Chagas disease is associated with a poor outcome at 1-year follow-up after cardiac resynchronization therapy

SUMMARY BACKGROUND: Cardiac resynchronization therapy (CRT) is a therapeutic modality for patients with heart failure (HF). The effectiveness of this treatment for event reduction is based on clinical trials where the population of patients with Chagas' disease (DC) is underrepresented. OBJECTIVE: To evaluate the prognosis after CRT of a population in which CD is an endemic cause of HF. METHODS: A retrospective cohort conducted between January 2015 and December 2016 that included patients with HF and left ventricular ejection fraction (LVEF) of less than 35% and undergoing CRT. Clinical and demographic data were collected to search for predictors for the combined outcome of death or hospitalization for HF at one year after CRT implantation. RESULTS: Fifty-four patients were evaluated, and 13 (24.1%) presented CD as the etiology of HF. The mean LVEF was 26.2± 6.1%, and 36 (66.7%) patients presented functional class III or IV HF. After the mean follow-up of 15 (±6,9) months, 17 (32.1%) patients presented the combined outcome. In the univariate analysis, CD was associated with the combined event when compared to other etiologies of HF, 8 (47%) vs. 9 (13,5%), RR: 3,91 CI: 1,46-10,45, p=0,007, as well as lower values of LVEF. In the multivariate analysis, CD and LVEF remained independent risk factors for the combined outcome. CONCLUSION: In a population of HF patients undergoing CRT, CD was independently associated with mortality and hospitalization for HF.

RESUMO INTRODUÇÃO: A terapia de ressincronização cardíaca (TRC) é uma modalidade terapêutica para pacientes com insuficiência cardíaca (IC). A eficácia desse tratamento para redução de eventos baseia-se em ensaios clínicos em que a população de pacientes com doença de Chagas (DC) é sub-representada. OBJETIVO: Avaliar o prognóstico após TRC em uma população em que a DC é uma causa frequente de IC. MÉTODOS: Coorte retrospectiva realizada entre janeiro de 2015 e dezembro de 2016, sendo incluídos pacientes portadores de IC com fração de ejeção do ventrículo esquerdo (Feve) menor que 35% e submetidos à TRC. Os dados clínicos e demográficos foram coletados para pesquisa de preditores para o desfecho combinado de morte ou internação por IC após implante da TRC. RESULTADOS: Foram avaliados 54 pacientes, dos quais 13 (24,1%) apresentavam a DC como etiologia da IC. A Feve média foi de 26,2% (±6,1) e 36 (66,7%) pacientes apresentavam classe funcional de IC III ou IV. Após o seguimento médio de 15 meses, 17 (32,1%) pacientes apresentaram o desfecho combinado. Na análise univariada, a DC esteve associada ao evento combinado quando comparada a outras etiologias de IC, 8 (47%) vs 9 (13,5%), RR: 3,91 IC: 1,46-10,45, p=0,007, assim como valores mais baixos da Feve. Na análise multivariada, a DC e a Feve permaneceram como fatores de risco independentes para o desfecho combinado. CONCLUSÃO: Em uma população de pacientes com IC submetidos à TRC, a doença de Chagas esteve independentemente associada à mortalidade e internação por insuficiência cardíaca no seguimento de 15 meses.

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.

An unusual case of heart failure due to Plasmodium vivax infection with a favorable outcome

Although malaria is one of the oldest types of parasitic infection, we have recently witnessed substantial changes in the outcome of malarial infections. Severe Plasmodium vivax infections have recently become more frequent, and are occasionally associated with fatal outcomes. Cardiac arrhythmia and myocardial failure have also been reported, typically in association with Plasmodium falciparum infections. We report a case of myocarditis and heart failure, due to Plasmodium vivax infection, along with the favorable outcome.

Prevalence of Trypanosoma cruzi antibodies and inflammatory markers in uncompensated heart failure / Prevalência de anticorpos anti-Trypanosoma cruzi e marcadores inflamatórios em pacientes com insuficiência cardíaca descompensada

INTRODUCTION: Heart failure (HF) represents the final stage of chronic chagasic cardiomyopathy (CChC). The diagnosis of CChC is based on the demonstration of anti-Trypanosoma cruzi antibodies (aTcAg) and clinical and epidemiological data. In Venezuela, there are no data about the prevalence of chagasic HF. The aim of this study was to determine the epidemiological, clinical, and inflammatory risk factors associated with seronegative or seropositive HF patients. METHODS: We performed a cross-sectional study in the Venezuelan central-west states among a healthy rural population and in patients admitted to the emergency room with uncompensated HF. RESULTS: The seroprevalence rates of Trypanosoma cruzi antibodies were 11.2 percent and 40.1 percent in the healthy population and in HF patients, respectively. Seropositivity in healthy individuals was associated with age, knowledge on triatomine vectors, and having seen wild reservoirs in the house; in HF patients, with contact with the vector and previous clinical diagnosis of Chagas' disease; and in both groups taken together, with age, knowledge on triatomines, and HF. Seropositive patients had prolonged QRS, decreased ejection fraction, and high serum magnesium, all significant as compared with HF seronegative cases. Left atrium enlargement and ventricular hypertrophy were most frequently observed in HF seronegative patients. CRP, IL6, ILβ1, IL2, and FNTα were elevated in 94.5 percent, 48 percent, 17.8 percent, 13.7 percent, and 6.9 percent of HF patients, respectively, but only IL2 levels were associated with chagasic HF. CONCLUSIONS: There is a high prevalence of aTcAg in HF patients from the central-west region of Venezuela, and their epidemiological, clinical, and inflammatory features are discreetly different as compared with those of seronegative cases.

INTRODUÇÃO: A insuficiência cardíaca (IC) representa o estágio final da cardiopatia chagásica crônica (CChC). O diagnóstico de CChC é baseado na demonstração de anticorpos anti-Trypanosoma cruzi (AgTc), dados clínicos e epidemiológicos. Na Venezuela, não há informação sobre a prevalência da IC chagásica. O objetivo deste estudo foi determinar fatores de risco epidemiológicos, clínicos e inflamatórios associados à IC chagásica. MÉTODOS: Realizamos um estudo prospectivo transversal em estados do centro-oeste da Venezuela em uma população rural saudável e em pacientes com IC descompensada. RESULTADOS: A soroprevalência de AgTc mostrou valores de 11,2 por cento e 40,1 por cento na população saudável e em pacientes com IC, respectivamente. A soropositividade de indivíduos sadios se associou com a idade, conhecimento de vetores e a observação de reservatórios silvestres na habitação. Em pacientes com IC, estavam relacionados ao contato com o vetor e ao diagnóstico clínico prévio de doença de Chagas. Em ambos os grupos juntos, a soropositividade foi associada com idade, conhecimento do vetor e com IC. Os pacientes soropositivos apresentavam prolongamento do intervalo QRS, fração de ejeção diminuída e magnésio sérico elevado. Aumento atrial esquerdo e hipertrofia ventricular foram as mais frequentemente observadas em pacientes com IC soronegativos. PCR, IL6, ILβ1, IL2 e FNTα foram elevados em 94,5, 48, 17,8, 13,7 e em 6,9 por cento dos pacientes com IC, respectivamente; os níveis de IL-2 foram associados com IC chagásica. CONCLUSÕES: Uma alta prevalência de AgTc foi observada em pacientes com IC na região centro-oeste da Venezuela, cujos aspectos epidemiológicos, clínicos e inflamatórios são discretamente diferentes dos soronegativos.

Chagas cardiomyopathy and serologic testing in a small rural hospital in Chiapas, Mexico

OBJETIVO: Llevar a cabo un estudio en un hospital rural pequeño del Estado de Chiapas, México, con el fin de: 1) examinar la prevalencia de miocardiopatía chagásica en pacientes con un diagnóstico de insuficiencia cardíaca congestiva y 2) estimar la prevalencia de positividad serológica en donantes de sangre del hospital, con objeto de determinar si la enfermedad de Chagas sigue siendo una causa importante de insuficiencia cardíaca en algunas partes de México. MÉTODOS: El estudio de los pacientes con miocardiopatía se llevó a cabo mediante la inspección retrospectiva de las fichas de pacientes con un diagnóstico de insuficiencia cardíaca congestiva tratados en el hospital durante el período de 2000­2002. En el caso de los donantes de sangre, los resultados de sus pruebas serológicas fueron revisados durante un período de seis meses que comenzó en abril de 2002. Los pruebas serológicas se efectuaron en ambos grupos mediante hemaglutinación indirecta (HAI) o ensayo de inmunoadsorción enzimática (ELISA), o ambos métodos. RESULTADOS: De 67 pacientes con insuficiencia cardíaca que no tenían factores de riesgo de sufrir otras causas de este trastorno, 40 fueron sometidos a pruebas serológicas. De estos cuarenta, 33 (82,5%) tuvieron resultados positivos en el ELISA, la HAI, o ambos. Del total de 97 donantes de sangre, 17 (17,5%) tuvieron una o dos pruebas con resultados positivos. CONCLUSIONES: Este estudio se suma a las pruebas ya existentes de que la enfermedad de Chagas sigue siendo una de las principales causas de insuficiencia cardíaca en algunas partes de México y de que sigue habiendo un riesgo de transmisión por transfusión de sangre si la sangre donada no se somete a tamizaje con regularidad.

Relação entre arritmia ventricular e função cardíaca na doença de Chagas / Relationship between ventricular arrhythmia and cardiac function in Chagas disease

PURPOSE--It is well established the association between heart failure and arrhythmias in different cardiopathies. There are no studies in Chagas' myocardiopathy that analyze the relation between arrhythmias and left ventricular function. METHODS--We studied 629 patients with Chagas' disease, divided in 3 groups, according to ejection fraction obtained through echocardiographic study (normal, between 0.64 and 0.45, and below 0.44). RESULTS--At conventional ECG, the presence of ventricular arrhythmias was respectively in the 3 groups: 15, 36 and 64, showing higher incidence when left ventricular function was getting worse. CONCLUSION--Ventricular arrhythmias in Chagas' disease are frequent in patients with normal ejection fraction, and become more intense as ventricular dysfunction progresses.