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Incidence and predictors of stroke in patients with rheumatic heart disease
  1. Marcelle Vasconcelos1,
  2. Luiz Vasconcelos1,
  3. Victor Ribeiro2,
  4. Carolina Campos2,
  5. Francisco Di-Flora2,
  6. Lara Abreu2,
  7. Lucas Silva2,
  8. Tatiana Diamantino2,
  9. Jose Luiz Padilha da Silva3,
  10. William Antonio M Esteves1,
  11. Antonio Lucio Teixeira4,
  12. Maria Carmo Pereira Nunes1,5
  1. 1Post Graduation Program in Infectious Diseases and Tropical Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
  2. 2School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
  3. 3Estatística, Universidade Federal do Parana, Curitiba, Brazil
  4. 4Neuropsychiatry Program, UT Health Science Center at Houston, Fort Worth, Texas, USA
  5. 5Internal Medicine, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
  1. Correspondence to Dr Maria Carmo Pereira Nunes, Internal Medicine, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil; mcarmo{at}


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.

  • stroke
  • atrial fibrillation
  • valvular heart disease

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  • Twitter @Lucas Campos Barbosa e Silva

  • 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.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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