Objective Ischaemic stroke is a severe complication of rheumatic heart disease (RHD), which may result in permanent disability and death. This study aimed to assess the incidence and predictors of stroke in patients with RHD in the current era of evidence-based recommendations for prevention.
Methods Consecutive patients with RHD diagnosed by clinical and echocardiographic criteria were selected. A structured clinical and neurological assessment was performed to determine the aetiology and classification of stroke at enrolment. The primary endpoint was an ischaemic cerebrovascular event, which included fatal or non-fatal stroke. Risk of stroke was estimated accounting for competing risks.
Results A total of 515 patients were enrolled, 438 women (85%), 46±12 years of age. The most frequent valve lesion was mixed mitral (80%). At the time of enrolment, 92 patients (18%) had a prior stroke, with anterior circulation infarction being the most frequent topography (72%). During the mean follow-up of 3.9 years, 27 patients (5.2%) had stroke with the overall incidence of 1.47 strokes per 100 patient-years. Predictors of stroke by the Cox model were prior stroke (adjusted HR 5.395, 95% CI 2.272 to 12.811), age (HR 1.591, 95% CI 1.116 to 2.269) and atrial fibrillation (AF) at baseline (HR 2.945, 95% CI 1.083 to 8.007). By considering death as a competing risk, the effect of AF on stroke risk was attenuated (HR 2.287, 95% CI 0.962 to 5.441).
Conclusions In this large cohort of patients with RHD, stroke occurred in 5.2% of the patients, which was predicted by age, AF and prior stroke. The effect of AF on stroke risk estimation was influenced by death as competing risk.
- atrial fibrillation
- valvular heart disease
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Contributors Conception and design of the research: MV, LV and ALT; acquisition of data: VR, CC, FD-F, LA, LS and TD; analysis and interpretation of data: MV, LV, ALT, WAME and MdCPN; statistical analysis: JLPdS and MdCPN; obtaining financing: ALT and MdCPN; writing of the manuscript: MV and MdCPN; critical revision of the manuscript for intellectual content: all authors; authors responsible for the overall content as guarantors: MV and MdCPN.
Funding This study was partly funded by grants from CAPES, FAPEMIG and CNPq (Brazil). MCPN and ALT are CNPq scholarship recipients. ALT is funded by the UTHealth Houston Department of Psychiatry.
Competing interests None declared.
Patient consent for publication Obtained.
Ethics approval All patients gave written informed consent, and the study protocol was approved by the institutional ethics committee (number 3.586.751).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement The data analytic methods and study materials will be made available to other researchers for purposes of reproducing the results or replicating the procedure from the corresponding author upon reasonable request.
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