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

Amaral, Claudio Henrique do; Amaral, Augusto R.; Nagel, Vivian; Venancio, Vanessa; Garcia, Adriana Coronetti; Magalhaes, Pedro SC; Longo, Alexandre L; Moro, Carla HC; Reis, Felipe I; D’Avila, Andre; Cabral, Norberto L

doi:10.1590/0004-282X20170039

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ARTICLES • Arq. Neuro-Psiquiatr. 75 (5) • May 2017 • https://doi.org/10.1590/0004-282X20170039 copy

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

Incidência e desfecho funcional de AVC cardioembólico com e sem fibrilação atrial em Joinville, Brazil: estudo de base populacional

Authorship SCIMAGO INSTITUTIONS RANKINGS

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 CHA₂DS₂VASc 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.

stroke; incidence; prognosis; population studies in public health

Variable	AF (n = 49)	Non-AF (n = 35)	All CE (n = 84)	p-value
Demographic
Men (SD)	19 (37.0)	19 (54.3)	38 (45.2)	18
Mean age (SD)	77.0 (10.5)	62.0 (14.4)	71.0 (14.2)	< 0.001
Education (years)
Illiterate or <3 years	20 (40.8)	9 (25.7)	29 (34.5)	0.84
4 years	21 (42.9)	8 (22.9)	29 (34.5)
8 years	4 (8.2)	6 (17.1)	10 (11.9)
11 years	2 (4.1)	8 (22.9)	10 (11.9)
> 11 years	1 (2.0)	3 (8.6)	4 (4.8)
Social class*
A1	0 (0.0)	0 (0.0)	0 (0.0)	1.0
A2	0 (0.0)	2 (5.7)	2 (2.4)
B1	1 (2.0)	2 (5.7)	3 (3.6)
B2	8 (16.2)	10 (28.6)	18 (21.4)
C1	23 (46.9)	11 (31.4)	34 (40.5)
C2	10 (20.4)	7 (20.0)	17 (20.2)
D	5 (10.2)	3 (8.6)	8 (9.5)
E	1 (2.0)	0 (0.0)	1 (1.2)
Cardiovascular risk factors
Hypertension	39 (79.6)	21 (60.0)	60 (714)	0.05
Diabetes mellitus	19 (38.8)	12 (34.3)	31 (36.9)	0.67
Dyslipidaemia	32 (65.3)	23 (65.7)	55 (65.5)	0.96
Current smoker	3 (6.1)	9 (25.7)	12 (14.3)	0.01
Ex-smoker	14 (28.6)	12 (34.3)	26 (31.0)	0.57
Never smoked	32 (65.3)	14 (40.0)	46 (54.8)	0.02
MI	0 (0.0)	2 (5.7)	2 (2.4)	0.17
CHF	14 (28.6)	17(48.6)	31 (36.9)	0.06
Vascular claudication	11 (22.4)	6 (17.1)	11 (20.2)	0.55
Alcoholism	3 (6.1)	10 (28.6)	8 (9.5)	0.27
BMI > 30	11 (22.4)	14 (40.0)	25 (29.8)	0.08
Stroke severity and stroke prediction scales
NIHSS at admission	6	4	5	0.59
CHA₂DS₂-VASc (median)	4
HAS-BLED (median)	2	1	1.5	0.01

Variable	Men	Women	Total population

	Incidence (95% CI)	Incidence (95% CI)	Incidence (95% CI)
AF-related CE
Age (years)
< 55	–	0.01 (0.002–0.04)	0.016 (0.007–0.03)
55–64	0.26 (0.08–0.6)	0.09 (0.01–0.34)	0.17 (0.07–0.35)
65–74	0.60 (0.2–1.40)	0.48 (0.15–1.11)	0.53 (0.26–0.98)
75–79	1.42 (0.29–4.16)	1.23 (0.34–3.14)	1.31 (0.52–2.69)
≥ 80	3.25 (1.2–7.1)	4.79 (2.83–7.57)	4.28 (2.74–6.37)
Total	0.07 (0.04–0.11)	0.11 (0.08–0.16)	0.09 (0.07–0.12)
Adjusted Brazil^*	–	–	0.08 (0.06–0.11)
Adjusted World^†	–	–	0.10 (0.07–0.13)
Non-AF-related CE
Age (years)
< 55	0.12 (0.04–0.29)	0.11 (0.03–0.28)	0.12 (0.05–0.22)
55–64	0.47 (0.21–0.88)	0.23 (0.07–0.55)	0.34 (0.19–0.58)
65–74	0.12 (00.2–0.67)	0.19 (0.02–0.69)	0.16 (0.03–0.47)
75–79	1.42 (0.29–4.16)	–	0.56 (0.11–1.63)
≥ 80	0.54 (0.01–3.02)	1.33 (0.43–3.10)	1.07 (0.39–2.33)
Total	0.07 (0.04–0.11)	0.06 (0.03–0.10)	0.07 (0.05–0.09)
Adjusted Brazil*	–	–	0.05 (0.04–0.08)
Adjusted World^†	–	–	0.07 (0.05–0.1)
All causes of CE
Age (years)
< 55	0.12 (0.04–0.29)	0.14 (0.05–0.32)	0.13 (0.06–0.23)
55–64	0.72 (0.40–1.21)	0.33 (0.13–0.68)	0.52 (0.32–0.80)
65–74	0.72 (0.26–1.56)	0.67 (0.27–1.38)	0.67 (0.37–1.18)
75–79	2.85 (1.04–6.19)	1.23 (0.34–3.14)	1.86 (0.89–3.43)
≥ 80	3.79 (1.52–7.81)	6.12 (3.88–9.18)	5.35 (3.61–7.64)
Total	0.14 (0.10–0.20)	0.17 (0.12–0.23)	0.16 (0.13–0.20)
Adjusted Brazil^*	–	–	0.16 (0.13–0.20)
Adjusted World^†	–	–	0.14 (0.11–0.17)

Variable	AF (n = 49)	Non-AF (n = 35)	All CE (n = 84)
Cranial tomography	49 (100)	35 (100)	84 (100)
Brain magnetic resonance	9 (18.4)	2 (2.7)	11 (13.1)
Electrocardiogram	49(100)	35 (100)	84 (100)
Chronic AF	26 (53)	-	26 (30.9)
Paroxistic AF	15 (30.6)	-	15 (17.8)
New AF	6 (12.2)	-	6 (7.1)
Atrial flutter	2 (4)	-	2 (2.3)
24-h Holter	6 (12.2)	1 (2.9)	7 (8.3)
Transthoracic echocardiogram	49 (100)	35 (100)	84 (100)
Transesophageal echocardiogram	3 (6.1)	3 (8.6)	6 (7.1)
Carotid ultrasound	43 (87.8)	27 (77.1)	70 (83.3)
Transcranial Doppler	17 (34.7)	19 (28.6)	27 (32.1)
Electroencephalogram	4 (8.2)	0 (0)	4 (4.8)
Carotid angio-tomography	1 (2)	1 (2.9)	2 (2.4)
Carotid angio-MRI	2 (4.1)	6 (17.1)	8 (9.5)
Cerebral angio-MRI	1 (2)	0 (0)	1 (1.2)

Non-AF-related CE	(n = 35)
High risk
Mechanical valve	4 (11.4)
Myocardial infarction <4 weeks	1 (2.9)
Dilated myocardiopathy	11 (31.4)
Left ventricular akinesia	3 (8.6)
Atrial myxoma	2 (5.7)
Medium risk
Mitral ring calcification	4 (11.4)
Mitral stenosis	1 (2.9)
FOP	1 (2.9)
Atrial flutter atrial	0 (0.0)
Chronic heart failure	7 (20.0)
Myocardial infarction >1 to 6 months	1 (2.9)

Anticoagulated	AF (n = 49)	Non- AF (n = 35)	p- value
Warfarin	26 (53.1)	15 (42.9)	0.35
Femcoprumon	1 (2.0)	0 (0.0)	1.00
Apixaban	3 (6.1)	0 (0.0)	0.26
Rivaroxaban	4 (8,2)	0 (0.0)	0.13
Dabigatran	3 (6.1)	1 (2.9)	0.63
Enoxaparin sodium	0 (0)	1 (2.9)	0.41
Not anticoagulated	12 (24.5)	18 (51.4)	0.01

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[1] Correspondence: Norberto L Cabral; Rua Plácido O. Oliveira, 1244; 89201-165 Joinville SC, Brasil; E-mail: norbertocabral@icloud.com