An estimated 18 million people worldwide are infected with the chronic form of Chagas disease, resulting in 50,000 deaths each year. Ischaemic stroke is a growing but neglected and unrecognised complication of the disease. More efforts are needed to raise awareness of the high risk of stroke in Chagas disease through education campaigns combined with screening of stroke patients for Trypanosoma cruzi infection if they are from endemic regions, and trials to assess the efficacy of long-term oral anticoagulants to prevent stroke recurrence. These are the conclusions of a Review published in the May edition of the Lancet Neurology.
Nearly a third of people with Chagas disease will develop severe heart problems. Irreversible heart damage can appear up to 30 years after the initial infection, with cardiomyopathy (congestive heart failure, sudden cardiac death, arrhythmias, and thromboembolism) being the most common symptom of the disease. Although it is well known that heart disease increases the risk of ischaemic stroke, the importance of Chagas disease as a cause of ischaemic stroke is not well understood.
In this Review, Francisco Javier Carod-Artal from Hospital Virgen de la Luz, Cuenca, Spain and Quim Gascon from Hospital Clinic Barcelona, Spain review the evidence for diagnosis, treatment, and prevention of stroke in Chagas disease.
Over the past 10 years, findings from a range of epidemiological studies have reported a link between ischaemic stroke and T cruzi infection, and several studies have shown that heart failure, mural thrombus, left ventricular apical aneurysm, and several types of cardiac arrhythmias are associated with stroke in Chagas disease.
However, the authors point out that many patients with Chagas disease do not know they are infected. One study showed that in 42% of patients with Chagas disease who had their first ischaemic stroke, infection was not diagnosed until after the stroke. Because chagasic stroke is clinically indistinguishable from other causes of cardioembolic stroke, the authors suggest that stroke patients from endemic countries should be screened for T Cruzi infection.
Additionally, although there is little data on the cumulative risk of stroke in people with T cruzi infection, the authors say that stroke could be the first sign of Chagas disease in patients with asymptomatic or chronic disease.
The Review also highlights the fact that an increase in stroke burden is expected with the ageing of the population infected with Chagas disease in Latin America. Additionally, the emigration of millions of people from countries where the disease is endemic to Europe, North America, Japan, and Australia over the past 20 years, has also made Chagas disease an emerging health problem in these countries with the potential to cause a substantial disease burden. One study estimates that more than 300 000 Latin American immigrants with Chagas disease could be living in the USA, resulting in 30 000 000 cardiomyopathy cases and 300 congenital infections every year.
The authors conclude: "Chagas disease is an independent risk factor for ischaemic stroke…Educational campaigns about the high risk of stroke in Chagas disease are therefore needed in schools and public health centres…Patients with ischaemic cardioembolic or cryptogenic stroke should be screened for T cruzi infection if they reside in or have emigrated from endemic regions…Clinical trials are needed to assess the efficacy of long-term oral anticoagulation in primary ad secondary prevention of stroke in Chagas disease."
Dr Francisco Javier Carod-Artal, Hospital Virgen de la Luz, Cuenca, Spain. T) +34 618 68 47 38 (cell) E) fjcarod-artal@hotmail.com
(please note-Dr Carod-Artal is currently at the American Academy of Neurology Meeting in Toronto and can also be contacted at the Cambridge Suites Hotel, Toronto, Canada T) +1 800 463 1990, Room 608)
For full Review, see: http://press.thelancet.com/tlnchagas.pdf
Journal
The Lancet Neurology