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Couto-Silva CM, Nunes K, Venturini G, Araújo Castro e Silva M, Pereira LV, Comas D, Pereira A, Hünemeier T. Indigenous people from Amazon show genetic signatures of pathogen-driven selection. SCIENCE ADVANCES 2023; 9:eabo0234. [PMID: 36888716 PMCID: PMC9995071 DOI: 10.1126/sciadv.abo0234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/08/2023] [Indexed: 06/18/2023]
Abstract
Ecological conditions in the Amazon rainforests are historically favorable for the transmission of numerous tropical diseases, especially vector-borne diseases. The high diversity of pathogens likely contributes to the strong selective pressures for human survival and reproduction in this region. However, the genetic basis of human adaptation to this complex ecosystem remains unclear. This study investigates the possible footprints of genetic adaptation to the Amazon rainforest environment by analyzing the genomic data of 19 native populations. The results based on genomic and functional analysis showed an intense signal of natural selection in a set of genes related to Trypanosoma cruzi infection, which is the pathogen responsible for Chagas disease, a neglected tropical parasitic disease native to the Americas that is currently spreading worldwide.
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Affiliation(s)
- Cainã M. Couto-Silva
- Departamento de Genética e Biologia Evolutiva, Instituto de Biociências, Universidade de São Paulo, São Paulo, SP, 05508090, Brazil
| | - Kelly Nunes
- Departamento de Genética e Biologia Evolutiva, Instituto de Biociências, Universidade de São Paulo, São Paulo, SP, 05508090, Brazil
| | - Gabriela Venturini
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
- Laboratório de Genética e Cardiologia Molecular, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Marcos Araújo Castro e Silva
- Departamento de Genética e Biologia Evolutiva, Instituto de Biociências, Universidade de São Paulo, São Paulo, SP, 05508090, Brazil
- Institut de Biologia Evolutiva, Departament de Medicina i Ciències de la Vida, Universitat Pompeu Fabra, Barcelona 08003, Spain
| | - Lygia V. Pereira
- Departamento de Genética e Biologia Evolutiva, Instituto de Biociências, Universidade de São Paulo, São Paulo, SP, 05508090, Brazil
| | - David Comas
- Institut de Biologia Evolutiva, Departament de Medicina i Ciències de la Vida, Universitat Pompeu Fabra, Barcelona 08003, Spain
| | - Alexandre Pereira
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
- Laboratório de Genética e Cardiologia Molecular, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Tábita Hünemeier
- Departamento de Genética e Biologia Evolutiva, Instituto de Biociências, Universidade de São Paulo, São Paulo, SP, 05508090, Brazil
- Institut de Biologia Evolutiva (CSIC/Universitat Pompeu Fabra), Barcelona 08003, Spain
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Casares-Marfil D, Guillen-Guio B, Lorenzo-Salazar JM, Rodríguez-Pérez H, Kerick M, Jaimes-Campos MA, Díaz ML, Estupiñán E, Echeverría LE, González CI, Martin J, Flores C, Acosta-Herrera M. Admixture mapping analysis reveals differential genetic ancestry associated with Chagas disease susceptibility in the Colombian population. Hum Mol Genet 2021; 30:2503-2512. [PMID: 34302177 PMCID: PMC8643504 DOI: 10.1093/hmg/ddab213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/02/2023] Open
Abstract
Chagas disease is an infection caused by the parasite Trypanosoma cruzi, endemic in Latino America. Leveraging the three-way admixture between Native American (AMR), European (EUR) and African (AFR) populations in Latin Americans, we aimed to better understand the genetic basis of Chagas disease by performing an admixture mapping study in a Colombian population. A two-stage study was conducted, and subjects were classified as seropositive and seronegative for T. cruzi. In stage 1, global and local ancestries were estimated using reference data from the 1000 Genomes Project (1KGP) and local ancestry associations were performed by logistic regression models. The AMR ancestry showed a protective association with Chagas disease within the Major Histocompatibility Complex region (OR = 0.74, 95%CI = 0.66-0.83, lowest p-value = 4.53x10-8). The fine mapping assessment on imputed genotypes combining data from stage 1 and 2 from an independent Colombian cohort, revealed nominally associated variants in high linkage disequilibrium with the top signal (rs2032134, OR = 0.93, 95%CI = 0.90-0.97, p-value = 3.54x10-4) in the previously associated locus. To assess ancestry-specific adaptive signals, a selective sweep scan in an AMR reference population from 1KGP together with an in silico functional analysis highlighted the Tripartite Motif family and the Human Leukocyte Antigen (HLA) genes, with crucial role in the immune response against pathogens. Furthermore, these analyses emphasized the macrophages, neutrophils, and eosinophils, as key players in the defense against T. cruzi. This first admixture mapping study in Chagas disease provided novel insights underlying the host immune response in the pathogenesis of this neglected disease.
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Affiliation(s)
| | - Beatriz Guillen-Guio
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Jose M Lorenzo-Salazar
- Genomics Division, Instituto Tecnológico y de Energías Renovables (ITER), Santa Cruz de Tenerife, Spain
| | - Héctor Rodríguez-Pérez
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Martin Kerick
- Institute of Parasitology and Biomedicine López-Neyra, CSIC, Granada, Spain
| | - Mayra A Jaimes-Campos
- Grupo de Inmunología y Epidemiología Molecular, Escuela de Microbiología, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Martha L Díaz
- Grupo de Inmunología y Epidemiología Molecular, Escuela de Microbiología, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Elkyn Estupiñán
- Institute of Parasitology and Biomedicine López-Neyra, CSIC, Granada, Spain.,Grupo de Inmunología y Epidemiología Molecular, Escuela de Microbiología, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Luis E Echeverría
- Heart Failure and Heart Transplant Clinic, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Clara I González
- Grupo de Inmunología y Epidemiología Molecular, Escuela de Microbiología, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Javier Martin
- Institute of Parasitology and Biomedicine López-Neyra, CSIC, Granada, Spain
| | - Carlos Flores
- Research Unit, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.,Genomics Division, Instituto Tecnológico y de Energías Renovables (ITER), Santa Cruz de Tenerife, Spain.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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3
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Spatiotemporal trends of Chagas disease-related mortality in the Northeast of Brazil, 2007–2017. Parasitology 2020; 147:1552-1558. [DOI: 10.1017/s0031182020001419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AbstractChagas disease (CD) is a neglected disease and endemic in Brazil. In the Brazilian Northeast Region, it affects millions of people. Therefore, it is necessary to identify the spatiotemporal trends of CD mortality in the Northeast of Brazil. This ecological study was designed, in which the unit of analysis was the municipality of the Brazilian northeast. The data source was the Information System of Mortality. It was calculated relative risk from socioeconomic characteristics. Mortality rates were smoothed by the Local Empirical Bayes method. Spatial dependency was analysed by the Global and Local Moran Index. Scan spatial statistics were also used. A total of 11 287 deaths by CD were notified in the study. An expressive parcel of this number was observed among 70-year-olds or more (n = 4381; 38.8%), no schooling (n = 4381; 38.8%), mixed-race (n = 4381; 62.3%), male (n = 6875; 60.9%). It was observed positive spatial autocorrelation, mostly in municipalities of the state of Bahia, Piauí (with high-high clusters), and Maranhão (with low-low clusters). The spatial scan statistics has presented a risk of mortality in 24 purely spatial clusters (P < 0.05). The study has identified the spatial pattern of CD mortality mostly in Bahia and Piauí, highlighting priority areas in planning and control strategies of the health services.
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Strauss M, Acosta-Herrera M, Alcaraz A, Casares-Marfil D, Bosch-Nicolau P, Lo Presti MS, Molina I, González CI, Martín J. Association of IL18 genetic polymorphisms with Chagas disease in Latin American populations. PLoS Negl Trop Dis 2019; 13:e0007859. [PMID: 31751351 PMCID: PMC6894881 DOI: 10.1371/journal.pntd.0007859] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 12/05/2019] [Accepted: 10/21/2019] [Indexed: 12/14/2022] Open
Abstract
Host genetic factors have been suggested to play an important role in the susceptibility to Chagas disease. Given the influence of interleukin 18 (IL-18) in the development of the disease, in the present study, we analyzed three IL18 genetic variants (rs2043055, rs1946518, rs360719) regarding the predisposition to Trypanosoma cruzi infection and the development of chronic Chagas cardiomyopathy (CCC), in different Latin America populations. Genetic data of 3,608 patients from Colombia, Bolivia, Argentina, and Brazil were meta-analyzed to validate previous findings with increased statistical power. Seropositive and seronegative individuals were compared for T. cruzi infection susceptibility. In the Colombian cohort, the allelic frequencies of the three variants showed a significant association, with adjustment for sex and age, and also after applying multiple testing adjustments. Among the Colombian and Argentinean cohorts, rs360719 showed a significant genetic effect in a fixed-effects meta-analysis after a Bonferroni correction (OR: 0.76, CI: 0.66-0.89, P = 0.001). For CCC, the rs2043055 showed an association with protection from cardiomyopathy in the Colombian cohort (OR: 0.79, CI: 0.64-0.99, P = 0.037), with adjustment for sex and age, and after applying multiple testing adjustments. The meta-analysis of the CCC vs. asymptomatic patients from the four cohorts showed no evidence of association. In conclusion, our results validated the association found previously in the Colombian cohort suggesting that IL18 rs360719 plays an important role in the susceptibility to T. cruzi infection and no evidence of association was found between the IL18 genetic variants and CCC in the Latin American population studied.
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Affiliation(s)
- Mariana Strauss
- Centro de Estudios e Investigación de la Enfermedad de Chagas y Leishmaniasis, FCM, INICSA-CONICET-UNC, Córdoba, Argentina
| | | | - Alexia Alcaraz
- Instituto de Parasitología y Biomedicina López-Neyra, IPBLN-CSIC, PTS Granada, Granada, España
| | - Desiré Casares-Marfil
- Instituto de Parasitología y Biomedicina López-Neyra, IPBLN-CSIC, PTS Granada, Granada, España
| | - Pau Bosch-Nicolau
- Unidad de Medicina Tropical y Salud Internacional Hospital Universitari Vall d'Hebron, PROSICS, Barcelona, España
| | - María Silvina Lo Presti
- Centro de Estudios e Investigación de la Enfermedad de Chagas y Leishmaniasis, FCM, INICSA-CONICET-UNC, Córdoba, Argentina
| | - Israel Molina
- Unidad de Medicina Tropical y Salud Internacional Hospital Universitari Vall d'Hebron, PROSICS, Barcelona, España
| | | | - Javier Martín
- Instituto de Parasitología y Biomedicina López-Neyra, IPBLN-CSIC, PTS Granada, Granada, España
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Teotônio IMSN, Dias N, Hagström-Bex L, Nitz N, Francisco AF, Hecht M. Intestinal microbiota - A modulator of the Trypanosoma cruzi-vector-host triad. Microb Pathog 2019; 137:103711. [PMID: 31491548 DOI: 10.1016/j.micpath.2019.103711] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/11/2019] [Accepted: 09/02/2019] [Indexed: 12/12/2022]
Abstract
Chagas disease affects millions of people, and it is a major cause of death in Latin America. Prevention and development of an effective treatment for this infection can be favored by a more thorough understanding of T. cruzi interaction with the microbiome of vectors and hosts. Next-generation sequencing technology vastly broadened the knowledge about intestinal bacteria composition, showing that microbiota within each host (triatomines and mammals) is composed by high diversity of species, although few dominant phyla. This fact may represent an ecological balance that was acquired during the evolutionary process of the microbiome-host complex, and that serves to perpetuate this system. In this context, commensal microbiota is also essential to protect hosts, conferring them resistance to pathogens colonization. However, in some situations, the microbiota is not able to prevent infection but only modulate it. Here we will review the role of the microbiota on the parasite-vector-host triad with a focus on the kinetoplastida of medical importance Trypanosoma cruzi. Novel strategies to control Chagas disease based on intestinal microbiome will also be discussed.
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Affiliation(s)
| | - Nayra Dias
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasilia, Brasilia, Federal District, Brazil
| | - Luciana Hagström-Bex
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasilia, Brasilia, Federal District, Brazil
| | - Nadjar Nitz
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasilia, Brasilia, Federal District, Brazil
| | - Amanda Fortes Francisco
- Department of Pathogen Molecular Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Mariana Hecht
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasilia, Brasilia, Federal District, Brazil.
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Abstract
Using data from the Philadelphia Neurodevelopmental Cohort, we examined whether European ancestry predicted cognitive ability over and above both parental socioeconomic status (SES) and measures of eye, hair, and skin color. First, using multi-group confirmatory factor analysis, we verified that strict factorial invariance held between self-identified African and European-Americans. The differences between these groups, which were equivalent to 14.72 IQ points, were primarily (75.59%) due to difference in general cognitive ability (g), consistent with Spearman’s hypothesis. We found a relationship between European admixture and g. This relationship existed in samples of (a) self-identified monoracial African-Americans (B = 0.78, n = 2,179), (b) monoracial African and biracial African-European-Americans, with controls added for self-identified biracial status (B = 0.85, n = 2407), and (c) combined European, African-European, and African-American participants, with controls for self-identified race/ethnicity (B = 0.75, N = 7,273). Controlling for parental SES modestly attenuated these relationships whereas controlling for measures of skin, hair, and eye color did not. Next, we validated four sets of polygenic scores for educational attainment (eduPGS). MTAG, the multi-trait analysis of genome-wide association study (GWAS) eduPGS (based on 8442 overlapping variants) predicted g in both the monoracial African-American (r = 0.111, n = 2179, p < 0.001), and the European-American (r = 0.227, n = 4914, p < 0.001) subsamples. We also found large race differences for the means of eduPGS (d = 1.89). Using the ancestry-adjusted association between MTAG eduPGS and g from the monoracial African-American sample as an estimate of the transracially unbiased validity of eduPGS (B = 0.124), the results suggest that as much as 20%–25% of the race difference in g can be naïvely explained by known cognitive ability-related variants. Moreover, path analysis showed that the eduPGS substantially mediated associations between cognitive ability and European ancestry in the African-American sample. Subtest differences, together with the effects of both ancestry and eduPGS, had near-identity with subtest g-loadings. This finding confirmed a Jensen effect acting on ancestry-related differences. Finally, we confirmed measurement invariance along the full range of European ancestry in the combined sample using local structural equation modeling. Results converge on genetics as a potential partial explanation for group mean differences in intelligence.
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7
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Soares-Souza G, Borda V, Kehdy F, Tarazona-Santos E. Admixture, Genetics and Complex Diseases in Latin Americans and US Hispanics. CURRENT GENETIC MEDICINE REPORTS 2018. [DOI: 10.1007/s40142-018-0151-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Lima-Costa MF, Gouveia MH, Cesar CC, Tarazona-Santos E, Stewart R, Ferri CP, Castro-Costa E. Genomic African and Native American Ancestry and 15-Year Cognitive Trajectory: Bambui Study, Brazil. J Am Geriatr Soc 2018; 66:1956-1962. [PMID: 30221750 DOI: 10.1111/jgs.15504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To investigate the association between African and Native American genomic ancestry and long-term cognitive trajectories in admixed Brazilians. DESIGN Population-based longitudinal study. SETTING Bambui-Epigen (Brazil) cohort study. PARTICIPANTS Adults aged 60 and older (N=1,215) MEASUREMENTS: Participants were followed from January 1997 to December 2011. Cognitive function was assessed annually using the Mini-Mental State Examination (MMSE), totaling 12,208 measurements. We used linear mixed-effects pattern models to assess MMSE score trajectories. Ancestry was assessed using a genome-wide approach. RESULTS After adjustments for covariates, the highest quintile of African ancestry was associated with poorer baseline cognitive performance (β=-0.73, 95% confidence interval (CI)=-1.36 to -0.11) but not with cognitive trajectory. Educational level modified the baseline association between highest African ancestry and cognitive performance in that the association was observed only in those with very low (<4 years) education (β=-1.13, 95% CI=-2.02 to -0.23). No association was found between Native American ancestry and baseline cognitive function or its trajectory. CONCLUSION Genomic African and Native American ancestry levels had no prognostic value for age-related cognitive decline in this admixed population.
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Affiliation(s)
| | - Mateus H Gouveia
- Instituto de Pesquisas René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Brazil.,Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Cibele C Cesar
- Instituto de Pesquisas René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Brazil.,Faculdade de Ciências Econômicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Eduardo Tarazona-Santos
- Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Rob Stewart
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Cleusa P Ferri
- Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Erico Castro-Costa
- Instituto de Pesquisas René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Brazil
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Lima-Costa MF, de Andrade FB, Souza PRBD, Neri AL, Duarte YADO, Castro-Costa E, de Oliveira C. The Brazilian Longitudinal Study of Aging (ELSI-Brazil): Objectives and Design. Am J Epidemiol 2018; 187:1345-1353. [PMID: 29394304 PMCID: PMC6031009 DOI: 10.1093/aje/kwx387] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 12/21/2017] [Indexed: 12/17/2022] Open
Abstract
Brazil is experiencing among the world’s fastest demographic aging worldwide. This demographic transition is occurring in a context of few resources and great social inequalities. The Brazilian Longitudinal Study of Aging (ELSI-Brazil) is a nationally representative study of 9,412 people aged 50 years or older, residing in 70 municipalities across the 5 Brazilian regions. ELSI-Brazil allows investigations of the aging process, its health, psychosocial and economic determinants, and societal consequences. The baseline examination (2015–2016) included detailed household and individual interviews and physical measurements (blood pressure, anthropometry, grip strength, and timed walk and balance tests). Blood tests and sample storage were performed in a subsample of study participants. Subsequent waves are planned for every 3 years. The study adopts a conceptual framework common to other large-scale longitudinal studies of aging in the world, such as the Health and Retirement Study, allowing cross-national comparisons. The goal of ELSI-Brazil is not only to build an understanding of aging in a large, Western, middle-income country in a rapid demographic transition but also to provide scientific data to support and study policy changes that may affect older adults. We describe the methodology of the study and some descriptive results of the baseline survey.
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Affiliation(s)
| | | | | | | | | | - Erico Castro-Costa
- Instituto de Pesquisas René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Brazil
| | - Cesar de Oliveira
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
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Nadruz W, Gioli-Pereira L, Bernardez-Pereira S, Marcondes-Braga FG, Fernandes-Silva MM, Silvestre OM, Sposito AC, Ribeiro AL, Bacal F, Fernandes F, Krieger JE, Mansur AJ, Pereira AC. Temporal trends in the contribution of Chagas cardiomyopathy to mortality among patients with heart failure. Heart 2018. [PMID: 29523589 DOI: 10.1136/heartjnl-2017-312869] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Chagas cardiomyopathy (ChC) prevalence is decreasing in Brazil and medical therapies for heart failure (HF) have improved in the last decade. Whether these changes modified the prognosis of ChC relative to non-Chagas cardiomyopathies (NChC) remains unknown. This study evaluated the temporal trends in population attributable risk (PAR) of ChC for 2-year mortality among patients with HF enrolled at years 2002-2004 (era 1) and 2012-2014 (era 2) in a Brazilian university hospital. METHODS We prospectively studied 362 (15% with ChC) and 582 (18% with ChC) HF patients with ejection fraction ≤50% in eras 1 and 2, respectively and estimated the PAR of ChC for 2-year mortality. RESULTS There were 145 deaths (29 in ChC) in era 1 and 85 deaths (26 in ChC) in era 2. In multivariable Cox-regression analysis adjusted for age, sex, ejection fraction, heart rate, body mass index, hypertension, diabetes mellitus, systolic blood pressure and ischaemic/valvar aetiology, ChC was associated with higher risk of death in era 1 (HR (95% CI)=1.92 (1.00 to 3.71), p=0.05) and era 2 (HR (95% CI)=3.51 (1.94 to 6.36), p<0.001). In fully adjusted analysis, the PAR of ChC for mortality increased twofold from era 1 (PAR (95% CI)=11.0 (2.8 to 18.5)%) to era 2 (PAR (95% CI)=21.9 (16.5 to 26.9)%; p=0.023 versus era 1). CONCLUSION Although the absolute death rates decreased over time in the ChC and NChC groups, the PAR of ChC for mortality increased among patients with HF, driven by increases in the HR associated with ChC. Our results highlight the need for additional efforts aiming to prevent and treat ChC.
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Affiliation(s)
- Wilson Nadruz
- Department of Internal Medicine, University of Campinas, Campinas, Brazil
| | | | | | | | - Miguel M Fernandes-Silva
- Medicine Department, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil.,Research Department, Quanta Diagnósticos e Terapia, Curitiba, Brazil
| | - Odilson M Silvestre
- Department of Internal Medicine, Federal University of Acre, Rio Branco, Brazil
| | - Andrei C Sposito
- Department of Internal Medicine, University of Campinas, Campinas, Brazil
| | - Antonio L Ribeiro
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Fernando Bacal
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Fabio Fernandes
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Jose E Krieger
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alfredo J Mansur
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alexandre C Pereira
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
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