International Journal of Cardiovascular Research

Samadoulougou et al., Int J Cardiovasc Res 2015, 4:1
http://dx.doi.org/10.4172/2324-8602.1000191
International Journal of
Cardiovascular Research
Research Article
A SCITECHNOL JOURNAL
Cardio embolic stroke: Data from
145 cases at the Teaching Hospital
of Yalgado Ouedraogo,
Ouagadougou, Burkina Faso
Samadoulougou K Andre 1,2, Mandi D Germain1, Naibe D Temoua1,
Yameogo R Aristide 1*, Yameogo N Valentin 1,2, Millogo RC
Georges 1,2, Kabore W Herve 1, Kologo K Jonas 1, Kabore B Jean
2,3 and Zabsonre Patrice 1,2
1Service
de Cardiologie du Centre Hospitalier Universitaire Yalgado, Ouedraogo,
Burkina Faso
2Unite
de Formation et de Recherche en Sciences de la Sante/ Universite de
Ouagadougou, Burkina Faso
3Service
de Neurologie du Centre Hospitalier Universitaire Yalgado, Ouedraogo,
Burkina Faso
*Corresponding author: Yameogo R Aristide, MD, MPH,11 PO Box 804, CMS
Ouagadougou 11, Burkina Faso, Tel: +(00226) 66485858; E-mail:
[email protected]
Rec date: Aug 12, 2014 Acc date: Dec 24, 2014 Pub date: Jan 01, 2015
Abstract
Introduction: Cardioembolic strokes represent a major public
health concern worldwide due to associated high morbidity and
mortality. Cardiac sources of embolism are leading cause of
stroke after atherosclerosis. We aim to describe the
epidemiological profile and outcome of cardioembolic stroke.
Patients and methods: We retrospectively analyzed medical
records of hospitalized patients who were admitted from
January 1rst 2010 to May the 31th 2012 in the departments of
Cardiology and Neurology at the Teaching University Hospital
of YalgadoOuédraogo, Burkina Faso, West Africa. All patients
diagnosed with ischaemic stroke on the basis of CT-scan and
known to have a heart disease were included in the study.
Results: Overall 582 cases of stroke were reported. Ischaemic
stroke was observed in 370 patients (63.6%). Cardioembolic
disease was reported in 145 patients (39.2%) among whom 73
female. Mean age was 61.7 ± 15 years (extremes: 21 - 90
years). Hypertension and active smoking were respectively
observed in 65.5% and 25.5% of cases. Etiologic factors were
atrial fibrillation (42.8%) and intra-cardiac blood clot (13.8%).
Vitamin K antagonists were prescribed in 41.4% of cases. A
two-week
in-hospital
follow-up
reported
hemorrhagic
transformation in 8.3% of cases. In-hospital mortality rate was
15.2% and was significantly associated with hemorrhagic
transformation (n = 10, RR = 9.24, CI95% = [5.1-16.8], p <
0.001) and congestive heart failure (n= 10, RR = 4, CI95%=
[1.9-8.2], p < 0.001) and altered consciousness on admission
(n= 8, RR = 2.7, CI95% = [1.3-5.8], p =0.009).
Conclusion: Cardioembolic strokes are of frequent occurrence
and associated with high in-hospital mortality. Therefore there
is a need for early management of their etiologic factors.
Keywords: Ischaemic stroke; Cardioembolic diseases; Atrial
fibrillation; Vitamin K antagonists; Burkina Faso; West Africa
Introduction
Cardioembolic strokes represent a major public health concern
worldwide due to associated high morbidity and mortality [1,2]. This
stroke-related burden will be increasing in future decades due to aging
population. Direct and indirect management of such disease is costly
particularly in developing countries where health insurance is barely
available [3,4]. Many sub-Saharan studies showed that ischaemic
stroke is predominant among all types of stroke [5–7]. It is mainly
caused by atherosclerosis and cardioembolic diseases.
In fact, up to 20% of ischemic stroke have a cardio embolic origin
[8,9] and atrial fibrillation is known to account for at least 50% of the
cases [10]. Heart lesions are classified as being at high, low or medium
risk for cerebral embolism [11]. Data on cardioembolic stroke are rare
in Burkina Faso. We aim to describe the epidemiological profile and
outcome of cardio embolic stroke in our setting more frequently in
clinical practice than often realized. A majority of these patients (70%)
are peri- or postmenopausal women [12-19] and younger than usual
age for atherosclerotic CAD (sportsmen). It has been observed that
more than 50% of angiograms done on women show no significant
CAD [20]. Several investigators have demonstrated that despite
normal coronary vessels, electrocardiographic evidence of myocardial
ischemia exists in affected patients as well as in their metabolism
[21-25].
Patients and Methods
We conducted a descriptive analysis on 582 medical records of
patients admitted in both cardiology and neurology departments at the
Teaching University Hospital of YalgadoOuedraogo, Burkina Faso
from January 31st 2010 to March 31st 2012
All patients diagnosed with ischemic stroke on the basis of CT-scan
and known to have a heart disease were included in the study. Twelve
leads ECG and trans-thoracic echocardiography (TTE) were used to
diagnose cardiac sources of embolism. A 24-hoursHolter ECG and a
trans-esophageal echocardiography (TOE) were performed when
cardiac causes of ischaemic stroke were not obvious. Doppler
ultrasonography was used to eliminate cervical large-artery
atherosclerotic source of embolism. Dosage of thyroid hormones was
done as clinical appropriate.
For statistical analysis, EPI Info TM software (version 7.0.9.34) was
used. The categorical variables were expressed as percentages.
Continuous variables were expressed in terms of means ± SD. Chi
square test or Fisher's exact test were used for proportions comparison
as appropriate. For each analysis, a significant difference was defined
as p < 0.05.
Results
We collected 582 medical records of patients who were hospitalized
for stroke including 370 cases of ischaemic stroke (63.6%). Within the
sub-group of ischaemic stroke, 145 patients (39.2%) had a
cardioembolic disease among with 73 patients being females. Mean
age was 61.7 ± 15 years (extremes: 21 and 90 years). Brain CT-scan
showed a hypodensity in 135 cases and absence of abnormalities in 10
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Citation:
Samadoulougou AK, Mandi DG, Naibe DT, Yameogo RA,Yameogo NV, et al. (2015) Cardio embolic stroke: Data from 145 cases at the Teaching
Hospital of Yalgado Ouedraogo, Ouagadougou, Burkina Faso. Int J Cardiovasc Res 4:1.
doi:http://dx.doi.org/10.4172/2324-8602.1000191
cases (6.9%). Single lesions were noticed in 86 patients (63.7%) and
multiple lesions reported in 49 patients (36.3%).
Cardiovascular risk factors included hypertension (65.5%),
dyslipidemia (22.4%) and smoking (25.5%). Smoking was prevalent in
15.1% of female and in 36.1% of male (OR = 3.1; RR = 1.3; p = 0.004).
One hundred and twenty patients (83.4%) had at least one
cardiovascular risk factor.
Clinical manifestations were impaired consciousness on admission
in 25 cases (17.8%) and hemiplegia in 140 cases (96.6%). Table 1 shows
socio-demographic and clinical characteristics in study patients on
admission.
Number (n)
Percentage (%)
[21 - 44]
20
13.8
[45 - 59]
36
24.8
[60 - 74]
60
41.4
[75 - 90]
29
20.0
Male / Female
72 / 73
-
Hypertension
95
65.5
Alcohol
52
35.9
Active smoking
37
25.5
Dyslipidemia
32
22.4
Type 2 Diabetes
22
15.2
History of ischemic stroke
25
17.2
Congestive heart failure
25
17.8
Impaired consciousness
25
17.8
Syncope
29
20.0
Hemiplegia
140
96.6
Isolated facial weakness
5
3.4
Aphasia
87
60.0
Cardiac arrhythmia
51
35.2
Age ranges (years)
Sex
Cardiovascular risk factors
Clinical manifestations
Table 1: Socio-demographic and clinical characteristics in 145 patients on admission
A twelve leads standard ECG revealed atrial fibrillation in 51 cases
(35.2%). Holter ECG was recorded in 20 patients (13.8%) and revealed
11 cases of paroxystic atrial fibrillation.
TTE revealed intra-cardiac thrombi in 17 cases (11.7%),
spontaneous intra-cavity contrast in 28 cases (19.3%), acute
myocardial infarction and ischemic heart disease were diagnosed in 8
cases (5.5%) and 19 cases (13.1%) respectively. TOE was performed in
35 patients (24.1%) and reported intra atrial thrombi in three cases,
and patent foramen ovale in six cases. Electrocardiographic
abnormalities in all 145 patients with cardioembolic stroke are shown
in Table 2.
Number (n)
Percentage (%)
Atrial Fibrillation*
62
42.8
Atrial Flutter
3
2.1
Volume 4 • Issue 1 • 1000191
• Page 2 of 6 •
Citation:
Samadoulougou AK, Mandi DG, Naibe DT, Yameogo RA,Yameogo NV, et al. (2015) Cardio embolic stroke: Data from 145 cases at the Teaching
Hospital of Yalgado Ouedraogo, Ouagadougou, Burkina Faso. Int J Cardiovasc Res 4:1.
doi:http://dx.doi.org/10.4172/2324-8602.1000191
Multifocal atrial tachycardia
1
0.7
Premature ventricular complex
27
18.6
Left ventricular hypertrophy
61
42.1
Left atrial hypertrophy
41
28.3
Myocardial ischemia
24
16.6
Table 2: Electrocardiographic abnormalities in study patients (*Including 11 cases of paroxystic atrial fibrillation diagnosed on Holter ECG)
Cardiac sources of cerebral embolism included atrial fibrillation in
62 cases (42.8%), spontaneous intra-cavity contrast in 20 cases (Table
3).
Possible cardiac causes of cerebral embolism
Number (n)
Percentage (%)
Atrial fibrillation
62
42.8
Atrial flutter
3
2.1
Intracardiac thrombi
20
13.8
Acute myocardial infarction
8
5.5
Dilated cardiomyopathy
17
11.7
Mitral stenosis
9
6. 3
Infectious endocarditis
7
4.8
Intracardiac spontaneous contrast
37
25.5
Ischemic heart disease
19
13.1
Valvular diseases‡
17
11.7
Patent foramen ovale
6
4.1
Inter atrial septal aneurysm
4
2.7
Restrictive cardiomyopathy
3
2.1
Myocarditis
1
0.7
Cardiothyreosis
1
0.7
Hypertrophic cardiomyopathy
1
0.7
Pacemaker
1
0.7
High risk causes of cerebral embolism
Medium to low risk causes of cerebral embolism
Table 3: Cardiac sources of cerebral embolism in 145 patients with stroke.(‡mitral stenosis is excluded)
Doppler ultrasonography of cervical large arteries was performed in
61 patients and reported carotid atheroma without significant stenosis
(stenosis < 50%) in 75.4% of cases.
Low molecular weight heparin (LMWH) was administered in 89
cases (61.4%) and was relayed by vitamin K antagonist dugs (VKA) in
60 cases (41.4%). Time lag before introduction of VKA drugs was ≥
one week in 55 patients. Antiplatelet drugs were administered in 86.2%
of cases. Table 4 summarizes the different treatments administered to
our patients during their inpatient stay.
Number
Volume 4 • Issue 1 • 1000191
Percentage (%)
• Page 3 of 6 •
Citation:
Samadoulougou AK, Mandi DG, Naibe DT, Yameogo RA,Yameogo NV, et al. (2015) Cardio embolic stroke: Data from 145 cases at the Teaching
Hospital of Yalgado Ouedraogo, Ouagadougou, Burkina Faso. Int J Cardiovasc Res 4:1.
doi:http://dx.doi.org/10.4172/2324-8602.1000191
Anticoagulants
89
61.4
LMWH
29
20
LMWH associated with VKA
60
41.4
None
50
34.5
125
86.2
Antiplatelet drugsalone
43
29.7
With VKA
48
33.1
With LMWH
34
23.2
None
20
13.8
ACE/ARBs
116
80
Digoxin
19
13.1
Amiodarone
27
18.6
Statins
107
73.8
115
79.3
Antiplatelet drugs
Other drugs
Rehabilitation
Table 4: Distribution of all 145 patients according to treatment during in-hospital period (LMWH: low molecular weight heparin, VKA: vitamin
K antagonist; ACE: angiotensin-converting enzyme inhibitors; ARBs: angiotensin receptor blockers)
Mean time of hospitalization was of 13.8 ± 8.4 days (extremes: 2 and
60 days). Complications were observed in 37 patients and included
hemorrhagic transformation (n=12 cases.). Complications in all 145
patients during hospitalization period are shown in Table 5.
Anticoagulant treatment had been administered in 75% of patients
with hemorrhagic transformation and in 60.2% of those without
hemorrhagic transformation (RR=1.88; p=0.37).
Complications
Number (n)
Percentage
Haemorrhagic transformation
12
8.3
Pressure ulcer
11
7.6
Venous thromboembolic disease
5
3.4
Seizures
5
3.4
Ischaemic stroke recurrence
3
2.1
Mesenteric infarction
1
0.6
Table 5: Complications during hospitalization period
Death was reported in 22 cases (15.2%). Mortality was significantly
associated with hemorrhagic transformation (n = 10, RR = 9.24,
CI95% = [5.1-16.8], p < 0.001), congestive heart failure (n= 10, RR = 4,
CI 95%= [1.9-8.2], p < 0.001) and impaired consciousness on
admission (n= 8, RR = 2.7, CI 95% = [1.3-5.8], p =0.009).
Discussion
Our study was a retrospective one and could have understated a
number of parameters due to the lack of follow up. However, current
results gave an idea on the magnitude of the problem in our setting.
Volume 4 • Issue 1 • 1000191
Incidence of cardiac sources of cerebral embolism was quite similar
in our study (39,2%) when compared to the one reported by Mbaye et
al. [26] in Senegal (38.46%). Incidence rate was higher than those
reported by Alzamora et al. [27] in Spain, Yip et al. [28] in Taiwan and
Han et al. [10] in South Korea (20%, 25% et 26,6% respectively).
Patients’ selection criteria and quality of usage of some cardioembolic
diagnostic tools may explain the disparity in these incidence rates [29].
As cardiovascular events increase proportionally with age, we
reported a mean age of 61.7 ± 15 years. This rate was comparable to
those reported by Bendriss et al. [12] in Morocco, Damorou et al. [13]
in Togo, and Kubo et al. [14] in Japan with mean ages of 60.8 ±12.14
years; 59.19 ± 11.45 yrs and 62 ± 13 yrs respectively.
• Page 4 of 6 •
Citation:
Samadoulougou AK, Mandi DG, Naibe DT, Yameogo RA,Yameogo NV, et al. (2015) Cardio embolic stroke: Data from 145 cases at the Teaching
Hospital of Yalgado Ouedraogo, Ouagadougou, Burkina Faso. Int J Cardiovasc Res 4:1.
doi:http://dx.doi.org/10.4172/2324-8602.1000191
Hypertension, especifically systolic hypertension is a major risk
factor for stroke. The reason for the enormous burden of hypertension
has been reported in numerous studies, showing that hypertensive
disease is strongly associated with overall cardiovascular risk.
Increased blood pressure contributes indeed to both cardiovascular
and cerebrovascular endpoints, including heart failure, myocardial
infarction, and stroke [15,16]. In fact we reported a hypertension rate
of 65.5% which was supported by data from Bendriss et al. [12] in
Morocco (65.5%) and Kim et al. [9] in Korea (63.8%). As hypertension
prevalence increases with aging, a Senegalese series [26] reported that
75% of patients over 60 years of age had high blood pressure.
Atrial fibrillation (AF) is a major determinant of cardioembolic
stroke. It can be clinically unnoticed especially in its paroxystic form
and only be diagnosed through complications. Its prevalence increases
with aging [17]. AF represented the most frequent cardiac source for
cerebral embolism in our study (42.8%). Mbaye et al [26] reported a
rate of 60% in patients over 60 years of age. AF was found to be
associated with other cardiac sources of cerebral embolism in 40 cases
(64.5% of all AF cases) similar to rate from Han et al [10] in Korea
with 69% of all AF cases. A poor rate of primary prevention of embolic
events in AF could explain these high rates of complications. Low
prevention rates could be due to physicians’ fear of haemorrhagic
complications, geographic and financial inaccessibility to vitamin K
antagonist (VKA) use and follow-up difficulties in our setting.
Valvular diseases were noticed in 18% of cases and were dominated
by mitral stenosis in our study (6.2%). Damorou et al. had reported a
higher mitral stenosis prevalence rate of 11% in Togo. These findings
highlighted the impact of rheumatic heart disease among
cardiovascular diseases in Sub-Saharan Africa.
Ischaemic stroke is a possible complication of myocardial infarction
in its acute phase and may affect up to 2-3% of patients with acute
coronary syndromes [18]. Major embolic risk factors are anterior
localization, infarction extend, presence of left ventricular thrombus,
and atrial fibrillation. Our study reported acute myocardial infarction
as cardiac source of cerebral embolism in 5.5% of cases. We reported
ischaemic heart diseases in 13.1% of the cases, a rate closer to Mbaye et
al [26] data in Senegal with 15%. Belo et al [19] in Togo reported a
higher rate of 7%.
Treatment with low molecular weight heparin (LMWH) during
acute phase of ischaemic stroke is not well codified up to this date.
Most studies did not recommend anticoagulation in acute phase of
ischaemic stroke due to the fact that this practice is not associated with
a significant reduction of recurrent strokes but is associated with
higher risk of intra-cerebral bleeding [20,21,29]. Oral anticoagulants
should be initiated one to two weeks following the onset of ischaemic
stroke and patients should be on antiplatelet drugs until
anticoagulation goals are reached. Early treatment with heparin could
be started in patients with concomitant high embolic risk and low
hemorrhagic risk [22, 23]. Overall 61.4% of our study patients
underwent heparin based anticoagulation. We reported VKA use of
41.4%, whereas antiplatelet drugs were prescribed in 86.2% of our
patients. Lavados et al [29] in Chili reported anticoagulant and
antiplatelet drugs use of 20% respectively in cardioembolic stroke. Low
rate of VKA use was supported by physicians’ fear for oral
anticoagulant bleeding risk. It is therefore necessary to set up
anticoagulation management centers.
We noticed hemorrhagic transformation in 8.3% of cases which
supported data from literature [26,24]. There was no significant
Volume 4 • Issue 1 • 1000191
association between hemorrhagic transformation and anticoagulant
use (RR=1.88; p= 0.37).
In-hospital mortality rate was 15.2% in our study and was close to
the 12% mortality rate reported by Alzamora et al [27] in Spain.
Damorou et al [13] reported a mortality rate of 27.5% in patients with
cardioembolic stroke after one month of follow-up in Togo. Mortality
rate of cardioembolic ischaemic stroke is known to be higher when
compared with stroke from atherosclerotic origin [8,29] mainly due to
cardiac comorbidities.
Conclusions
Cardio embolic stroke accounts for more than one third of ischemic
stroke and have a more severe prognosis. Investigation of cardiac
sources of cerebral embolism is costly. Therefore, it is necessary to
promote early and effective management of ischemic stroke risk
factors such as hypertension and atrial fibrillation. Proper assessment
of benefit/risk of oral anticoagulant use may help to reduce the
incidence of cardio embolic stroke.
Acknowledgements
We want to acknowledge Professor Jean B. KABORE, the head of
the neurology department at Yalgado Ouédraogo University Hospital
and his team for their frank partnership.
Conflict of Interest
None
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Citation:
Samadoulougou AK, Mandi DG, Naibe DT, Yameogo RA,Yameogo NV, et al. (2015) Cardio embolic stroke: Data from 145 cases at the Teaching
Hospital of Yalgado Ouedraogo, Ouagadougou, Burkina Faso. Int J Cardiovasc Res 4:1.
doi:http://dx.doi.org/10.4172/2324-8602.1000191
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