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Doctoral Thesis
DOI
https://doi.org/10.11606/T.98.2021.tde-23022022-142032
Document
Author
Full name
Diandro Marinho Mota
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2021
Supervisor
Committee
Avezum Junior, Alvaro (President)
Drager, Luciano Ferreira
Póvoa, Rui Manoel dos Santos
Timerman, Ari
Title in Portuguese
Estudo epidemiológico populacional para avaliação de hipertensão arterial sistêmica e ocorrência de acidente vascular encefálico
Keywords in Portuguese
Acidente vascular encefálico
Doenças cardiovasculares
Estudo caso-controle
Fatores de risco
Hipertensão
Abstract in Portuguese
INTRODUÇÃO: as doenças cardiovasculares (DCV) são as principais responsáveis pela carga global das doenças crônicas não transmissíveis, sobretudo pelo impacto do infarto agudo do miocárdio e do acidente vascular encefálico (AVE). Dentre os fatores de risco potencialmente modificáveis associados a esses eventos, a hipertensão arterial sistêmica (HAS) se destaca, configurando-se como a principal causa de morbimortalidade cardiovascular no mundo contemporâneo. O presente estudo tem como objetivos determinar a força da associação da HAS em relação à ocorrência do AVE (e seus subtipos) e investigar o risco atribuível populacional (RAP) da doença associado ao evento e seus subtipos, na população brasileira. CASUÍSTICA E MÉTODOS: trata-se de um estudo caso-controle, no qual foram avaliados participantes do INTERSTROKE Study incluídos no Brasil. As características clínicas e demográficas da população do estudo foram avaliadas e as variáveis com significância clínica ou estatística associadas à ocorrência de AVE foram incluídas no modelo multivariado para identificar a força da associação entre HAS e AVE (e seus subtipos). RESULTADOS: no Brasil, 734 indivíduos foram incluídos no INTERSTROKE Study, sendo 367 casos e 367 controles. A média de idade dos participantes foi de 64,8 anos e a prevalência do sexo masculino foi de 55,0%. O grupo caso, em relação ao controle, apresentou maior prevalência de HAS (80,9% versus 56,9%, p < 0,0001), tabagismo ativo (19,9% versus 10,1%, p = 0,0003), sedentarismo (91,0% versus 77,9%, p < 0,0001), fatores psicossociais (estresse e/ou depressão) (42,9% versus 27,2%, p < 0,0001), etilismo elevado ou libação alcoólica (6,5% versus 0,8%, p = 0,0004), bem como valor médio mais elevado da relação cintura/quadril (0,95 versus 0,93, p = 0,0118) e da relação ApoB/ApoA1 (0,81 versus 0,79, p = 0,0094), além de avaliação qualitativa desfavorável do padrão dietético pelo Índice de Alimentação Saudável Alternativo modificado (porcentagem no terceiro tercil de 44,4% versus 54,0%, p = 0,0196). Na análise multivariada, observou-se razão de chances (RC) da HAS para a ocorrência de AVE (independentemente do subtipo) de 3,34 (IC = 95,0%, 2,13 - 5,24), com risco atribuível populacional (RAP) de 56,72% (IC = 95,0%, 42,88 - 70,56). Para o AVE isquêmico, identificou-se RC de 3,19 (IC = 95,0%, 2,00 - 5,09), com RAP de 55,60% (IC = 95,0%, 40,30 - 70,91). Para o AVE hemorrágico, constatou-se RC de 6,54 (IC = 95,0%, 2,07 - 20,69), com RAP de 68,59% (IC = 95,0%, 14,62 - 122,56). Para o sexo masculino, na análise multivariada, foi evidenciada RC de 3,34 (IC = 95,0%, 1,80 - 6,20), com RAP de 56,72% (IC = 95,0%, 32,53 - 80,90) do fator para o AVE total, e RC de 3,17 (IC = 95,0%, 1,66 - 6,05), com RAP de 55,41% (IC = 95,0%, 27,68 - 83,13) para o AVE isquêmico. Já para o sexo feminino, foi identificada RC de 4,21 (IC = 95,0%, 2,06 - 8,60), com RAP de 61,74% (IC = 95,0%, 31,50 - 91,98) da HAS para o AVE total, e RC de 3,88 (IC = 95,0%, 1,97 - 7,97), com RAP de 60,09% (IC = 95,0%, 27,24 - 92,94) para o AVE isquêmico. CONCLUSÃO: A HAS foi identificada como preditor independente e de alto impacto clínico associado à ocorrência de primeiro AVE na população brasileira. A associação observada foi mantida para os subtipos do evento, com maior força no grupo AVE hemorrágico. Em relação ao sexo, entre as mulheres, foi observada maior RC da HAS para ocorrência de AVE (total e isquêmico). Estratégias de saúde pública devem ser desenvolvidas para a identificação e o controle efetivo desse importante fator de risco cardiovascular na população brasileira.
Title in English
Population observational study for the assessment of systemic arterial hypertension and the occurrence of stroke
Keywords in English
Cardiovascular diseases
Case-control study
Hypertension
Risk factors
Stroke
Abstract in English
INTRODUCTION: cardiovascular diseases (CVD) are the main cause for the global burden of chronic non-communicable diseases, especially due to its association with acute myocardial infarction and stroke. Among the potentially modifiable risk factors associated with these events, systemic arterial hypertension (SAH) stands out, being considered the main cause of cardiovascular morbidity and mortality in the contemporary world. The current study aims to determine the strength of the association of SAH in relation to the occurrence of stroke (and its subtypes) and to evaluate the clinical impact through the population attributable risk (RAP) of the disease associated with the event and its subtypes, in the Brazilian population. CASUISTICS AND METHODS: this is a case-control study, in which participants from the INTERSTROKE Study included in Brazil were evaluated. The clinical and demographic characteristics of the study population were assessed and variables with clinical or statistical significance associated with the occurrence of stroke were included in the multivariate model to identify the strength of the association between SAH and stroke (and their subtypes), and its clinical impact. RESULTS: in Brazil, 734 individuals were included in the INTERSTROKE Study, with 367 cases and 367 controls. The average age of the participants was 64.8 year and the male prevalence was 55.0%. Cases had a higher prevalence of SAH compared to controls (80.9% versus 56.9%, p < 0.0001), current smoking (19.9% versus 10.1%, p = 0.0003), sedentary lifestyle (91.0% versus 77.9%, p < 0.0001), psychosocial factors (stress and / or depression) (42.9% versus 27.2%, p < 0.0001), high alcohol consumption or binge (6.5% versus 0.8%, p = 0.0004), in addition to presenting a higher waist / hip ratio (0.95 versus 0.93, p = 0.0118) and ApoB/ApoA1 ratio (0.81 versus 0.79, p = 0.0094) and worse qualitative assessment of the dietary pattern by the modified Alternative Healthy Eating Index (percentage in the third tertile of 44.4% versus 54.0%, p = 0.0196). In the multivariate analysis, the odds ratio (OR) of SAH for the occurrence of stroke (regardless of subtype) was 3.34 (95.0% CI, 2.13 - 5.24), with a population attributable risk (PAR) of 56.72% (95.0% CI, 42.88 - 70.56). For ischemic stroke, an OR of 3.19 (95.0% CI, 2.00 - 5.09) was identified, with PAR of 55.60% (95.0% CI, 40.30 - 70.91). For hemorrhagic stroke, OR of 6.54 was found (95.0% CI, 2.07 - 20.69), with PAR of 68.59% (95.0% CI, 14.62 - 122.56). Male gender presented OR of 3.34 (95.0% CI, 1.80 - 6.20), with PAR of 56.72% (95.0% CI, 32.53 - 80.90) for total stroke and OR of 3.17 (95.0% CI, 1.66 - 6.05), with PAR of 55.41% (95.0% CI, 27.68 - 83.13) for ischemic stroke. For women, an OR of 4.21 (95.0% CI, 2.06 - 8.60) was identified, with PAR of 61.74% (95.0% CI, 31.50 - 91.98) for total stroke and OR of 3.88 (95.0% CI, 1.97 - 7.97), with PAR of 60.09% (95.0% CI, 27.24 - 92.94) for ischemic stroke. CONCLUSION: SAH was identified as an independent predictor with high clinical impact associated with the occurrence of a first stroke in the Brazilian population. The observed association was maintained for the subtypes of the event, with greater strength in the hemorrhagic stroke group. In relation to sex, a greater OR of SAH was observed among women for the occurrence of stroke (total and ischemic). Public health strategies must be developed to identify and effectively control this important cardiovascular risk factor in the Brazilian population.
 
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Publishing Date
2022-04-13
 
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