) is caused by the flagellate protozoan Trypanosoma cruzi and its main mechanism of transmission is transcutaneous inoculation of the parasite by excreta of infected insects [13]. Infection with T cruzi is an enzootic disease, which can lead to human disease when the insect vectorstriatomine bugsreach their domestic cycle by infesting human mud houses in poor communities. In non-endemic countries, blood transfusion, organ transplantation, and vertical transmission are more likely routes of infection [1,36]. Oral transmission, common in the enzootic cycle [6], has only recently been reported in humans [7,8]. An estimated 10 million people are infected worldwide, mostly in Latin America and more than 25 million are at infection risk [911]. Its annual death toll is estimated to claim 10,000 lives [11,12] and the 10-year mortality rate may range from 9% to 85%, depending on clinical markers of cardiac damage [13]. Although vector transmission has been virtually interrupted in most endemic countries [9], non-permanent sanitation control [9,14,15], alternative transmission routes [7,8], escalating migration [4,12], and the increase in life expectancy have resulted in a pressing pattern of Chagas cardiomyopathy on the overall burden of chronic disease [4,1618]. Nonetheless, Chagas disease is still posted among the 20 most important neglected tropical diseases [12]. There are two successive stages, an acute and a chronic phase. The acute phase lasts 6 to 8 weeks, with spontaneous recovery in more than 95% of patients. In the first years of the chronic phase, most infected patients have no clinical evidence of an ongoing illness. This stage of the chronic phase is called the indeterminate form and in most patients it persists indefinitely [13,5,6]. Ten to thirty years after it started, up to 30% of individuals will present organ damage mainly affecting the heart muscle, leading to Chagas cardiomyopathy which may result in severe cardiac dilatation and contractile dysfunction [36], mostly due to a parasite-triggered immune-mediated inflammation [19]. Patients will often present malignant arrhythmias, heart blocks or cardiogenic embolism; the latter one a common cause of ischemic stroke [3,5,6]. Likewise, stroke carries significant morbidity and lethality [4,20,21], is often (...truncated)


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José Alberto Martins da Matta, Roque Aras, Cristiano Ricardo Bastos de Macedo, Cristiano Gonçalves da Cruz, Eduardo Martins Netto. Stroke Correlates in Chagasic and Non-Chagasic Cardiomyopathies, PLOS ONE, 2012, Volume 7, Issue 4, DOI: 10.1371/journal.pone.0035116