1
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Lima ACGB, Formiga MF, Giollo LT, da Silva ML, da Silva VZM, Otto MEB, Chiappa GR, Cipriano G. Arterial stiffness and pulse wave morphology in Chagas heart failure: insights from noninvasive applanation tonometry. J Cardiovasc Med (Hagerstown) 2022; 23:e36-e38. [PMID: 34839319 DOI: 10.2459/jcm.0000000000001287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | | | - Vinicius Z M da Silva
- University of Brasília, Distrito Federal
- University Center of Anapólis (UniEVANGÉLICA), Goiás, Brazil
| | | | - Gaspar R Chiappa
- University of Brasília, Distrito Federal
- University Center of Anapólis (UniEVANGÉLICA), Goiás, Brazil
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2
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Senra T. Can Transthoracic Echocardiography Replace Chest Radiography in the Evaluation of Cardiomegaly in Chagas Cardiomyopathy? Arq Bras Cardiol 2021; 116:75-76. [PMID: 33566968 PMCID: PMC8159511 DOI: 10.36660/abc.20200625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Tiago Senra
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
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3
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Lidani KCF, Sandri TL, Castillo-Neyra R, Andrade FA, Guimarães CM, Marques EN, Beltrame MH, Gilman RH, de Messias-Reason I. Clinical and epidemiological aspects of chronic Chagas disease from Southern Brazil. Rev Soc Bras Med Trop 2020; 53:e20200225. [PMID: 33111908 PMCID: PMC7580281 DOI: 10.1590/0037-8682-0225-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/31/2020] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Patients with Chagas disease (CD), caused by Trypanosoma cruzi, present a higher risk of developing other chronic diseases, which may contribute to CD severity. Since CD is underreported in the southern state of Paraná, Brazil, we aimed to characterize clinical and epidemiological aspects of individuals chronically infected with T. cruzi in Southern Brazil. METHODS A community hospital-based study was performed, recording clinical/demographic characteristics of 237 patients with CD from Southern Brazil. To estimate the association between different forms of CD and sociodemographic and clinical variables, multiple logistic regression models were built using the Akaike information criterion. RESULTS Mean age was 57.5 years and 59% were females. Most patients' (60%) place of origin/birth was within Paraná and they were admitted to the CD outpatient clinic after presenting with cardiac/digestive symptoms (64%). The predominant form of CD was cardiac (53%), followed by indeterminate (36%), and digestive (11%). The main electrocardiographic changes were in the right bundle branch block (39%) and left anterior fascicular block (32%). The average number of comorbidities per patient was 3.9±2.3; systemic arterial hypertension was most common (64%), followed by dyslipidemia (34%) and diabetes (19%); overlapping comorbidities were counted separately. Male sex was associated with symptomatic cardiac CD (OR=2.92; 95%CI: 1.05-8.12; p=0.040). CONCLUSIONS This study provided greater understanding of the distribution and clinical profile of CD patients in Southern Brazil, indicating a high prevalence of comorbidities among these patients who are a vulnerable group due to advanced age and substantial risk of morbidity.
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Affiliation(s)
| | - Thaisa Lucas Sandri
- University of Tübingen, Institute of Tropical Medicine, Tübingen,
BW, Germany
| | - Ricardo Castillo-Neyra
- University of Pennsylvania, Perelman School of Medicine, Department
of Biostatistics, Epidemiology & Informatics, Philadelphia, PA, USA
| | - Fabiana Antunes Andrade
- Universidade Federal do Paraná, Departamento de Patologia Médica,
Hospital de Clínicas, Curitiba, PR, Brasil
| | - Cesar Maistro Guimarães
- Universidade Federal do Paraná, Hospital de Clínicas, Unidade de
Terapia Intensiva, Curitiba, PR, Brasil
| | - Eduardo Nunes Marques
- Universidade Federal do Paraná, Departamento de Patologia Médica,
Hospital de Clínicas, Curitiba, PR, Brasil
| | - Marcia Holsbach Beltrame
- Universidade Federal do Paraná, Departamento de Genética,
Laboratório de Genética Molecular Humana, Curitiba, PR, Brasil
| | - Robert Hugh Gilman
- Johns Hopkins Bloomberg School of Public Health, Department of
International Health, Baltimore, MD, USA
| | - Iara de Messias-Reason
- Universidade Federal do Paraná, Departamento de Patologia Médica,
Hospital de Clínicas, Curitiba, PR, Brasil
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4
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Di Lorenzo Oliveira C, Nunes MCP, Colosimo EA, de Lima EM, Cardoso CS, Ferreira AM, de Oliveira LC, Moreira CHV, Bierrenbach AL, Haikal DSA, Peixoto SV, Lima-Costa MF, Sabino EC, Ribeiro ALP. Risk Score for Predicting 2-Year Mortality in Patients With Chagas Cardiomyopathy From Endemic Areas: SaMi-Trop Cohort Study. J Am Heart Assoc 2020; 9:e014176. [PMID: 32157953 PMCID: PMC7335521 DOI: 10.1161/jaha.119.014176] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Risk stratification of Chagas disease patients in the limited‐resource setting would be helpful in crafting management strategies. We developed a score to predict 2‐year mortality in patients with Chagas cardiomyopathy from remote endemic areas. Methods and Results This study enrolled 1551 patients with Chagas cardiomyopathy from Minas Gerais State, Brazil, from the SaMi‐Trop cohort (The São Paulo‐Minas Gerais Tropical Medicine Research Center). Clinical evaluation, ECG, and NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) were performed. A Cox proportional hazards model was used to develop a prediction model based on the key predictors. The end point was all‐cause mortality. The patients were classified into 3 risk categories at baseline (low, <2%; intermediate, ≥2% to 10%; high, ≥10%). External validation was performed by applying the score to an independent population with Chagas disease. After 2 years of follow‐up, 110 patients died, with an overall mortality rate of 3.505 deaths per 100 person‐years. Based on the nomogram, the independent predictors of mortality were assigned points: age (10 points per decade), New York Heart Association functional class higher than I (15 points), heart rate ≥80 beats/min (20 points), QRS duration ≥150 ms (15 points), and abnormal NT‐proBNP adjusted by age (55 points). The observed mortality rates in the low‐, intermediate‐, and high‐risk groups were 0%, 3.6%, and 32.7%, respectively, in the derivation cohort and 3.2%, 8.7%, and 19.1%, respectively, in the validation cohort. The discrimination of the score was good in the development cohort (C statistic: 0.82), and validation cohort (C statistic: 0.71). Conclusions In a large population of patients with Chagas cardiomyopathy, a combination of risk factors accurately predicted early mortality. This helpful simple score could be used in remote areas with limited technological resources.
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Affiliation(s)
| | - Maria Carmo P Nunes
- Hospital das Clínicas and Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | - Enrico Antonio Colosimo
- Department of Statistics Instituto de Ciência Exatas Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | - Emilly Malveira de Lima
- Department of Statistics Instituto de Ciência Exatas Universidade Federal de Minas Gerais Belo Horizonte Brazil
| | | | - Ariela Mota Ferreira
- Health Science Program Universidade Estadual de Montes Claros Montes Claros Brazil
| | - Lea Campos de Oliveira
- Laboratório de Investigação Médica (LIM03) Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Carlos Henrique Valente Moreira
- Laboratório de Investigação Médica (LIM03) Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | | | | | | | | | - Ester Cerdeira Sabino
- Instituto de Medicina Tropical e Departamento de Moléstias Infecciosas e Parasitarias da Faculdade de Medicina da Universidade de São Paulo São Paulo Brazil
| | - Antonio Luiz P Ribeiro
- Hospital das Clínicas and Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte Brazil
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5
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Brito BODF, Ribeiro ALP. Electrocardiogram in Chagas disease. Rev Soc Bras Med Trop 2018; 51:570-577. [PMID: 30304260 DOI: 10.1590/0037-8682-0184-2018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/29/2018] [Indexed: 11/21/2022] Open
Abstract
Since the initial descriptions of Chagas cardiomyopathy (ChCM), the electrocardiography has played a key role in patient evaluations. The diagnostic criterion of chronic ChCM is the presence of characteristic electrocardiographic (ECG) abnormalities in seropositive individuals, regardless of the presence of symptoms. However, these ECG abnormalities are rarely specific to ChCM and, particularly among the elderly, can be caused by other simultaneous cardiomyopathies. ECG abnormalities can predict the occurrence of heart failure, stroke, and even death. Nevertheless, most prognostic studies have included Chagas disease (ChD) populations and, not exclusively, ChCM. Thus, more studies are required to evaluate the efficacy of ECG in predicting reliable prognoses in established chronic ChCM. This review exclusively discusses the role of the 12-lead ECG in the clinical evaluation of chronic ChD.
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Affiliation(s)
- Bruno Oliveira de Figueiredo Brito
- Programa de Pós-Graduação Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.,Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Antônio Luiz Pinho Ribeiro
- Programa de Pós-Graduação Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.,Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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6
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Nunes MCP, Beaton A, Acquatella H, Bern C, Bolger AF, Echeverría LE, Dutra WO, Gascon J, Morillo CA, Oliveira-Filho J, Ribeiro ALP, Marin-Neto JA. Chagas Cardiomyopathy: An Update of Current Clinical Knowledge and Management: A Scientific Statement From the American Heart Association. Circulation 2018; 138:e169-e209. [DOI: 10.1161/cir.0000000000000599] [Citation(s) in RCA: 201] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background:
Chagas disease, resulting from the protozoan
Trypanosoma cruzi
, is an important cause of heart failure, stroke, arrhythmia, and sudden death. Traditionally regarded as a tropical disease found only in Central America and South America, Chagas disease now affects at least 300 000 residents of the United States and is growing in prevalence in other traditionally nonendemic areas. Healthcare providers and health systems outside of Latin America need to be equipped to recognize, diagnose, and treat Chagas disease and to prevent further disease transmission.
Methods and Results:
The American Heart Association and the Inter-American Society of Cardiology commissioned this statement to increase global awareness among providers who may encounter patients with Chagas disease outside of traditionally endemic environments. In this document, we summarize the most updated information on diagnosis, screening, and treatment of
T cruzi
infection, focusing primarily on its cardiovascular aspects. This document also provides quick reference tables, highlighting salient considerations for a patient with suspected or confirmed Chagas disease.
Conclusions:
This statement provides a broad summary of current knowledge and practice in the diagnosis and management of Chagas cardiomyopathy. It is our intent that this document will serve to increase the recognition of Chagas cardiomyopathy in low-prevalence areas and to improve care for patients with Chagas heart disease around the world.
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7
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Sherbuk JE, Okamoto EE, Marks MA, Fortuny E, Clark EH, Galdos-Cardenas G, Vasquez-Villar A, Fernandez AB, Crawford TC, Do RQ, Flores-Franco JL, Colanzi R, Gilman RH, Bern C. Biomarkers and mortality in severe Chagas cardiomyopathy. Glob Heart 2016; 10:173-80. [PMID: 26407513 DOI: 10.1016/j.gheart.2015.07.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 05/16/2015] [Accepted: 07/09/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chagas cardiomyopathy is a chronic sequela of infection by the parasite, Trypanosoma cruzi. Advanced cardiomyopathy is associated with a high mortality rate, and clinical characteristics have been used to predict mortality risk. Though multiple biomarkers have been associated with Chagas cardiomyopathy, it is unknown how these are related to survival. OBJECTIVES This study aimed to identify biomarkers associated with mortality in individuals with severe Chagas cardiomyopathy in an urban Bolivian hospital. METHODS The population included individuals with and without T. cruzi infection recruited in an urban hospital in Santa Cruz, Bolivia. Baseline characteristics, electrocardiogram findings, medications, and serum cardiac biomarker levels (B-type natriuretic peptide [BNP], N-terminal pro-B-type natriuretic peptide [NT-proBNP], creatine kinase-myocardial band [CK-MB], troponin I, matrix metalloproteinase [MMP]-2, MMP-9, tissue inhibitor of metalloproteinases [TIMP] 1 and 2, transforming growth factor [TGF] beta 1 and 2) were ascertained. Echocardiograms were performed on those with cardiac symptoms or electrocardiogram abnormalities at baseline. Participants were contacted approximately 1 year after initial evaluation; deaths were reported by family members. Receiver-operating characteristic curves (ROC) were used to optimize cutoff values for each marker. For markers with area under the curve (AUC) >0.55, Cox proportional hazards models were performed to determine the hazards ratio (HR) and 95% confidence interval (CI) for the association of each marker with mortality. RESULTS The median follow-up time was 14.1 months (interquartile range 12.5, 16.7). Of 254 individuals with complete cardiac data, 220 (87%) had follow-up data. Of 50 patients with severe Chagas cardiomyopathy at baseline, 20 (40%) had died. Higher baseline levels of BNP (HR: 3.1, 95% CI: 1.2 to 8.4), NT-proBNP (HR: 4.4, 95% CI: 1.8 to 11.0), CK-MB (HR: 3.3, 95% CI: 1.3 to 8.0), and MMP-2 (HR: 4.2, 95% CI: 1.5 to 11.8) were significantly associated with subsequent mortality. CONCLUSIONS Severe Chagas cardiomyopathy is associated with high short-term mortality. BNP, NT-proBNP, CK-MB, and MMP-2 have added predictive value for mortality, even in the presence of decreased ejection fraction and other clinical signs of congestive heart failure.
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Affiliation(s)
| | - Emi E Okamoto
- Hospital of University of Pennsylvania, Philadelphia, PA, USA
| | - Morgan A Marks
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Merck and Co. Inc., West Point, PA, USA
| | - Enzo Fortuny
- Universidad Catolica Boliviana, Santa Cruz, Plurinational State of Bolivia
| | - Eva H Clark
- Baylor College of Medicine, Houston, TX, USA
| | - Gerson Galdos-Cardenas
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Universidad Catolica Boliviana, Santa Cruz, Plurinational State of Bolivia
| | | | | | | | - Rose Q Do
- Veterans Affairs Medical Center and University of Colorado School of Medicine, Denver, CO, USA
| | | | - Rony Colanzi
- Universidad Catolica Boliviana, Santa Cruz, Plurinational State of Bolivia
| | - Robert H Gilman
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caryn Bern
- University of California San Francisco, San Francisco, CA, USA.
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8
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Bestetti RB, Restini CBA, Couto LB. Carlos Chagas Discoveries as a Drop Back to Scientific Construction of Chronic Chagas Heart Disease. Arq Bras Cardiol 2016; 107:63-70. [PMID: 27223644 PMCID: PMC4976958 DOI: 10.5935/abc.20160079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/01/2016] [Indexed: 11/20/2022] Open
Abstract
The scientific construction of chronic Chagas heart disease (CCHD) started in 1910 when Carlos Chagas highlighted the presence of cardiac arrhythmia during physical examination of patients with chronic Chagas disease, and described a case of heart failure associated with myocardial inflammation and nests of parasites at autopsy. He described sudden cardiac death associated with arrhythmias in 1911, and its association with complete AV block detected by Jacquet's polygraph as Chagas reported in 1912. Chagas showed the presence of myocardial fibrosis underlying the clinical picture of CCHD in 1916, he presented a full characterization of the clinical aspects of CCHD in 1922. In 1928, Chagas detected fibrosis of the conductive system, and pointed out the presence of marked cardiomegaly at the chest X-Ray associated with minimal symptomatology. The use of serological reaction to diagnose CCHD was put into clinical practice in 1936, after Chagas' death, which along with the 12-lead ECG, revealed the epidemiological importance of CCHD in 1945. In 1953, the long period between initial infection and appearance of CCHD was established, whereas the annual incidence of CCHD from patients with the indeterminate form of the disease was established in 1956. The use of heart catheterization in 1965, exercise stress testing in 1973, Holter monitoring in 1975, Electrophysiologic testing in 1973, echocardiography in 1975, endomyocardial biopsy in 1981, and Magnetic Resonance Imaging in 1995, added to the fundamental clinical aspects of CCHD as described by Carlos Chagas.
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9
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Silva SDA, Gontijo ED, Dias JCP, Andrade CGDS, Amaral CFS. Predictive factors for the progression of chronic Chagas cardiomyopathy in patients without left ventricular dysfunction. Rev Inst Med Trop Sao Paulo 2016; 57:153-63. [PMID: 25923895 PMCID: PMC4435014 DOI: 10.1590/s0036-46652015000200009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 07/22/2014] [Indexed: 11/22/2022] Open
Abstract
The identification of predictors for the progression of chronic Chagas cardiomyopathy (CCC) is essential to ensure adequate patient management. This study looked into a non-concurrent cohort of 165 CCC patients between 1985 and 2010 for independent predictors for CCC progression. The outcomes were worsening of the CCC scores and the onset of left ventricular dysfunction assessed by means of echo-Doppler cardiography. Patients were analyzed for social, demographic, epidemiologic, clinical and workup-related variables. A descriptive analysis was conducted, followed by survival curves based on univariate (Kaplan-Meier and Cox's univariate model) and multivariate (Cox regression model) analysis. Patients were followed from two to 20 years (mean: 8.2). Their mean age was 44.8 years (20-77). Comparing both iterations of the study, in the second there was a statistically significant increase in the PR interval and in the QRS duration, despite a reduction in heart rates (Wilcoxon < 0.01). The predictors for CCC progression in the final regression model were male gender (HR = 2.81), Holter monitoring showing pauses equal to or greater than two seconds (HR = 3.02) increased cardiothoracic ratio (HR = 7.87) and time of use of digitalis (HR = 1.41). Patients with multiple predictive factors require stricter follow-up and treatment.
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Affiliation(s)
| | - Eliane Dias Gontijo
- Depto. Medicina Preventiva e Social, Faculdade de Medicina, Univ. Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - João Carlos Pinto Dias
- Centro de Pesquisas René Rachou, Fundação Oswaldo Cruz (FIOCRUZ), Belo Horizonte, MG, Brasil
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10
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Tanowitz HB, Machado FS, Spray DC, Friedman JM, Weiss OS, Lora JN, Nagajyothi J, Moraes DN, Garg NJ, Nunes MCP, Ribeiro ALP. Developments in the management of Chagas cardiomyopathy. Expert Rev Cardiovasc Ther 2015; 13:1393-409. [PMID: 26496376 DOI: 10.1586/14779072.2015.1103648] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Over 100 years have elapsed since the discovery of Chagas disease and there is still much to learn regarding pathogenesis and treatment. Although there are antiparasitic drugs available, such as benznidazole and nifurtimox, they are not totally reliable and often toxic. A recently released negative clinical trial with benznidazole in patients with chronic Chagas cardiomyopathy further reinforces the concerns regarding its effectiveness. New drugs and new delivery systems, including those based on nanotechnology, are being sought. Although vaccine development is still in its infancy, the reality of a therapeutic vaccine remains a challenge. New ECG methods may help to recognize patients prone to developing malignant ventricular arrhythmias. The management of heart failure, stroke and arrhythmias also remains a challenge. Although animal experiments have suggested that stem cell based therapy may be therapeutic in the management of heart failure in Chagas cardiomyopathy, clinical trials have not been promising.
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Affiliation(s)
- Herbert B Tanowitz
- a Department of Pathology , Albert Einstein College of Medicine , Bronx , NY , USA.,b Department of Medicine , Albert Einstein College of Medicine , Bronx , NY , USA
| | - Fabiana S Machado
- c Department of Biochemistry and Immunology, Institute of Biological Science , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil.,d Program in Health Sciences: Infectious Diseases and Tropical Medicine, Medical School , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - David C Spray
- b Department of Medicine , Albert Einstein College of Medicine , Bronx , NY , USA.,e Dominick P. Purpura Department of Neuroscience , Albert Einstein College of Medicine , Bronx , NY , USA
| | - Joel M Friedman
- f Department of Physiology & Biophysics , Albert Einstein College of Medicine , Bronx , NY , USA
| | - Oren S Weiss
- a Department of Pathology , Albert Einstein College of Medicine , Bronx , NY , USA
| | - Jose N Lora
- a Department of Pathology , Albert Einstein College of Medicine , Bronx , NY , USA
| | - Jyothi Nagajyothi
- g Public Health Research Institute, New Jersey Medical School , Rutgers University , Newark , NJ , USA
| | - Diego N Moraes
- d Program in Health Sciences: Infectious Diseases and Tropical Medicine, Medical School , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil.,h Department of Internal Medicine and University Hospital , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Nisha Jain Garg
- i Department of Microbiology & Immunology and Institute for Human Infections and Immunity , University of Texas Medical Branch , Galveston , TX , USA
| | - Maria Carmo P Nunes
- d Program in Health Sciences: Infectious Diseases and Tropical Medicine, Medical School , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil.,h Department of Internal Medicine and University Hospital , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Antonio Luiz P Ribeiro
- d Program in Health Sciences: Infectious Diseases and Tropical Medicine, Medical School , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil.,h Department of Internal Medicine and University Hospital , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
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11
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Campi-Azevedo AC, Gomes JAS, Teixeira-Carvalho A, Silveira-Lemos D, Vitelli-Avelar DM, Sathler-Avelar R, Peruhype-Magalhães V, Béla SR, Silvestre KF, Batista MA, Schachnik NCC, Correa-Oliveira R, Eloi-Santos SM, Martins-Filho OA. Etiological treatment of Chagas disease patients with benznidazole lead to a sustained pro-inflammatory profile counterbalanced by modulatory events. Immunobiology 2015; 220:564-74. [PMID: 25648688 DOI: 10.1016/j.imbio.2014.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 11/28/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
Abstract
In the present study, we characterized the phagocytic capacity, cytokine profile along with the FCγ-R and TLR expression in leukocytes from Chagas disease patients (indeterminate-IND and cardiac-CARD) before and one-year after Bz-treatment (INDT and CARDT). A down-regulation of IL-17, IFN-γ and IL-10 synthesis by neutrophils was observed in CARDT. The Bz-treatment did not impact on the expression of phagocytosis-related surface molecules or monocyte-derived cytokine profile in INDT. Although CARDT showed unaltered monocyte-phagocytic capacity, up-regulated expression of Fcγ-RI/III and TLR-4 may be related to their ability to produce IL-10 and TGF-β. Down-regulation of lymphocyte-derived cytokine was observed in INDT whereas up-regulated cytokine profile was observed for lymphocytes in CARDT. Analysis of cytokine network revealed that IND displayed a multifaceted cytokine response characterized by strong connecting axes involving pro-inflammatory/regulatory phagocytes and lymphocytes. On the other hand, CARD presented a modest cytokine network. The Bz-treatment leads to distinct cytokine network: decreasing the links in INDT, with a pivotal role of IL-10(+) monocytes and expanding the connections in CARDT. Our findings highlighted that the Bz-treatment contributes to an overall immunomodulation in INDT and induces a broad change of immunological response in CARDT, eliciting an intricate phenotypic/functional network compatible with beneficial and protective immunological events.
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Affiliation(s)
- A C Campi-Azevedo
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
| | - J A S Gomes
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil; Laboratório de Imunologia Celular e Molecular, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil; Laboratório de Biologia das Interações Celulares, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil; Programa de Pós- graduação em Medicina Tropical e Infectologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil.
| | - A Teixeira-Carvalho
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
| | - D Silveira-Lemos
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
| | - D M Vitelli-Avelar
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
| | - R Sathler-Avelar
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
| | - V Peruhype-Magalhães
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
| | - S R Béla
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
| | - K F Silvestre
- Laboratório de Biologia das Interações Celulares, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
| | - M A Batista
- Laboratório de Biologia das Interações Celulares, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
| | - N C C Schachnik
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
| | - R Correa-Oliveira
- Laboratório de Imunologia Celular e Molecular, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais - INCT-DT, Brasil
| | - S M Eloi-Santos
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
| | - O A Martins-Filho
- Laboratório de Biomarcadores de Diagnóstico e Monitoração, Centro de Pesquisas René Rachou, Fiocruz, Belo Horizonte, Brasil
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Enriquez A, Conde D, Femenia F, de Luna AB, Ribeiro A, Muratore C, Valentino M, Retyk E, Galizio N, Hopman WM, Baranchuk A. Relation of interatrial block to new-onset atrial fibrillation in patients with Chagas cardiomyopathy and implantable cardioverter-defibrillators. Am J Cardiol 2014; 113:1740-3. [PMID: 24698463 DOI: 10.1016/j.amjcard.2014.02.036] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 02/21/2014] [Accepted: 02/21/2014] [Indexed: 01/05/2023]
Abstract
Chagas cardiomyopathy is an endemic disease in Latin America. A significant proportion of patients develop atrial fibrillation (AF), which may result in stroke and increased morbidity or mortality. Interatrial block (IAB) has been associated with the development of AF in different clinical scenarios. The aim of our study was to determine whether IAB can predict new-onset AF in patients with Chagas cardiomyopathy and implantable cardioverter-defibrillators (ICDs). We conducted a retrospective study of patients with Chagas cardiomyopathy and ICDs from 14 centers in Latin America. Demographics, clinical, and device follow-up were collected. Surface electrocardiograms were scanned at 300 dpi and maximized ×8. Semiautomatic calipers were used to determine P-wave onset and offset. Partial IAB was defined as a P wave of >120 ms and advanced IAB as a P wave of >120 ms with biphasic morphology (±) in inferior leads. AF events and ICD therapies were reviewed during follow-up by 2 independent investigators. A total of 80 patients were analyzed. Mean age was 54.6 ± 10.4 years, and 52 (65%) were male. Mean left ventricular ejection fraction was 40 ± 12%. IAB was detected in 15 patients (18.8%), with 8 (10.0%) partial and 7 (8.8%) advanced. During a follow-up of 33 ± 20 months, 11 patients (13.8%) presented with new AF. IAB (partial + advanced) was strongly associated with new AF (p <0.0001) and inappropriate therapy by the ICD (p = 0.014). In conclusion, IAB (partial + advanced) predicted new-onset AF in patients with Chagas cardiomyopathy and ICDs.
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Affiliation(s)
| | - Diego Conde
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | | | - Antoni Bayés de Luna
- Cardiovascular Research Center, CSIC-ICCC, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonio Ribeiro
- Universidade Federal de Minais Gerais, Belo Horizonte, Brazil
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Ribeiro ALP, Marcolino MS, Prineas RJ, Lima-Costa MF. Electrocardiographic abnormalities in elderly Chagas disease patients: 10-year follow-up of the Bambui Cohort Study of Aging. J Am Heart Assoc 2014; 3:e000632. [PMID: 24510116 PMCID: PMC3959704 DOI: 10.1161/jaha.113.000632] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Electrocardiography has been considered an important tool in the management of Chagas disease (ChD) patients, although its value in elderly infected patients is unknown. This study was designed to investigate the prevalence and prognostic value of electrocardiographic abnormalities in Trypanosoma cruzi infected and noninfected older adults. Methods and Results We studied 1462 participants in Bambuí City, Brazil, with electrocardiogram (ECG) records classified by the Minnesota Code. Follow‐up time was 10 years; the endpoint was mortality. Adjustment for potential confounding variables included age, gender, conventional risk factors, and B‐type natriuretic peptide (BNP). The mean age was 69 years (60.9% women). The prevalence of ChD was 38.1% (n=557). ECG abnormalities were more frequent in ChD patients (87.6% versus 77.7%, P<0.001). Right bundle branch block (RBBB) with left anterior hemiblock (LAH) was strongly related to ChD (OR: 11.99 [5.60 to 25.69]). During the mean follow‐up time of 8.7 years, 556 participants died (253 with ChD), and only 89 were lost to follow‐up. ECG variables of independent prognostic value for death in ChD included absence of sinus rhythm, frequent ventricular and supraventricular premature beats, atrial fibrillation, RBBB, old and possible old myocardial infarction, and left ventricular hypertrophy. The presence of any major ECG abnormalities doubled the risk of death in ChD patients (HR: 2.18 [1.35 to 3.53]), but it also increased the risk in non‐ChD subjects (HR: 1.50 [1.07 to 2.10]); the risk of death increased with the number of major abnormalities in the same patient. Conclusion ECG abnormalities are more common among elderly Chagas disease patients and strongly predict adverse outcomes.
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Affiliation(s)
- Antonio Luiz P Ribeiro
- Department of Internal Medicine, Medical School, Universidade Federal de Minas Gerais, Brazil
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14
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Nunes MCP, Carmo AALD, Rocha MOC, Ribeiro AL. Mortality prediction in Chagas heart disease. Expert Rev Cardiovasc Ther 2014; 10:1173-84. [DOI: 10.1586/erc.12.111] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Marques J, Mendoza I, Noya B, Acquatella H, Palacios I, Marques-Mejias M. ECG manifestations of the biggest outbreak of Chagas disease due to oral infection in Latin-America. Arq Bras Cardiol 2013; 101:249-54. [PMID: 23887736 PMCID: PMC4032305 DOI: 10.5935/abc.20130144] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 04/15/2013] [Indexed: 11/29/2022] Open
Abstract
Background Chagas disease affects more than 15 million people worldwide. Although
vector-borne transmission has decreased, oral transmission has become important.
Recently, our group published the clinical and epidemiological characteristics of
the largest outbreak of orally transmitted Chagas disease reported till date.
Objective: To describe electrocardiographic changes occurring in the study
population during the outbreak caused by ingestion of contaminated guava juice.
Methods We evaluated 103 positive cases, of which 76 (74%) were aged ≤ 18 years (average
age: 9.1 ± 3.1 years) and 27 (26%) were aged > 18 years (average age: 46 ± 11.8
years). All patients underwent clinical evaluations and ECG. If the patients had
palpitations or evident alterations of rhythm at baseline, ambulatory ECG
monitoring was performed. Results A total of 68 cases (66%; 53 children and 15 adults) had ECG abnormalities.
Further, 69.7% (53/76) of those aged ≤ 18 years and 56% (15/27) of those aged
>18 years showed some ECG alteration (p = ns). ST-T abnormalities were observed
in 37.86% cases (39/103) and arrhythmias were evident in 28.16% cases (29/103). ST
alterations occurred in 72% of those aged ≤18 years compared with 19% of th ose
aged >18 years (p < 0.0001). Conclusion This study reports the largest number of cases in the same outbreak of acute
Chagas disease caused by oral contamination, with recorded ECGs. ECG changes
suggestive of acute myocarditis and arrhythmias were the most frequent
abnormalities found.
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Affiliation(s)
| | | | | | | | | | - María Marques-Mejias
- Mailing Address: María Marques-Mejias, Calle San Francisco, Qta. Gálata,
Prados del este. Postal Code 1080, Caracas, Miranda. E-mail:
, juan.alberto.marques@gmail.
com
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16
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Ribeiro AL, Sabino EC, Marcolino MS, Salemi VMC, Ianni BM, Fernandes F, Nastari L, Antunes A, Menezes M, Oliveira CDL, Sachdev V, Carrick DM, Busch MP, Murphy EL. Electrocardiographic abnormalities in Trypanosoma cruzi seropositive and seronegative former blood donors. PLoS Negl Trop Dis 2013; 7:e2078. [PMID: 23469305 PMCID: PMC3585012 DOI: 10.1371/journal.pntd.0002078] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 01/10/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Blood donor screening leads to large numbers of new diagnoses of Trypanosoma cruzi infection, with most donors in the asymptomatic chronic indeterminate form. Information on electrocardiogram (ECG) findings in infected blood donors is lacking and may help in counseling and recognizing those with more severe disease. OBJECTIVES To assess the frequency of ECG abnormalities in T.cruzi seropositive relative to seronegative blood donors, and to recognize ECG abnormalities associated with left ventricular dysfunction. METHODS The study retrospectively enrolled 499 seropositive blood donors in São Paulo and Montes Claros, Brazil, and 483 seronegative control donors matched by site, gender, age, and year of blood donation. All subjects underwent a health clinical evaluation, ECG, and echocardiogram (Echo). ECG and Echo were reviewed blindly by centralized reading centers. Left ventricular (LV) dysfunction was defined as LV ejection fraction (EF)<0.50%. RESULTS Right bundle branch block and left anterior fascicular block, isolated or in association, were more frequently found in seropositive cases (p<0.0001). Both QRS and QTc duration were associated with LVEF values (correlation coefficients -0.159,p<0.0003, and -0.142,p = 0.002) and showed a moderate accuracy in the detection of reduced LVEF (area under the ROC curve: 0.778 and 0.790, both p<0.0001). Several ECG abnormalities were more commonly found in seropositive donors with depressed LVEF, including rhythm disorders (frequent supraventricular ectopic beats, atrial fibrillation or flutter and pacemaker), intraventricular blocks (right bundle branch block and left anterior fascicular block) and ischemic abnormalities (possible old myocardial infarction and major and minor ST abnormalities). ECG was sensitive (92%) for recognition of seropositive donors with depressed LVEF and had a high negative predictive value (99%) for ruling out LV dysfunction. CONCLUSIONS ECG abnormalities are more frequent in seropositive than in seronegative blood donors. Several ECG abnormalities may help the recognition of seropositive cases with reduced LVEF who warrant careful follow-up and treatment.
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Affiliation(s)
- Antonio L. Ribeiro
- Hospital das Clínicas and Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ester C. Sabino
- Department of Infectious Disease and Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
| | - Milena S. Marcolino
- Hospital das Clínicas and Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Vera M. C. Salemi
- Cardiomyopathy Unit ofthe Heart Institute (InCor) da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Barbara M. Ianni
- Cardiomyopathy Unit ofthe Heart Institute (InCor) da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fábio Fernandes
- Cardiomyopathy Unit ofthe Heart Institute (InCor) da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luciano Nastari
- Cardiomyopathy Unit ofthe Heart Institute (InCor) da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - André Antunes
- Centro de Ciências Biológicas e da Saúde, Universidade Estadual de Montes Claros, Montes Claros, Brazil
| | - Márcia Menezes
- Centro de Ciências Biológicas e da Saúde, Universidade Estadual de Montes Claros, Montes Claros, Brazil
| | | | - Vandana Sachdev
- National Heart, Lung and Blood Institute, Bethesda, Maryland, United States of America
| | | | - Michael P. Busch
- Blood Systems Research Institute (BSRI) and University of California at San Francisco, San Francisco, California, United States of America
| | - Eduard L. Murphy
- Blood Systems Research Institute (BSRI) and University of California at San Francisco, San Francisco, California, United States of America
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Nascimento BR, Araújo CG, Rocha MOC, Domingues JDP, Rodrigues AB, Barros MVL, Ribeiro ALP. The prognostic significance of electrocardiographic changes in Chagas disease. J Electrocardiol 2012; 45:43-8. [DOI: 10.1016/j.jelectrocard.2011.04.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Indexed: 10/18/2022]
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18
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Pereira Nunes MDC, Barbosa MM, Ribeiro ALP, Amorim Fenelon LM, Rocha MOC. Predictors of mortality in patients with dilated cardiomyopathy: relevance of chagas disease as an etiological factor. Rev Esp Cardiol 2010; 63:788-97. [PMID: 20609312 DOI: 10.1016/s1885-5857(10)70163-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND OBJECTIVES Previous studies on the influence of Chagas disease on mortality in patients with heart failure were limited by the heterogeneity of the patient populations. Few data are available on the association between the underlying cause of dilated cardiomyopathy and long-term prognosis. The aims of this study were to identify risk factors for mortality in patients with dilated cardiomyopathy that was either secondary to Chagas disease or idiopathic and to determine the prognostic value of identifying Chagas disease as the underlying etiology of dilated cardiomyopathy. METHODS We investigated outcomes in 287 patients with heart failure secondary to dilated cardiomyopathy. Patients were divided into two groups according to the underlying etiology: Chagas cardiomyopathy (224 patients) and idiopathic dilated cardiomyopathy (63 patients). The study end-points were death and heart transplantation. RESULTS Over a median follow-up period of 39.5 months, 104 patients died and 9 underwent heart transplantation. Under multivariate Cox proportional hazards analysis, New York Heart Association functional class, left ventricular ejection fraction, right ventricular function and left atrial volume remained predictors of an adverse outcome. Chagas etiology was also independently associated with a poor prognosis (hazard ratio=2.48; 95% confidence interval, 1.28-4.78; P=.007) compared with idiopathic disease, after adjustment for other well-established predictive parameters in heart failure. CONCLUSIONS The identification of Chagas etiology in patients with dilated cardiomyopathy was of prognostic significance. Chagas cardiomyopathy was associated with poorer survival compared with idiopathic disease, irrespective of other clinical and echocardiographic parameters related to a poor prognosis in heart failure.
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Gonçalves JGF, Dias Silva VJ, Calzada Borges MC, Prata A, Correia D. Mortality indicators among chronic Chagas patients living in an endemic area. Int J Cardiol 2010; 143:235-42. [DOI: 10.1016/j.ijcard.2009.02.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Revised: 02/04/2009] [Accepted: 02/11/2009] [Indexed: 11/29/2022]
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Factores predictivos de la mortalidad en pacientes con miocardiopatía dilatada: importancia de la enfermedad de Chagas como etiología. Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70181-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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21
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Rassi A, Rassi A, Marin-Neto JA. Chagas heart disease: pathophysiologic mechanisms, prognostic factors and risk stratification. Mem Inst Oswaldo Cruz 2010; 104 Suppl 1:152-8. [PMID: 19753470 DOI: 10.1590/s0074-02762009000900021] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 05/26/2009] [Indexed: 10/21/2023] Open
Abstract
Chagas heart disease (CHD) results from infection with the protozoan parasite Trypanosoma cruzi and is the leading cause of infectious myocarditis worldwide. It poses a substantial public health burden due to high morbidity and mortality. CHD is also the most serious and frequent manifestation of chronic Chagas disease and appears in 20-40% of infected individuals between 10-30 years after the original acute infection. In recent decades, numerous clinical and experimental investigations have shown that a low-grade but incessant parasitism, along with an accompanying immunological response [either parasite-driven (most likely) or autoimmune-mediated], plays an important role in producing myocardial damage in CHD. At the same time, primary neuronal damage and microvascular dysfunction have been described as ancillary pathogenic mechanisms. Conduction system disturbances, atrial and ventricular arrhythmias, congestive heart failure, systemic and pulmonary thromboembolism and sudden cardiac death are the most common clinical manifestations of chronic Chagas cardiomyopathy. Management of CHD aims to relieve symptoms, identify markers of unfavourable prognosis and treat those individuals at increased risk of disease progression or death. This article reviews the pathophysiology of myocardial damage, discusses the value of current risk stratification models and proposes an algorithm to guide mortality risk assessment and therapeutic decision-making in patients with CHD.
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Affiliation(s)
- Anis Rassi
- Anis Rassi Hospital, Goiânia, GO, Brasil.
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Abstract
A hundred years from its description, Chagas cardiomyopathy remains a challenging disease. Although successful vector-control strategies have decreased the incidence of Chagas disease in several Latin American countries, both migration to urban areas and immigration have spread the disease worldwide; and now, blood transfusion, organ transplantation, and vertical transmission are a concern. The pathogenesis of Chagas cardiomyopathy involves complex host-parasite interactions, where low-grade but incessant systemic infection and triggered autoimmune reaction are the main mechanisms for its development, with the contribution of autonomic damage and microvascular disturbances. Chagas cardiomyopathy is the most important clinical presentation of Chagas disease and comprises a wide range of manifestations, including heart failure, arrhythmias, heart blocks, sudden death, thromboembolism, and stroke. Recently, simple clinical prognostic scores have been developed to identify high-risk patients and help with management. The treatment of Chagas cardiomyopathy focuses mostly on managing heart failure, arrhythmias, and thromboembolism. The role of specific antiparasitic therapy in the chronic form is not yet defined, and a randomized trial is now under way to address this crucial point. In this article, we review the main clinical aspects of Chagas cardiomyopathy and underscore some upcoming challenges for the appropriate control, diagnosis, and management of this complex disease.
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Affiliation(s)
- Andréia Biolo
- Division of Cardiology, Hospital de Clínicas de Porto Alegre and Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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23
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Benchimol-Barbosa P, Barbosa-Filho J. Mechanical cardiac remodeling and new-onset atrial fibrillation in long-term follow-up of subjects with chronic Chagas' disease. Braz J Med Biol Res 2009; 42:251-62. [DOI: 10.1590/s0100-879x2009000300006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Accepted: 01/07/2009] [Indexed: 11/21/2022] Open
Affiliation(s)
- P.R. Benchimol-Barbosa
- Universidade do Estado do Rio de Janeiro, Brasil; Corpo de Bombeiros Militar do Estado do Rio de Janeiro, Brasil; Universidade Gama Filho, Brasil
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Bestetti RB, Theodoropoulos TAD, Cardinalli-Neto A, Cury PM. Treatment of chronic systolic heart failure secondary to Chagas heart disease in the current era of heart failure therapy. Am Heart J 2008; 156:422-30. [PMID: 18760121 DOI: 10.1016/j.ahj.2008.04.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Accepted: 04/29/2008] [Indexed: 11/19/2022]
Abstract
The treatment of chronic heart failure secondary to Chagas disease has been based on extrapolation of data achieved in the treatment of non-Chagas disease heart failure. Because beta-blockers decrease the incidence of sudden cardiac death in non-Chagas disease heart failure and sudden cardiac death occurs preferentially in patients with mild Chagas disease heart failure, beta-blockers may be administered first to class I/II patients with Chagas disease heart failure. In advanced Chagas disease heart failure, angiotensin-converting enzyme inhibitor and diuretics may be given at first to compensate for congestive symptoms. After clinical status improvement, beta-blockers should be given at targeted doses, if necessary reducing angiotensin-converting enzyme inhibitor doses. Primary and secondary prevention of sudden cardiac death may be accomplished with implantable cardioverter defibrillators because of the high recurrence of life-threatening arrhythmias despite amiodarone administration. In refractory heart failure, heart transplantation is the treatment of choice.
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Affiliation(s)
- Reinaldo B Bestetti
- Outpatient Cardiomyopathy Service, Division of Cardiology, São José do Rio Preto Medical School, São José do Rio Preto City, Brazil.
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Theodoropoulos TA, Bestetti RB, Otaviano AP, Cordeiro JA, Rodrigues VC, Silva AC. Predictors of all-cause mortality in chronic Chagas' heart disease in the current era of heart failure therapy. Int J Cardiol 2008; 128:22-9. [DOI: 10.1016/j.ijcard.2007.11.057] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Accepted: 11/12/2007] [Indexed: 10/22/2022]
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Gascón J, Albajar P, Cañas E, Flores M, Gómez i Prat J, Herrera RN, Lafuente CA, Luciardi HL, Moncayo Á, Molina L, Muñoz J, Puente S, Sanz G, Treviño B, Sergio-Salles X. Diagnóstico, manejo y tratamiento de la cardiopatía chagásica crónica en áreas donde la infección por Trypanosoma cruzi no es endémica. Enferm Infecc Microbiol Clin 2008; 26:99-106. [DOI: 10.1157/13115545] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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27
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Benchimol-Barbosa PR, Barbosa-Filho J. Atrial mechanical remodeling and new onset atrial fibrillation in chronic Chagas' heart disease. Int J Cardiol 2007; 127:e113-5. [PMID: 17689724 DOI: 10.1016/j.ijcard.2007.04.103] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Accepted: 04/23/2007] [Indexed: 10/23/2022]
Abstract
Atrial fibrillation (AF) is a common arrhythmia, mechanistically linked to underlying heart disease. AF affects about one fifth of subjects with Chagas' heart disease and is a harbinger of poor prognosis. In a retrospective longitudinal analysis, 50 subjects were investigated in long-term follow-up for the first documented atrial fibrillation (AF) episode. During a follow-up of (mean+/-SD) 84.2+/-39.0 months, nine subjects developed AF (incidence: 3.3+/-1.0%/year). Five subjects had nonfatal embolic stroke and nine died due to cardiac causes. The relative risk of AF for stroke was 3.0 (p=0.22) and for cardiac death was 3.6 (p=0.04). A faster left atrial diameter (LAD) enlargement during follow-up was tracked in subjects with more severe cardiac damage at presentation, and large LAD was detected at both presentation (p=0.02) and end of follow-up (p=0.002) in subjects who experienced AF. Atrial remodeling in chronic Chagas' disease is associated with severity of underlying heart disease at presentation and impacts AF incidence in this population.
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Abstract
BACKGROUND Chagas disease is a major cause of morbidity and mortality in Latin America. Knowledge of the predictors of prognosis can help clinical decision making by identifying patients' level of risk. METHODS AND RESULTS We reviewed the published literature on prognostic factors in patients with Chagas disease by performing a PubMed search for articles published in any language between 1985 and February 2006 and hand searches of the reference lists of retrieved articles. Studies were selected if they included patients in the chronic phase of Chagas disease, analyzed a clearly defined outcome (all-cause mortality, sudden cardiac deaths, and/or cardiovascular deaths), and used multivariable regression models of prognosis. From 606 potentially relevant studies, 12 met the inclusion criteria: 8 clinic-based studies including 3928 patients and 4 hospital-based studies including 349 patients. Impaired left ventricular function by echocardiogram or cineventriculogram was found to be the most common and consistent independent predictor of death. New York Heart Association functional class III/IV and cardiomegaly on the chest radiography also were independently associated with higher mortality. More recently, strong evidence was found that nonsustained ventricular tachycardia on 24-hour Holter monitoring indicated an adverse prognosis. The typical ECG abnormalities showed limited additional prognostic value. Other often-mentioned risk factors, advanced age and male sex, showed inconsistent results. A formal meta-analysis was not feasible because of the heterogeneity of published studies and the lack of minimal standards in reporting results. CONCLUSIONS A systematic review of published studies indicates that impaired left ventricular function, New York Heart Association class III/IV, cardiomegaly, and nonsustained ventricular tachycardia indicate a poor prognosis in patients with chronic Chagas disease.
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Affiliation(s)
- Anis Rassi
- Division of Cardiology, Anis Rassi Hospital, Avenida José Alves 453, Setor Oeste, Goiânia, Brazil.
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29
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Gascón J, Albajar P, Cañas E, Flores M, Gómez i Prat J, Herrera RN, Lafuente CA, Luciardi HL, Moncayo Á, Molina L, Muñoz J, Puente S, Sanz G, Treviño B, Sergio-Salles X. Diagnóstico, manejo y tratamiento de la cardiopatía chagásica crónica en áreas donde la infección por Trypanosoma cruzi no es endémica. Rev Esp Cardiol 2007. [DOI: 10.1157/13100280] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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30
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Diagnosis, Management, and Treatment of Chronic Chagas' Heart Disease in Areas Where Trypanosoma cruzi Infection Is Not Endemic. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1885-5857(07)60153-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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31
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Benchimol-Barbosa P. Noninvasive prognostic markers for cardiac death and ventricular arrhythmia in long-term follow-up of subjects with chronic Chagas' disease. Braz J Med Biol Res 2006. [DOI: 10.1590/s0100-879x2006005000061] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- P.R. Benchimol-Barbosa
- Universidade do Estado do Rio de Janeiro, Brasil; Corpo de Bombeiros Militar do Estado do Rio de Janeiro, Brasil
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Rassi A, Rassi A, Little WC, Xavier SS, Rassi SG, Rassi AG, Rassi GG, Hasslocher-Moreno A, Sousa AS, Scanavacca MI. Development and validation of a risk score for predicting death in Chagas' heart disease. N Engl J Med 2006; 355:799-808. [PMID: 16928995 DOI: 10.1056/nejmoa053241] [Citation(s) in RCA: 403] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chagas' disease is an important health problem in Latin America, and cardiac involvement is associated with substantial morbidity and mortality. We developed a model to predict the risk of death in patients with Chagas' heart disease. METHODS We retrospectively evaluated 424 outpatients from a regional Brazilian cohort. The association of potential risk factors with death was tested by Cox proportional-hazards analysis, and a risk score was created. The model was validated in 153 patients from a separate community hospital. RESULTS During a mean follow-up of 7.9 years, 130 patients in the development cohort died. Six independent prognostic factors were identified, and each was assigned a number of points proportional to its regression coefficient: New York Heart Association class III or IV (5 points), evidence of cardiomegaly on radiography (5 points), left ventricular systolic dysfunction on echocardiography (3 points), nonsustained ventricular tachycardia on 24-hour Holter monitoring (3 points), low QRS voltage on electrocardiography (2 points), and male sex (2 points). We calculated risk scores for each patient and defined three risk groups: low risk (0 to 6 points), intermediate risk (7 to 11 points), and high risk (12 to 20 points). In the development cohort, the 10-year mortality rates for these three groups were 10 percent, 44 percent, and 84 percent, respectively. In the validation cohort, the corresponding mortality rates were 9 percent, 37 percent, and 85 percent. The C statistic for the point system was 0.84 in the development cohort and 0.81 in the validation cohort. CONCLUSIONS A simple risk score was developed to predict death in Chagas' heart disease and was validated in an independent cohort.
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Affiliation(s)
- Anis Rassi
- Division of Cardiology, Anis Rassi Hospital, Goiânia, Brazil.
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Dourado KC, Bestetti RB, Cordeiro JA, Theodoropoulos TA. Assessment of quality of life in patients with chronic heart failure secondary to Chagas' cardiomyopathy. Int J Cardiol 2006; 108:412-3. [PMID: 16520133 DOI: 10.1016/j.ijcard.2005.03.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2005] [Accepted: 03/12/2005] [Indexed: 11/28/2022]
Abstract
Quality of Life was assessed by the Minnesota Living With Heart Failure Questionnaire in 61 patients with Chronic Systolic Heart Failure secondary to Chagas' cardiomyopathy. Mean total score was 37.3+/-21.4, mean physical dimension score 15.3+/-9.9 and mean emotional dimension score 7.4+/-5.2. A negative correlation between total score and hemoglobin levels, Systolic and Diastolic Blood Pressure and the 6-Minute Walk Test were observed. Total score was higher in patients in Class IV, on amiodarone, furosemide and carvedilol, and in non-sinus rhythm patients. Quality of Life Assessment in chagasic patients is similar to that found in patients with nonchagasic heart failure.
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Viotti RJ, Vigliano C, Laucella S, Lococo B, Petti M, Bertocchi G, Ruiz Vera B, Armenti H. Value of echocardiography for diagnosis and prognosis of chronic Chagas disease cardiomyopathy without heart failure. BRITISH HEART JOURNAL 2004; 90:655-60. [PMID: 15145872 PMCID: PMC1768261 DOI: 10.1136/hrt.2003.018960] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To establish the usefulness of echocardiography for the clinical classification of patients with Chagas disease and to determine the predictors of mortality and clinical events. METHODS 849 patients with chronic Chagas disease with a mean follow up of 9.9 years were studied. On admission, ECG, chest radiograph, and two dimensional echocardiogram were obtained from all patients. Clinical events were defined as new ECG abnormalities, change in clinical status resulting in transfer to another group, and death. Morphologically characterised segmental lesions were also seen in 12 patients on a second harmonic echocardiogram with intravenous contrast agent. Univariate and multivariate analysis for clinical events and mortality were performed. SETTING Community of San Martín, Buenos Aires, Argentina. RESULTS Change in clinical group (68 of 833 survivors v 15 of 16 who died, p < 0.001), left ventricular systolic dimension (mean (SD) 3.06 (0.72) cm v 4.71 (0.90) cm, p < 0.0001), and ejection fraction (mean (SD) 0.67 (0.11)% v 0.42 (0.17)%, p < 0.0001) were found to be the only predictors of mortality. ECG abnormalities related to the disease (in 220 of 699 patients with no clinical event v 98 of 150 patients with a clinical event, p < 0.0001), left ventricular diastolic dimension (mean (SD) 4.88 (0.54) cm v 5.44 (0.83) cm, p < 0.0001), left ventricular systolic dimension (mean (SD) 2.98 (0.62) cm v 3.64 (1.03) cm, p < 0.0001), and ejection fraction (mean (SD) 0.68 (0.10)% v 0.60 (0.16)%, p < 0.0001) were predictors of clinical events. Segmental lesions were observed in 211 of 849 patients (25%). Segmental lesions were seen in 66 (13%) and systolic dysfunction was seen in four of 505 (0.8%) patients with normal ECG. Significant differences were found between the groups of patients (group 0: reactive serology and normal ECG and chest radiography without cardiac enlargement and no signs of heart failure; group 1: reactive serology and abnormal ECG and chest radiography without cardiac enlargement; group 2: reactive serology and abnormal ECG and chest radiography with cardiac enlargement and no signs of heart failure). CONCLUSION Echocardiography was useful both to characterise and to determine the prognosis of patients with chronic Chagas disease without heart failure.
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Affiliation(s)
- R J Viotti
- Cardiology Department, Hospital Eva Perón, San Martin, Buenos Aires, Argentina
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Salles GF, Cardoso CRL, Xavier SS, Sousa AS, Hasslocher-Moreno A. Electrocardiographic ventricular repolarization parameters in chronic Chagas' disease as predictors of asymptomatic left ventricular systolic dysfunction. Pacing Clin Electrophysiol 2003; 26:1326-35. [PMID: 12822748 DOI: 10.1046/j.1460-9592.2003.t01-1-00190.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Electrocardiographic repolarization parameters are potential markers of arrhythmogenic risk and have not been evaluated in Chagas' disease. The aim of this report was to investigate their associations with LV systolic function assessed by two-dimensional echocardiography. In a cross-sectional study involving 738 adult outpatients in the chronic phase of Chagas' disease, maximal QTc and T wave peak-to-end (TpTe) intervals, and QT, QTapex (QTa), IT and TpTe interval dispersions, and variation coefficients were measured and calculated from 12-lead standard ECGs. Clinical, radiological, ECG, and echocardiographic data were recorded. In bivariate statistical analysis, all repolarization parameters were significantly increased in patients with moderate or severe LV systolic dysfunction, and these patients showed more clinical, radiologic, and ECG abnormalities. Receiver operating characteristic curve analysis demonstrated that isolatedly QTd had the best predictive performance for LV dysfunction, with an 80% specificity and 67% sensitivity for values >60 ms in the subgroup of chagasic patients with abnormal ECGs and no heart failure. Multivariate logistic regression selected, as the best predictive model for LV dysfunction in this subgroup of patients, the presence of cardiomegaly on chest X ray (OR 14.06, 95% CI, 5.54-35.71), QTd >60 ms (OR 9.35, 95% CI, 4.01-21.81), male gender (OR 7.70, 95% CI, 2.98-19.91) and the presence of frequent premature ventricular contractions (PVCs) on ECG (OR 4.06, 95% CI, 1.65-9.97). This model showed 90% specificity and 71% sensitivity. In conclusion, QTd was associated to LV systolic function and could be used to predict asymptomatic dysfunction in chronic Chagas' disease. The presence of cardiomegaly, frequent PVCs, and male sex refined LV function stratification in these patients.
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Affiliation(s)
- Gil F Salles
- Department of Internal Medicine, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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Abstract
The aim of this study was to detect clinical predictors of left ventricular dysfunction, left ventricular dilatation and apical aneurysm on echocardiography, all known as independent predictors of lethal outcome for patients with chronic Chagas' disease. Seventy-four patients with a positive complement-fixation test for Chagas' disease participated; 44 (59%) had left ventricular dysfunction, 41 (55%) left ventricular dilatation and 15 (20%) apical aneurysm. A stepwise logistic regression analysis showed that systolic blood pressure (P < 0.001) and male sex (P < 0.001) were independent predictors of left ventricular dilatation on echocardiography. A receiver-operating characteristic curve provided a systolic blood pressure of 120 mmHg with a sensitivity of 70% and a specificity of 63% to predict left ventricular dilatation. The combination of male sex and systolic blood pressure of 120 mmHg had a sensitivity of 56% and a specificity of 91% to predict left ventricular dilatation. In a separate stepwise logistic regression analysis, left ventricular systolic dysfunction was independently predicted by systolic blood pressure (P = 0.006) and New York Heart Association functional class (P = 0.01). Receiver-operating curves provided a blood pressure of 120 mmHg with a sensitivity of 72% and a specificity of 59% to predict left ventricular dysfunction, whereas a New York Heart Association functional score of 2 predicted left ventricular systolic dysfunction with a sensitivity of 78% and a specificity of 50%. The combination of New York Heart Association functional class and a systolic blood pressure of 120 mmHg predicted left ventricular dysfunction with a sensitivity of 59% and a specificity of 77%. The apical aneurysm was independently predicted by myocardial necrosis on the resting ECG, but only with a sensitivity of 20%. Hence, echocardiographic markers of cardiac mortality and sudden cardiac death in Chagas' disease can be independently predicted by clinical examination. This may be useful for screening high-risk chagasic patients.
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Affiliation(s)
- R B Bestetti
- Faculdade de Medicina Barão de Mauá, Ribeirão Preto City, and Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto City, Brazil.
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Ribeiro AL, Rocha MO, Barros MV, Rodrigues AR, Machado FS. A narrow QRS does not predict a normal left ventricular function in Chagas' disease. Pacing Clin Electrophysiol 2000; 23:2014-7. [PMID: 11139981 DOI: 10.1111/j.1540-8159.2000.tb07076.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Left ventricular (LV) systolic dysfunction is a major prognostic determinant in Chagas' disease (ChD), a potentially fatal disorder which affects nearly 20 million individuals in Latin America. Therefore, reliable screening methods are needed to identify patients in need of a detailed evaluation of LV function. Since previous reports have suggested that a prolonged QRS duration may be an accurate predictor of LV dysfunction, the relationship between QRS duration and LV function was evaluated in ChD patients, in order to determine whether a narrow QRS on surface electrocardiogram (ECG) predicts a normal LV function. Ninety-eight patients with ChD and no other cardiac or systemic illness were underwent standard 12-lead ECG and Doppler echocardiogram (echo) examination. An investigator (blinded to the echo data) measured manually the QRS duration. LV dysfunction was defined by the presence of LV dilatation (LV diastolic dimension > 55 mm), depressed LV ejection fraction (LVEF < 0.50), segmental contractile abnormalities (SCA) or LV aneurysm. QRS duration was significantly correlated with LV diastolic dimension (r = 0.44, P = 0.000) and LVEF (r = 0.24, P = 0.016). A significant percentage of patients with QRS < 100 ms had abnormal systolic LV parameters, including LV dilatation (8.1%), reduced EF (10.2%), SCA (42.8%) and LV aneurysm (14.2%). A narrow QRS does not exclude the presence of significant global and segmental LV dysfunction in ChD patients. Since these abnormalities have prognostic and therapeutic implications, further evaluation of LV systolic performance is desirable in such patients.
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Affiliation(s)
- A L Ribeiro
- Hospital das Clínicas, and School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.
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Ribeiro AL, Rocha MO. [Indeterminate form of Chagas disease: considerations about diagnosis and prognosis]. Rev Soc Bras Med Trop 1998; 31:301-14. [PMID: 9612022 DOI: 10.1590/s0037-86821998000300008] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The indeterminate form of Chagas' disease is defined by the absence of clinical, radiological and electrocardiographic manifestations of cardiac or digestive involvement in Trypanosoma cruzi chronic infected persons. When submitted to advanced cardiovascular tests, these patients may present significant abnormalities. However, the indeterminate form concept was reaffirmed as valid, since diagnostic criteria are simple and prognosis is benignant. In clinical practice, diagnostic difficulties are frequent, related to subjectivity and uncertain meaning of clinical, electrocardiographic and radiological findings. Moreover, indeterminate form prognosis is not equally good: after five to 10 years, a third of patients will have cardiopathy. Sudden death, a rare complication, may be the first manifestation of Chagas' disease. It is necessary to reappraise indeterminate form concept, redefining diagnostic criteria and therapeutic management. Clinical and noninvasive evaluation may allow individual risk stratification; therapeutic interventions may be beneficial in high risk groups. Since etiologic treatment may prevent cardiopathy, its role in indeterminate form management must be reassessed.
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Affiliation(s)
- A L Ribeiro
- Hospital das Clínicas e na Faculdade de Medicina da Universidade Federal de Minas Gerais.
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Rodriguez-Salas LA, Klein E, Acquatella H, Catalioti F, Davalos V, Gomez-Mancebo JR, Gonzalez H, Bosch F, Puigbo JJ. Echocardiographic and Clinical Predictors of Mortality in Chronic Chagas' Disease. Echocardiography 1998; 15:271-278. [PMID: 11175040 DOI: 10.1111/j.1540-8175.1998.tb00607.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND: In a prospective epidemiological study of chronic Chagas' disease, several clinical and echocardiographic variables were analyzed as predictors of mortality. METHODS: Among 960 subjects seropositive for Chagas' disease who were examined between June 1981 and June 1992, 283 had echocardiograms. RESULTS: During a mean follow-up period of 48.3 +/- 36.4 months (range, 1-156 months), 108 subjects died. Echocardiographic end-diastolic and -systolic left ventricular internal dimensions, fractional shortening, radius-to-thickness ratio, left ventricular mass, mitral E-point septal separation, and 17 other nonechocardiographic variables were predictors of death on univariate analysis (P < 0.001 for each). On stepwise multiple regression analysis of 215 subjects, significant risk covariates in a Cox model analysis were clinical group (P < 0.0001), M-mode echocardiographic E-point septal separation of 22 mm (P = 0.003), presence of first- or second-degree heart block (P = 0.003), chest radiologic cardiothoracic ratio >/= 0.55 (P = 0.012), presence of electrocardiographic ST segment elevation on precordial leads (P = 0.014), age >/= 56 years (P = 0.028), and presence of right bundle-branch block (P = 0.045). Patients with an apical aneurysm on two-dimensional echocardiography had an increased mortality (Chi-square = 11.5, P < 0.001). CONCLUSIONS: Echocardiography is a valuable tool to assess the risk of death in prospective studies on chronic Chagas' heart disease.
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Affiliation(s)
- R B Bestetti
- Health Service of the University of São Paulo at Ribeirão Preto, Brazil
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Carrasco HA, Parada H, Guerrero L, Duque M, Durán D, Molina C. Prognostic implications of clinical, electrocardiographic and hemodynamic findings in chronic Chagas' disease. Int J Cardiol 1994; 43:27-38. [PMID: 8175216 DOI: 10.1016/0167-5273(94)90087-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
To evaluate the prognostic importance of 19 clinical, electrocardiographic and hemodynamic variables, 556 chronic chagasic patients were submitted to an extensive protocol, including left cineventriculogram and Holter monitoring, and followed for up to 15 years. The protagonist role of the magnitude of the myocardial compromise in the evolution of chagasic patients is underscored by our results, which indicated the independent prognostic value of an ejection fraction below 0.30 (P < 0.001), a heart rate higher than 89 beats/min (P < 0.01), grade IV functional capacity (P < 0.05), end systolic stress > 120 g/cm2 (P < 0.05), and end diastolic volume index > 200 ml/m2 (P < 0.05). When only patients with an ejection fraction over 0.29 were considered, variables with independent prognostic value were: the cardio-thoracic ratio (P < 0.01), functional capacity (P < 0.05) and heart rate (P < 0.05). Survival analysis demonstrated that the presence of complex (Lown III, IV) ventricular arrhythmias increased mortality significantly (P < 0.01) only in patients with an ejection fraction over 0.29. Therefore, preservation of myocardial function is the capital measure in the treatment of chronic chagasic patients.
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Affiliation(s)
- H A Carrasco
- Centro de Investigaciones Cardiovasculares Dr Abdel Fuenmayor, Universidad de Los Andes, Mérida, Venezuela
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