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Information on the association between arterial stiffness and cerebral small vessel disease (cSVD) is limited and confined to white and Asian populations. More regional information is needed to confirm this association in different ethnic groups. Using the Atahualpa Project cohort, we aimed to assess whether the aortic pulse wave velocity (PWV) is associated with the total cSVD score, as well as with each of the neuroimaging signatures of cSVD, in a population of Amerindians living in rural Ecuador. Atahualpa residents aged ⩾ 60 years were offered a brain magnetic resonance imaging scan (MRI) and aortic PWV determination. An ordinal logistic regression model, adjusted for demographics and cardiovascular risk factors, was constructed to predict the total cSVD score by levels of aortic PWV. The association between the neuroimaging signatures of cSVD and the aortic PWV was assessed by adjusted logistic regression models. Of 437 candidates, 303 (69%) underwent a brain MRI and aortic PWV determinations. The total cSVD score was 0 points in 65% of individuals, 1 point in 18%, 2 points in 11%, and 3–4 points in 6%. The mean aortic PWV was 10.4 ± 1.8 m/s, which increased from 9.8 ± 1.2 to 12.3 ± 1.8 m/s in individuals with a cSVD score of 0 and 3–4, respectively (p < 0.001). An ordinal logistic regression model showed significant association between the PWV and the cSVD score. A change of one unit of the aortic PWV increased the odds of having a higher total cSVD score by 1.73 (95% CI: 1.28–2.35; p < 0.001). In addition, individual neuroimaging signatures of cSVD, with the exception of lacunar infarcts, were associated with the aortic PWV. This study shows a significant association between the aortic PWV and total cSVD score and most of its individual components in older Amerindians. [ABSTRACT FROM AUTHOR]

Background: There is no information on stroke incidence in rural areas of Latin America, where living conditions and cardiovascular risk factors are different from urban centers. Aim: Using a population-based prospective cohort study design, we aimed to assess risk factors influencing stroke incidence in community-dwelling adults living in rural Ecuador. Methods: First-ever strokes occurring from 1 June 2012 to 31 May 2016, in Atahualpa residents aged ⩾40 years, were identified from yearly door-to-door surveys and other overlapping sources. Poisson regression models adjusted for demographics, cardiovascular risk factors, edentulism and the length of observation time per subject were used to estimate stroke incidence rate ratio as well as factors influencing such incidence. Results: Of 807 stroke-free individuals prospectively enrolled in the Atahualpa Project, follow-up was achieved in 718 (89%), contributing 2,499 years of follow-up (average 3.48±0.95 years). Overall stroke incidence rate was 2.97 per 100 person-years of follow-up (95% CI: 1.73-4.2), which increased to 4.77 (95% CI: 1.61-14.1) when only persons aged ⩾57 years were considered. Poisson regression models, adjusted for relevant confounders, showed that high blood pressure (IRR: 5.24; 95% CI: 2.55-7.93) and severe edentulism (IRR: 5.06; 95% CI: 2.28-7.85) were the factors independently increasing stroke incidence. Conclusions: Stroke incidence in this rural setting is comparable to that reported from the developed world. Besides age and high blood pressure, severe edentulism is a major factor independently predicting incident strokes. Public awareness of the consequences of poor dental care might reduce stroke incidence in rural settings. [ABSTRACT FROM AUTHOR]

Background An abnormal ankle-brachial index has been associated with overt stroke and coronary heart disease, but little is known about its relationship with silent cerebral small vessel disease. Aim To assess the value of ankle-brachial index as a predictor of silent small vessel disease in an Ecuadorian geriatric population. Methods Stroke-free Atahualpa residents aged ≥60 years were identified during a door-to-door survey. Ankle-brachial index determinations and brain magnetic resonance imaging were performed in consented persons. Ankle-brachial index ≤0·9 and ≥1·4 were proxies of peripheral artery disease and noncompressible arteries, respectively. Using logistic regression models adjusted for age, gender, and cardiovascular health status, we evaluated the association between abnormal ankle-brachial index with silent lacunar infarcts, white matter hyperintensities, and cerebral microbleeds. Results Mean age of the 224 participants was 70 ± 8 years, 60% were women, and 80% had poor cardiovascular health status. Ankle-brachial index was ≤0·90 in 37 persons and ≥1·4 in 17. Magnetic resonance imaging showed lacunar infarcts in 27 cases, moderate-to-severe white matter hyperintensities in 47, and cerebral microbleeds in 26. Adjusted models showed association of lacunar infarcts with ankle-brachial index ≤ 0·90 ( OR: 3·72, 95% CI: 1·35-10·27, P = 0·01) and with ankle-brachial index ≥ 1·4 ( OR: 3·85, 95% CI: 1·06-14·03, P = 0·04). White matter hyperintensities were associated with ankle-brachial index ≤ 0·90 ( P = 0·03) and ankle-brachial index ≥ 1·4 ( P = 0·02) in univariate analyses. There was no association between ankle-brachial index groups and cerebral microbleeds. Conclusions In this population-based study conducted in rural Ecuador, apparently healthy individuals aged ≥60 years with ankle-brachial index values ≤0·90 and ≥1·4 are almost four times more likely to have a silent lacunar infarct. Ankle-brachial index screening might allow recognition of asymptomatic people who need further investigation and preventive therapy. [ABSTRACT FROM AUTHOR]

Background Cerebral small vessel disease is probably one of the most common pathogenetic mechanisms underlying stroke in Latin America. However, the importance of silent markers of small vessel disease, including white matter hyperintensities of presumed vascular origin, has not been assessed so far. Aim The study aims to evaluate prevalence and correlates of white matter hyperintensities in community-dwelling elders living in Atahualpa (rural Ecuador). Methods Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo brain magnetic resonance imaging for identification and grading white matter hyperintensities and other markers of small vessel disease. Using multivariate logistic regression models, we evaluated whether white matter hyperintensities is associated with demographics, cardiovascular health status, stroke, cerebral microbleeds, and cortical atrophy, after adjusting for the other variables. Results Out of 258 enrolled persons (mean age, 70 ± 8 years; 59% women), 172 (67%) had white matter hyperintensities, which were moderate to severe in 63. Analyses showed significant associations of white matter hyperintensities presence and severity with age and cardiovascular health status, as well as with overt and silent strokes, and a trend for association with cerebral microbleeds and cortical atrophy. Conclusions Prevalence and correlates of white matter hyperintensities in elders living in rural Ecuador is almost comparable with that reported from industrialized nations, reinforcing the concept that the burden of small vessel disease is on the rise in underserved Latin American populations. [ABSTRACT FROM AUTHOR]

Rationale Stroke and cardiovascular diseases will be the next health epidemics in Latin America due to increased life expectancy and changes in the lifestyle and dietary habits of the population. Knowledge of the cardiovascular health status of the inhabitants will allow the implementation of policies directed to reduce the burden of stroke and cardiovascular diseases in the region. Aims To evaluate the cardiovascular health status of the inhabitants of Atahualpa (a rural village in coastal Ecuador) and to determine the prevalence and incidence of stroke and ischemic heart disease in the region. Design Three-phase epidemiologic survey. During phase I, Atahualpa residents aged ≥40 years will be screened with standardized questionnaires to evaluate their cardiovascular health and to identify those with suspected stroke or ischemic heart disease. In phase II, neurologists and cardiologists will examine suspected cases of stroke or ischemic heart disease, as well as a random sample of matched negative individuals, to assess the prevalence and incidence of these conditions. In phase III, patients with a diagnosis of stroke and ischemic heart disease will undergo complementary tests for achieving a more specific diagnosis. Discussion Implementation of public health strategies directed to improve the cardiovascular health status of a given population must be based on studies evaluating specific risk factors at regional levels. Epidemiologic surveys such as the Atahualpa Project may prove cost-effective in improving the cardiovascular health status of people living in Latin American rural villages by increasing the knowledge on the particular needs of these populations. [ABSTRACT FROM AUTHOR]

We aimed to assess whether carotid siphon calcifications (as seen on computed tomography) are associated with worse performance in the Montreal Cognitive Assessment in 584 stroke-free individuals living in rural Ecuador. Using mean Montreal Cognitive Assessment score of subjects with Grade 1 calcifications (23.1±4.2) as the referent category, fully adjusted generalized linear models showed significant associations between severity of carotid siphon calcifications and cognitive performance (mean Montreal Cognitive Assessment scores: 20.2±4.8 for Grade 2 (p=0.004), 19.7±5.3 for Grade 3 (p=0.0001), and 18.8±4.1 for Grade 4 (p=0.02)). Predictive Montreal Cognitive Assessment score margins were higher in individuals with Grade 1 calcifications than in other groups. This study shows an inverse relationship between calcium content in the carotid siphon and cognitive performance in Amerindians. [ABSTRACT FROM AUTHOR]

All studies attempting to find an association between vitaminD deficiency and cerebrovascular diseases have been conducted at latitudes far away from the Equator, where living conditions, cardiovascular risk factors, and sunshine exposure are different from tropical regions. We aimed to assess cerebrovascular correlates of vitamin D deficiency in community-dwelling older adults living in Atahualpa, a village located in rural coastal Ecuador. Out of 267 individuals enrolled in the neuroimaging substudy of the Atahualpa Project, 220 (82%) signed the informed consent. Mean age of participants was 70·9 ± 7·8 years, and 126 (57%) were women. Fifty-four (25%) persons have vitamin D levels <20 ng/ml, 47 (21%) had ischemic strokes, and 53 (24%) had moderate-to-severe white matter hyperintensities of presumed vascular origin. Exposure effect models constructed with vitamin D deficiency as the exposure, white matter hyperintensities and ischemic stroke as the outcomes, and confounders -- age, gender, body mass index, physical activity, blood pressure, fasting glucose, total cholesterol, ionized calcium, phosphorus, intact parathormone, and serum creatinine -- as independent variables revealed a significant association of vitamin D deficiency with white matter hyperintensities (P = 0·006) but not with ischemic strokes (P = 0·359). This study shows an association of vitamin D deficiency with diffuse subcortical brain damage in older adults living in a tropical region. Lack of awareness of the importance of vitamin D deficiency might be one of the factors influencing the high prevalence of white matter hyperintensities of presumed vascular origin in underserved Latin American populations. [ABSTRACT FROM AUTHOR]

Stroke will be South America's next epidemic. Therefore, information on stroke particularities in the region will help to overcome its impact burden. We evaluated prevalence, pattern of sub-types, and pathogenic mechanisms underlying stroke in Atahualpa, a village representative of rural coastal Ecuador. In a three-phase epidemiologic study, suspected cases were detected by a door-to-door survey (Phase I). Then, neurologists evaluated suspected cases and randomly selected negative persons (Phase II), and confirmed patients underwent complementary exams (Phase III). We found 20 stroke patients (mean age 70 years, 60% men) among 642 persons aged ≥40 years. Stroke prevalence was 31·15‰ that increased with age. Most patients had sub-cortical infarctions associated with leukoaraiosis or microbleeds. Hypertensive arteriolopathy was the most likely mechanism underlying strokes (55% patients). Intracranial arterial lesions were found in 47% cases. Extracranial atherosclerotic lesions or cardiac sources of emboli were not found in any case. Comparison of our findings with a previous survey performed in the same village showed an alarming increase in stroke prevalence (from 14·08‰ in 2003 to 31·15‰ in 2012, P = 0·03). [ABSTRACT FROM AUTHOR]

A letter to the editor is presented offering information on relationship between sleep disorders and stroke in underserved populations in Ecuadorian and Mestizos natives.