Inspiratory Muscle Strength in Chagas Cardiomyopathy: A Systematic Scoping Review

ABSTRACT The increase in inflammatory markers associated with persistent chronic fibrosing myocarditis, a characteristic of chronic Chagas disease, can result in a reduction in inspiratory muscle strength (IMS) in Chagas cardiomyopathy (CC). However, literature in this field is still scarce. This review aimed to map and summarize the evidence regarding IMS in patients with CC. The inclusion criteria included reports with adult participants with a CC diagnosis, with or without heart failure (HF). The core concept examined was the maximum inspiratory pressure evaluated in the untrained and trained groups in the pre-training period. The context was open, including but not limited to hospitals and health centers. Two authors independently identified eligible studies and extracted the data. Descriptive synthesis was used as the primary strategy for analyzing the results. Nine studies (five clinical trials, three cross-sectional, and one cohort) were included. The CC classification differed among the studies, with no mention of HF in five and no CC staging specification in six. IMS was assessed using a manovacuometer, and only six studies analyzed and interpreted the data concerning the predicted values. The CC population with HF appeared to have impaired IMS. All studies involved only Brazilian volunteers. In conclusion, randomized clinical trials evaluating IMS and the effects of inspiratory muscle training need to be conducted to better understand the prevalence and risk of inspiratory muscle weakness in the CC population, as well as the effects of training. Such studies should be conducted at different stages of CC in different populations and countries.

Epidemiological-clinical profile and mortality in patients coinfected with Trypanosoma cruzi/HIV: experience from a Brazilian reference center

ABSTRACT Background: The recent urbanization of Chagas disease (CD) has contributed to a greater risk of coexistence with human immunodeficiency virus (HIV) and AIDS. Methods: This retrospective observational study included patients who were followed at INI-Fiocruz between July 1986 and October 2021. All patients underwent an assessment protocol that included sociodemographic profile, epidemiological history, and clinical evaluation. Descriptive data analyses included reports of the medians and frequencies of variables of interest. Differences in medians between groups were tested using the Mann-Whitney U test. Differences in frequency were tested using Fisher's exact test. Results: Among 2201 patients, 11 (0.5%) were identified with Trypanosoma cruzi/HIV coinfection. Of these, 63.6% were women with a median age of 51.0 years old. Two patients had the indeterminate form of CD, six had the cardiac form, two had the digestive form and one had the cardio-digestive form. Half of the patients were undergoing antiretroviral treatment at the time of coinfection diagnosis with a median CD4+ count of 350 cells/μL and a viral load of 1500 copies/μL. Four patients underwent a xenodiagnosis test at coinfection diagnosis, which all yielded positive results; two of them presented high parasitemia under the risk of reactivation. Prophylaxis for CD reactivation was administered to four patients; two with ketoconazole and two with benznidazole. Six patients died after a median follow-up of 22.5 months, with AIDS being the most common cause of death. Only one case of reactivation was observed. Conclusions: Early diagnosis and prompt treatment of CD reactivation dramatically reduced mortality. Identification of Trypanosoma cruzi/HIV co-infection is crucial to planning a close follow-up of coinfected patients.

The CUIDA Chagas Project: towards the elimination of congenital transmission of Chagas disease in Bolivia, Brazil, Colombia, and Paraguay

ABSTRACT Background: Mother-to-child transmission of Chagas disease (CD) has become a relevant problem in both endemic and non-endemic areas. Methods: Description of the CUIDA Chagas Project - Communities United for Innovation, Development and Attention for Chagas disease'. Results: Through innovative and strategic research, this project will provide improved diagnostic and treatment options as well as replicable implementation models that are adaptable to different contexts. Conclusions: By integrating test, treat and care actions for CD into primary health care practices, the burden of CD on people and health systems may be significantly reduced.

Chagas disease mortality during the coronavirus disease 2019 pandemic: A Brazilian referral center experience

ABSTRACT Background We investigated the mortality rates of patients with Chagas disease (CD) during the coronavirus disease 2019 (COVID-19) pandemic and assessed the association between this mortality and CD clinical presentation and comorbidities. Methods: This was an observational retrospective study with clinical data retrieved from medical records. Results: Comorbidities were more prevalent among patients who died from COVID-19 than those who died from other causes. The proportion of patients according to CD clinical presentation was similar between the two groups. Conclusions: The prevalence of comorbidities seems to be related to a poorer prognosis in CD and COVID-19.

Critical analysis of Chagas disease treatment in different countries

As a result of globalization and constant migratory flows, Chagas disease is now present in almost all continents. The management and treatment of the disease is often influenced by the economic and social context of the societies that host patients. In this manuscript, we aim to provide a comparative review of approaches to patients with Chagas disease in the Americas and Europe.

Prognosis of chronic Chagas heart disease and other pending clinical challenges

In this chapter, the main prognostic markers of Chagas heart disease are addressed, with an emphasis on the most recent findings and questions, establishing the basis for a broad discussion of recommendations and new approaches to managing Chagas cardiopathy. The main biological and genetic markers and the contribution of the electrocardiogram, echocardiogram and cardiac magnetic resonance are presented. We also discuss the most recent therapeutic proposals for heart failure, thromboembolism and arrhythmias, as well as current experience in heart transplantation in patients suffering from severe Chagas cardiomyopathy. The clinical and epidemiological challenges introduced by acute Chagas disease due to oral contamination are discussed. In addition, we highlight the importance of ageing and comorbidities in influencing the outcome of chronic Chagas heart disease. Finally, we discuss the importance of public policies, the vital role of funding agencies, universities, the scientific community and health professionals, and the application of new technologies in finding solutions for better management of Chagas heart disease.

Functional capacity and rehabilitation strategies in Covid-19 patients: current knowledge and challenges

Abstract Covid-19 is a novel infectious disease whose spectrum of presentation ranges from absence of symptoms to widespread interstitial pneumonia associated with severe acute respiratory syndrome (SARS), leading to significant mortality. Given the systemic pattern of Covid-19, there are many factors that can influence patient's functional capacity after acute infection and the identification of such factors can contribute to the development of specific rehabilitation strategies. Pulmonary impairment is the primary cause of hospitalization due to Covid-19, and can progress to SARS as well as increase length of hospitalization. Moreover, cardiac involvement is observed in approximately 30% of hospitalized patients, with an increased risk of acute myocarditis, myocardial injury, and heart failure, which may compromise functional capacity in the long-term. Thromboembolic complications have also been reported in some patients with Covid-19 and are associated with a poor prognosis. Musculoskeletal complications may result from long periods of hospitalization and immobility, and can include fatigue, muscle weakness and polyneuropathy. Studies that address the functional capacity of patients after Covid-19 infection are still scarce. However, based on knowledge from the multiple systemic complications associated with Covid-19, it is reasonable to suggest that most patients, especially those who underwent prolonged hospitalization, will need a multiprofessional rehabilitation program. Further studies are needed to evaluate the functional impact and the rehabilitation strategies for patients affected by Covid-19.

Temporal changes in the clinical-epidemiological profile of patients with Chagas disease at a referral center in Brazil

Abstract INTRODUCTION We aimed to describe the sociodemographic, epidemiological, and clinical characteristics of patients with chronic Chagas disease (CD) at an infectious disease referral center. Changes in patient profiles over time were also evaluated. METHODS This retrospective study included patients with CD from November 1986-December 2019. All patients underwent an evaluation protocol that included sociodemographic profile; epidemiological history; anamnesis; and physical, cardiologic, and digestive examinations. Trend differences for each 5-year period from 1986 to 2019 were tested using a nonparametric trend test for continuous and generalized linear models with binomial distribution for categorical variables. RESULTS A total of 2,168 patients (52.2% women) were included, with a mean age of 47.8 years old. White patients with low levels of education predominated. The reported transmission mode was vectorial in 90.2% of cases. The majority came from areas with a high prevalence (52.2%) and morbidity (67.8%) of CD. The most common clinical presentation was the indeterminate form (44.9%). The number of patients referred gradually decreased and the age at admission increased during the study period, as did the patients' levels of education. CONCLUSIONS The clinical profile of CD is characterized by a predominance of the indeterminate form of the disease. Regarding the patients who were followed up at the referral center, there was a progressive increase in the mean age and a concomitant decrease in the number of new patients. This reflects the successful control of vector and transfusion transmission in Brazil as well as the aging population of patients with CD.

Reassessment of quality of life domains in patients with compensated Chagas heart failure after participating in a cardiac rehabilitation program

Abstract INTRODUCTION: We evaluated the effects of a cardiac rehabilitation program on quality of life. METHODS This secondary analysis of a single-arm study included 12 patients with Chagas heart failure. The cardiac rehabilitation program comprised exercise training and nutritional and pharmaceutical counseling. Quality of life was assessed using the SF-36 questionnaire. RESULTS: The program promoted improved physical functioning (β= +5.7; p=0.003), role-physical (β= +1.9; p=0.03), and bodily pain (β= +3.5; p=0.02) scores. Moreover, the summary physical health score (β= +1.4; p=0.001) improved. CONCLUSION: The cardiac rehabilitation program significantly improved the physical quality of life of patients with Chagas heart failure.

Cardiac rehabilitation program in patients with Chagas heart failure: a single-arm pilot study

Abstract: INTRODUCTION: The benefit of a cardiac rehabilitation (CR) program for patients with Chagas heart failure (CHF) remains unclear. Therefore, we aimed to investigate the effects of CR for CHF patients. METHODS: A single-arm pilot study, including 12 patients with CHF, was performed. Patients participated in an 8-month physical exercise intervention, comprising aerobic, strength, and stretching exercises (3 times per week, 60 minutes per session). Nutritional and pharmaceutical counseling were also performed. Functional capacity (cardiopulmonary exercise test), muscle respiratory strength (manovacuometry), and body composition (anthropometry and skinfolds) were evaluated at baseline, and after 4 and 8 months of intervention. Cardiac function (echocardiography), biomarkers (lipid profile, glucose, and glycated hemoglobin) and quality of life (Minnesota Living with Heart Failure Questionnaire) were assessed at baseline and at the end of the intervention. RESULTS: Seven of 12 patients included in the study completed the 8-month follow-up period. Only 2 moderate adverse events occurred during the exercise training. Functional capacity improved after 4 months of CR, while left ventricular ejection fraction (LVEF) and respiratory strength improved after 8 months. Patients with right ventricular (RV) dysfunction at baseline exhibited an improvement in functional capacity after 4 months, and improvements in left ventricular (LV) diastolic pressure, respiratory strength, and quality of life at the end of follow-up. Conversely, those with normal baseline RV function demonstrated LVEF increases that were not observed in patients with RV dysfunction. CONCLUSIONS: CR was feasible, safe, and has important clinical benefits for patients with CHF, specifically for cardiac function and muscle respiratory strength.

Atrial Fibrillation in Decompensated Heart Failure: Associated Factors and In-Hospital Outcome / Fibrilação Atrial em Insuficiência Cardíaca Descompensada: Fatores Associados e Evolução Hospitalar

Background: Studies on atrial fibrillation (AF) in decompensated heart failure (DHF) are scarce in Brazil. Objectives: To determine AF prevalence, its types and associated factors in patients hospitalized due to DHF; to assess their thromboembolic risk profile and anticoagulation rate; and to assess the impact of AF on in-hospital mortality and hospital length of stay. Methods: Retrospective, observational, cross-sectional study of incident cases including 659 consecutive hospitalizations due to DHF, from 01/01/2006 to 12/31/2011. The thromboembolic risk was assessed by using CHADSVASc score. On univariate analysis, the chi-square, Student t and Mann Whitney tests were used. On multivariate analysis, logistic regression was used. Results: The prevalence of AF was 40%, and the permanent type predominated (73.5%). On multivariate model, AF associated with advanced age (p < 0.0001), non-ischemic etiology (p = 0.02), right ventricular dysfunction (p = 0.03), lower systolic blood pressure (SBP) (p = 0.02), higher ejection fraction (EF) (p < 0.0001) and enlarged left atrium (LA) (p < 0.0001). The median CHADSVASc score was 4, and 90% of the cases had it ≥ 2. The anticoagulation rate was 52.8% on admission and 66.8% on discharge, being lower for higher scores. The group with AF had higher in-hospital mortality (11.0% versus 8.1%, p = 0.21) and longer hospital length of stay (20.5 ± 16 versus 16.3 ± 12, p = 0.001). Conclusions: Atrial fibrillation is frequent in DHF, the most prevalent type being permanent AF. Atrial fibrillation is associated with more advanced age, non-ischemic etiology, right ventricular dysfunction, lower SBP, higher EF and enlarged LA. Despite the high thromboembolic risk profile, anticoagulation is underutilized. The presence of AF is associated with longer hospital length of stay and high mortality. .

Fundamento: Estudos sobre fibrilação atrial (FA) na insuficiência cardíaca descompensada (ICD) são muito escassos no Brasil. Objetivos: Determinar a prevalência, os tipos e os fatores associados à FA em pacientes hospitalizados por ICD; analisar perfil de risco embólico e taxa de anticoagulação; e avaliar o impacto da FA na mortalidade hospitalar e no tempo de internação. Métodos: Estudo seccional de casos incidentes, retrospectivo, observacional. Analisaram-se 659 internações consecutivas por ICD entre 01/01/2006 a 31/12/2011. Risco embólico foi avaliado pelo acrônimo CHADSVASc. Na análise univariada, foram utilizados o qui-quadrado, teste t de Student ou Mann Whitney. Na análise multivariada, utilizou-se a regressão logística. Resultados: A prevalência de FA foi de 40%, predominando o tipo permanente (73,5%). No modelo multivariado, a FA se associou à idade avançada (p < 0,0001), etiologia não isquêmica (p = 0,02), disfunção ventricular direita (VD) (p = 0,03), menor pressão arterial sistólica (PAS) (p = 0,02), maior fração de ejeção (FE) (p < 0,0001) e aumento atrial esquerdo (AE) (p < 0,0001). A mediana do CHADSVASc foi quatro e 90% tinham escore ≥ 2. A taxa de anticoagulação foi de 52,8% na admissão e 66,8% na alta, sendo menor em escores mais elevados. O grupo com FA apresentou maior mortalidade hospitalar (11,0% versus 8,1%, p = 0,21) e internação mais prolongada (20,5 ± 16 versus 16,3 ± 12, p = 0,001). Conclusões: A FA é frequente na ICD, predominando o tipo permanente. Associa-se com idade avançada, etiologia não isquêmica, disfunção de VD, menor PAS, maior FE e aumento AE. O perfil de risco embólico é elevado e a anticoagulação é subutilizada. ...

Preditores ecocardiográficos de mortalidade hospitalar na insuficiência cardíaca descompensada: valor adicional ao escore ADHERE / Echocardiographic Predictors of In-Hospital Mortality for Decompensated Heart Failure: added value for ADHERE score

Fundamentos: A insuficiência cardíaca é um graveproblema de saúde pública com alto custo, frequenteshospitalizações e elevada mortalidade. Conhecer as características clínicas, laboratoriais e ecocardiográficas dos pacientes com insuficiência cardíaca (IC)descompensada é fundamental para o clínico. A partirdo registro ADHERE, elaborou-se um escore para avaliaro risco de mortalidade hospitalar com acurácia limitada na coorte de derivação (área sob a curva ROC - ASC 0,76). Objetivos: Avaliar o desempenho do escore ADHERE na população de hospital universitário no Rio de Janeiro e testar os parâmetros ecocardiográficos que, associados ao escore ADHERE, melhorariam sua acurácia. Métodos: Estudo retrospectivo, observacional de 634 casos internados com IC descompensada no Hospital Universitário Clementino Fraga Filho, no período de 01/01/2006 a 28/02/2011, dentre os quais, 413 continham dados do ecoDopplercardiograma, constituindo a população do estudo. Resultados: A mediana das idades foi 64 anos, com predomínio do sexo masculino (55,0%) e disfunção sistólica do ventrículo esquerdo (82,1%). A área sob acurva ROC do escore ADHERE da população geral e daqueles que realizaram ecoDopplercardiograma foi diferente do valor derivado do estudo ADHERE (0,63 vs.0,62 vs. 0,76, respectivamente). Associando a pressão sistólica de artéria pulmonar ao modelo preditivo de mortalidade hospitalar, houve incremento para 0,70(IC95% 0,59-0,80).Conclusões: Nesta coorte de pacientes com IC descompensada, a estimativa do risco de mortalidade utilizando somente o escore ADHERE foi limitada. O parâmetro ecocardiográfico pressão sistólica de artéria pulmonar adicionou informação prognóstica independente, permitindo modesto incremento na acurácia desse escore.

Background: Heart failure (HF) is a major public health problem with high costs, frequent hospitalizations andhigh mortality rates. An awareness of clinical aspects and the laboratory and echocardiography findings ofdecompensated HF patients is crucial for clinicians. Through the ADHERE registry, a score was constructed to evaluate the risk of in-hospital death, with limitedaccuracy for the derivation cohort (ROC area under the curve - AUC 0.76).Objectives: To evaluate the ADHERE score performance in a university hospital population in Rio de Janeiro, testing echocardiography parametersthat, in association with the ADHERE score, would improve its accuracy.Methods: Retrospective observational study of 634 cases hospitalized for decompensated HF in the Clementino Fraga Filho University Hospital betweenJanuary 1, 2006 and February 28, 2011, of whom 413 included echoDopplercardiogram data, constituting the study population.Results: The median age was 64 years old, with male predominance (55.0%) and systolic dysfunction of the left ventricle (82.1%). The ADHERE score area under the ROC curve for the general population and patients with echoDopplercardiograms differed from the ADHERE study values (0.63 vs. 0.62 vs 0.76 respectively). Associating the pulmonary artery systolic pressure with the predictive in-hospital mortality model resulted in an increase to 0.70 (CI 95% 0.59-0.80). Conclusions: In this cohort of decompensated HFpatients, the in-hospital death risk estimate using only the ADHERE score was limited. The pulmonary artery systolic pressure parameter added independent prognostic data, allowing a modest increase in the accuracy of this score.

Obesos apresentam menor aderência a programa de exercício supervisionado / Less adherence to supervised exercise program among obese patients

Fundamentos: A atual crescente incidência de obesidade, assim como a de doenças crônico-degenerativas ligadas a essa condição, torna relevante desenvolver intervenções de prevenção primária com o potencial de reduzir esse processo. Dentre essas intervenções, sabe-se que o exercício físico regular e maior condição aeróbica trazem efeitos benéficos reduzindo a morbimortalidade cardiovascular e por todas as causas. Objetivo: Determinar a associção entre obesidade e aderência a programa de exercício com supervisão médica (PES). Métodos: Selecionados 267 pacientes provenientes de um PES entre janeiro 2007 e setembro 2009 que se submeteram à avaliação médica pré-participação, incluíndo medidas antropométricas. Foram considerados aderentes ao PES: (A) aqueles que frequentaram pelo menos cinco sessões de exercício nos três primeiros meses do ano de 2010, sendo classificados como não aderentes (NA) os demais. As variáveis selecionadas foram comparadas, sendo o índice de massa corporal (IMC kg/m ao quadrado) estratificado...

Background: The current upsurge in obesity and the chronic degenerative diseases related to this conditionunderscore the need to develop preventive primary interventions that could counteract this process. Among these interventions, it is known that regular physical exercise and greater aerobic fitness offer benefits by reducing cardiovascular and all-cause morbidity and mortality. Objective: To determine the association between obesity and adherence with a medically-supervisedexercise program (MEP). Methods: Selected from a MEP between January 2007 and September 2009, 267 patients underwent preparticipationmedical evaluations that includedanthropometric measurements. Participants adherent to the MEP were taken as being: (A) those who attended at least, five exercise sessions in the first three months of 2010, ranking the others as non-adherent (NA). The selected variables were compared and the body mass index (BMI, kg/m2) stratified...