恰加斯病中心源性栓塞性缺血性卒中的预防策略。

Prevention strategies of cardioembolic ischemic stroke in Chagas' disease.

作者信息

Sousa Andréa Silvestre de, Xavier Sérgio Salles, Freitas Gabriel Rodriguez de, Hasslocher-Moreno Alejandro

机构信息

Instituto de Pesquisa Clínica Evandro Chagas, FIOCRUZ, Rio de Janeiro, RJ, Brasil.

出版信息

Arq Bras Cardiol. 2008 Nov;91(5):306-10. doi: 10.1590/s0066-782x2008001700004.

DOI:10.1590/s0066-782x2008001700004

PMID:19142374

Abstract

BACKGROUND

The cardioembolic (CE) ischemic stroke is an important clinical manifestation of chronic chagasic cardiopathy; however, its incidence and the risk factors associated to this event have yet to be defined.

OBJECTIVE

To determine prevention strategies for a common and devastating complication of Chagas' disease, the cardioembolic (CE) ischemic stroke.

METHODS

1,043 patients with Chagas' disease were prospectively evaluated from 03/1990 to 03/2002 and followed up to 03/2003. Cox regression was performed to create the CE risk score that was related with the annual incidence of this event: 4-5 points-->4%; 3 points--2-4%; 2 points--1-2%; 0-1 points--<1%. We evaluated the efficacy and safety of two treatment cohorts: (1) 52 patients who used warfarin (INR 2-3) for 14+/-14 months; (2) 104 patients who used acetylsalicylic acid (ASA) (200 mg/d) for 22+/-21 months.

RESULTS

In group (1), the risk of a major bleeding that needed blood transfusion was 1.9% a year, without CE. Cox regression was used to identify 4 independent variables associated to the event (systolic dysfunction, apical aneurysm, primary alteration of ventricular repolarization and age > 48 years) and an CE risk score was developed, which was associated with the annual incidence of this event. In group (2) there were no bleeding complications and the annual incidence of CE was 3.2%, all of them in patients with 4-5 points.

CONCLUSION

Based on the risk-benefit analysis, warfarin prophylaxis for cardioembolic stroke in Chagas' disease is recommended for patients with a score of 4-5 points, in whom the risk of CE overweighs the risk of a major bleeding. With a 3-point score, the risks of bleeding and CE are the same, so the medical decision of using either warfarin or ASA has to be an individual one. In patients with a low risk of CE (2-point score) either ASA or no therapy can be chosen. The prophylaxis is not necessary in patients with 0-1 point scores, in whom the stroke incidence is near zero.

摘要

背景

心源性栓塞性（CE）缺血性卒中是慢性恰加斯病的重要临床表现；然而，其发病率以及与该事件相关的危险因素尚未明确。

目的

确定恰加斯病常见且严重的并发症——心源性栓塞性（CE）缺血性卒中的预防策略。

方法

对1990年3月至2002年3月期间的1043例恰加斯病患者进行前瞻性评估，并随访至2003年3月。采用Cox回归分析得出与该事件年发病率相关的CE风险评分：4 - 5分→4%；3分→2 - 4%；2分→1 - 2%；0 - 1分→<1%。我们评估了两个治疗组的疗效和安全性：（1）52例患者使用华法林（国际标准化比值[INR]为2 - 3）治疗14±14个月；（2）104例患者使用阿司匹林（ASA）（200毫克/天）治疗22±21个月。

结果

在第（1）组中，每年需要输血的严重出血风险为1.9%，未发生CE。采用Cox回归分析确定了与该事件相关的4个独立变量（收缩功能障碍、心尖部动脉瘤、心室复极原发性改变以及年龄>48岁），并制定了CE风险评分，该评分与该事件的年发病率相关。在第（2）组中，未出现出血并发症，CE的年发病率为3.2%，所有病例均为4 - 5分的患者。

结论

基于风险效益分析，对于评分4 - 5分的恰加斯病患者，推荐使用华法林预防心源性栓塞性卒中，此类患者CE风险超过严重出血风险。评分3分时，出血风险和CE风险相同，因此使用华法林或ASA的医疗决策必须因人而异。对于CE低风险（2分）的患者，可以选择ASA或不进行治疗。评分0 - 1分的患者无需预防，此类患者卒中发病率接近零。