ABC | Volume 111, Nº3, September 2018

Brief Communication Silent Cerebral Infarctions with Reduced, Mid-Range and Preserved Ejection Fraction in Patients with Heart Failure Márcia Maria Carneiro Oliveira, 1 Elieusa e Silva Sampaio, 1 Jun Ramos Kawaoka, 2 Maria Amélia Bulhões Hatem, 3 Edmundo José Nassri Câmara, 4 André Maurício Souza Fernandes, 5 Jamary Oliveira-Filho, 3 Roque Aras 6 Escola de Enfermagem da Universidade Federal da Bahia, 1 Salvador, BA - Brazil Hospital Cardio Pulmonar, 2 Salvador, BA - Brazil Hospital Universitário Professor Edgard Santos (HUPES) - Universidade Federal da Bahia, 3 Salvador, BA - Brazil Hospital Ana Nery - Universidade Federal da Bahia, 4 Salvador, BA - Brazil Programa de Pós-graduação em Medicina e Saúde - Universidade Federal da Bahia, 5 Salvador, BA - Brazil Ambulatório de Cardiomiopatias e Insuficiência Cardíaca - Universidade Federal da Bahia, 6 Salvador, BA - Brazil Keywords Heart Failure; Cerebral Infarction; Stroke Volume; Stroke. Mailing Address: Márcia Maria Carneiro Oliveira • Escola de Enfermagem da Universidade Federal da Bahia. Rua Dr. Augusto Viana, S/N. Postal Code 40110-060, Canela, Salvador, BA - Brazil E-mail: marcia.carneiro@ufba.br, marcianinhas@yahoo.com.br Manuscript received April 04, 2018, revised manuscript June 06, 2018, accepted June 12, 2018 DOI: 10.5935/abc.20180140 Abstract Heart failure predisposes to an increased risk of silent cerebral infarction, and data related to left ventricular ejection fraction are still limited. Our objective was to describe the clinical and echocardiographic characteristics and factors associated with silent cerebral infarction in patients with heart failure, according to the left ventricular ejection fraction groups. A prospective cohort was performed at a referral hospital in Cardiology between December 2015 and July 2017. The left ventricular ejection fraction groups were: reduced (≤ 40%), mid-range (41-49%) and preserved (≥ 50%). All patients underwent cranial tomography, transthoracic and transesophageal echocardiography. Seventy-five patients were studied. Silent cerebral infarction was observed in 14.7% of the study population (45.5% lacunar and 54.5% territorial) and was more frequent in patients in the reduced left ventricular ejection fraction group (29%) compared with the mid-range one (15.4%, p = 0.005). There were no cases of silent cerebral infarction in the group of preserved left ventricular ejection fraction. In the univariate analysis, an association was identified between silent cerebral infarction and reduced (OR = 8.59; 95%CI: 1.71 - 43.27; p = 0.009) and preserved (OR = 0.05; 95%CI: 0.003-0.817, p = 0.003) left ventricular ejection fraction and diabetes mellitus (OR = 4.28, 95%CI: 1.14‑16.15, p = 0.031). In patients with heart failure and without a clinical diagnosis of stroke, reduced and mid-range left ventricular ejection fractions contributed to the occurrence of territorial and lacunar silent cerebral infarction, respectively. The lower the left ventricular ejection fraction, the higher the prevalence of silent cerebral infarction. Introduction Heart failure (HF) predisposes to an increased risk of cerebral abnormalities, including silent cerebral infarction, which is defined by the presence of infarctions (territorial or lacunar) in the brain parenchyma, verified through imaging methods, without a documented previous episode of stroke. 1,2 The independent risk factors associated with silent stroke in HF are usually due to the impairment of left ventricular function, restrictive diastolic filling patterns in echocardiography, left atrial (LA) spontaneous echo contrast, and complex or calcified atherosclerotic aortic lesions. 3-5 Ischemic stroke is a common complication of HF regardless of the Preserved (pLVEF) or reduced (rLVEF) Left Ventricular Ejection Fraction (LVEF). 5 LVEF predicts the risk of cerebral infarctions, especially with rLVEF. It is believed that reduced blood flow may favor the formation of spontaneous echo contrast, intracavitary thrombi and consequent cardioembolic events. 6 However, data explaining the stroke mechanism in HF in patients with LVEF are still limited, 7 and data related to stroke and mid-range LVEF are scarce. The objective of this study was to describe the clinical and echocardiographic characteristics and factors associated with silent cerebral infarction in patients with HF according to the LVEF groups. Methods This is a prospective cohort performed at a referral hospital for the care of patients with HF in the city of Salvador, state of Bahia, Brazil, between December 2015 and July 2017. Thediagnosis ofHFwasmade according to the recommendations of the European Society of Cardiology (ESC), 8 with patients who had signs and symptoms of HF, relevant structural heart disease (left ventricle (LV) body mass index ≥ 115 g in men and ≥ 95 g in women, or left atrial dilatation ≥ 40 mm) and or diastolic abnormality (E/A ratio < 0.75 or ≥ 1.5, or E-wave deceleration time < 140 ms). The LVEF groups were characterized as follows: rLVEF (≤ 40%), mid-range LVEF (mrLVEF; 41-49%) and pLVEF (≥ 50%). 9 The diagnosis of Atrial Fibrillation (AF) was based on information available in medical records and the electrocardiogram. Assessment of cranial tomography The cranial tomography was performed in all the patients to identify infarctions in the brain parenchyma (territorial or lacunar). The reports were analyzed by a neurologist, blinded to the patients’ clinical data. These examinations were performed using a 1385 Toshiba Medical Systems Corporation device, (Shimo Ishigami, Otawara-Shi, Tochigi, Japan). 419