Effects of trypanocidal treatment on echocardiographic parameters in chagas cardiomyopathy and prognostic value of wall motion score index: A BENEFIT trial echocardiographic substudy

Serial echocardiographic studies in chronic Chagas cardiomyopathy are scarce. The aims of this study were to evaluate whether therapy with benznidazole modifies the progression of cardiac impairment and to identify baseline echocardiographic parameters related to prognosis. METHODS: A prospective sub study was conducted in 1,508 patients with chronic Chagas cardiomyopathy randomized to benznidazole or placebo, who underwent two-dimensional echocardiography at enrollment, 2 years, and final follow-up (5.4 years). Left ventricular (LV) ejection fraction, LV wall motion score index (WMSI), indexed left atrial volume, and chamber dimensions were collected and correlated to all-cause death and a composite hard outcome using univariate and multivariate analyses. RESULTS: At enrollment, most patients had normal chamber dimensions, and 70.5% had preserved LV ejection fractions. During follow-up, all chamber dimensions increased similarly in both treatment arms. LV ejection fraction was comparably reduced (55.7 ± 12.7% to 52.1 ± 14.6% vs 56.3 ± 12.7% to 52.8 ± 14.1%) and LV WMSI similarly increased (1.31 ± 0.41 to 1.49 ± 0.03 and 1.27 ± 0.38 to 1.51 ± 0.03) for the benznidazole and placebo groups, respectively (P > .05). A higher baseline LV WMSI was identified in subjects who died compared with those alive at final echocardiography (1.76 ± 0.517 vs 1.271 ± 0.393, P < .0001). There was a significant (P < .0001) graded increase in the risk for the composite outcome with worsening LV WMSI (hazard ratios, 2.27 [95% CI, 1.69-3.06] and 6.42 [95% CI, 4.94-8.33]) and also of death (hazard ratios, 2.45 [95% CI, 1.62-3.71] and 8.99 [95% CI, 6.3-12.82]) for 1 < LV WMSI < 1.5 and LV WMSI > 1.5, respectively. Both LV WMSI and indexed left atrial volume remained independent predictors in multivariate analysis. CONCLUSIONS: Trypanocidal treatment had no effect on echocardiographic progression of chronic Chagas cardiomyopathy over 5.4 years. Despite normal global LV systolic function, regional wall motion abnormalities and indexed left atrial volume identified patients at higher risk for hard adverse clinical outcomes. Copyright © 2018 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved. KEYWORDS: Chagas cardiomyopathy; Echocardiography; Prognosis; Trypanocidal therapy. (AU)

Beneficial effects of coronary revascularization in patients with ischaemic left ventricular dysfunction with and without anginal symptoms.

Therapy for ischaemic congestive heart failure has been well documented in patients with angina. The goal of this study was to compare the benefit of revascularization in patients with and without chest pain. A series of 180 patients with ischaemic heart failure symptoms (New York Heart Association III-IV class) and low ejection fraction (28+/-9%) were recruited and followed for 3 years. Group A, 97/180 patients, had chest pain. Group B, 83/180 patients, did not have angina. The two groups did not differ with respect to known determinants of postinfarction prognosis. The relative presence of viable tissue versus scar was defined by Thallium-201 uptake. Intraoperative mortality was 5 and 7% in Groups A and B (P=not significant); in particular, in both groups, it was lower when only patients with mostly viable myocardium were considered. At 6 months, the presence of viable myocardium was highly predictive of improvement of heart failure symptoms and wall motion abnormalities. At 3 years, revascularized patients of Group A with mostly viable myocardium had a survival of 89% compared to 87% for corresponding Group B patients (P=not significant). In conclusion, similarly to patients with angina, patients with left ventricular dysfunction, maintained viability and without anginal symptoms may benefit from coronary revascularization.