Acometimento miocárdico na Doença de Chagas: uma perspectiva a partir da avaliação pela ressonância magnética cardiovascular / Myocardial involvement in Chagas Disease: from the perspective of cardiovascular magnetic ressonance assessment

A doença de Chagas representa um importante problema de saúde pública, sobretudo nos países endêmicos da América Latina. Dentre suas apresentações clínicas, a cardiomiopatia crônica é a mais frequente. De patogênese multifatorial, o acometimento miocárdico pode levar à insuficiência cardíaca, a eventos tromboembólicos, a arritmias e à morte súbita. Nesse contexto, a ressonância magnética cardiovascular é um excelente método não invasivo para a investigação do dano miocárdico e a compreensão dos mecanismos e consequências relacionados às essas lesões. Com elevada resolução espacial e capacidade de caracterização tecidual, a ressonância magnética cardiovascular proporciona análise morfofuncional altamente confiável e possibilita a identificação de marcadores de risco de eventos adversos em pacientes com doença de Chagas, sendo de grande utilidade para o diagnóstico e o acompanhamento desses indivíduos na rotina clínica. (AU)

Chagas disease represents an important public health problem, especially in endemic countries in Latin America. Chronic cardiomyopathy is its most frequent clinical presentation. Myocardial involvement has a multifactorial pathogenesis and can lead to heart failure, thromboembolic events, arrhythmias, and sudden death. In this context, cardiovascular magnetic resonance imaging (CMR) is an excellent noninvasive method for investigating myocardial damage and understanding the mechanisms and consequences of these injuries. CMR has high spatial resolution and tissue characterization capacity, enabling a highly reliable morphofunctional analysis and the identification of risk markers for adverse events in patients with Chagas disease. This exam is very useful for the diagnosis and follow-up of these patients in the routine clinical setting. (AU)

COVID-19: Implications for People with Chagas Disease.

As the global COVID-19 pandemic advances, it increasingly impacts those vulnerable populations who already bear a heavy burden of neglected tropical disease. Chagas disease (CD), a neglected parasitic infection, is of particular concern because of its potential to cause cardiac, gastrointestinal, and other complications which could increase susceptibility to COVID-19. The over one million people worldwide with chronic Chagas cardiomyopathy require special consideration because of COVID-19's potential impact on the heart, yet the pandemic also affects treatment provision to people with acute or chronic indeterminate CD. In this document, a follow-up to the WHF-IASC Roadmap on CD, we assess the implications of coinfection with SARS-CoV-2 and Trypanosoma cruzi, the etiological agent of CD. Based on the limited evidence available, we provide preliminary guidance for testing, treatment, and management of patients affected by both diseases, while highlighting emerging healthcare access challenges and future research needs.

Risk Score for Predicting 2-Year Mortality in Patients With Chagas Cardiomyopathy From Endemic Areas: SaMi-Trop Cohort Study.

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.

Severity of Chagasic Cardiomyopathy Is Associated With Response to a Novel Rapid Diagnostic Test for Trypanosoma cruzi TcII/V/VI.

Background: Trypanosoma cruzi causes Chagas disease in the Americas. The outcome of infection ranges from lifelong asymptomatic status to severe disease. Relationship between T. cruzi lineage (TcI-TcVI) infection history and prognosis is not understood. We previously described peptide-based lineage-specific enzyme-linked immunosorbent assay (ELISA) with trypomastigote small surface antigen (TSSA). Methods: A novel rapid diagnostic test (RDT; Chagas Sero K-SeT) that incorporates a peptide that corresponds to the TSSA II/V/VI common epitope was developed and validated by comparison with ELISA. Patients from Bolivia and Peru, including individuals with varying cardiac pathology, and matched mothers and neonates, were then tested using Chagas Sero K-SeT. Results: Chagas Sero K-SeT and ELISA results, with a Bolivian subset of cardiac patients, mothers, and neonates, were in accord. In adult chronic infections (n = 121), comparison of severity class A (no evidence of Chagas cardiomyopathy) with class B (electrocardiogram suggestive of Chagas cardiomyopathy) and class C/D (decreased left ventricular ejection fraction; moderate/severe Chagas cardiomyopathy) revealed a statistically significant increase in Chagas Sero K-SeT reactivity with increasing severity (χ2 for trend, 7.39; P = .007). In Peru, Chagas Sero K-SeT detected the sporadic TcII/V/VI infections. Conclusions: We developed a low cost RDT that can replace ELISA for identification of TSSA II/V/VI immunoglobulin G. Most importantly, we show that response to this RDT is associated with severity of Chagas cardiomyopathy and thus may have prognostic value. Repeated challenge with T. cruzi infection may both exacerbate disease progression and boost the immune response to the TSSApep-II/V/VI epitope.

¿Puede considerarse portadores asintomáticos a los donantes de sangre seropositivos para Trypanosoma cruzi?: un estudio de validación en el proyecto CHICAMOCHA / Can Seropositive Blood Donors be Considered Asymptomatic Carriers for Trypanosoma cruzi?: a validation study in CHICAMOCHA project / Poderiam ser considerados portadores assintomáticos os doadores de sangue soropositivos para Trypanosoma cruzi? um estudo de validação no projeto CHICAMOCHA

Identificar el deterioro clínico de individuos seropositivos para la enfermedad de Chagas requiere observar la evolución de personas con infección establecida por Trypanosoma cruzi (T.cruzi), libres de signos y síntomas de cardiomiopatía en una línea de base. Objetivo: Realizar una comparación entre donantes de bancos de sangre de Bucaramanga con serología positiva y negativa para T. cruzi. Metodología: La muestra consistio en donantes elegibles con pruebas de tamización positivas para T. cruzi, pero negativas para otros agentes infecciosos tamizados por los bancos de sangre. Estos registros fueron apareados con una muestra aleatoria 1:4 de donantes con pruebas negativas a todas las pruebas de tamizaci¾n. Los participantes fueron entrevistados para conocer aspectos sociodemográficos y de percepción de su estado de salud, se realizó examen físico y se tomaron muestras de sangre para examenes paraclínicos. Se reportaron las frecuencias y proporciones de los participantes. Se hicieron pruebas de hipótesis de no diferencias entre los dos grupos con la prueba Chi cuadrado, con un nivel alfa de significancia de 5%. Resultados: La muestra consistió en 2,132 donantes de sangre incluidos entre mayo de 2000 y marzo de 2004. Mediante prueba serológica se identificaron 488 (22.9%) seropositivos y 1644 (77.1%) seronegativos. Los seropositivos fueron mayores en edad, presentaron indicadores socioeconómicos menos favorables y menor afiliación a seguridad social con el régimen contributivo y tenÝan una mejor percepción de su salud en comparación con los seronegativos (p<0.05). No se observaron diferencias estadísticamente significativas en cuanto a la percepción del funcionamiento de los tres sistemas evaluados (cardiovascular, urinario y gastrointestinal) en ambos grupos.

In order to identify the clinical deterioration of seropositive individuals for Chagas disease, it is necessary to observe the evolution of people infected by Trypanosoma cruzi (T. cruzi), who do not show signs and symptoms of cardiomyopathy on a baseline. Objective: To compare blood donors with positive and negative serology for Trypanosoma cruzi in the city of Bucaramanga. Methodology: The sample consisted of eligible donors with positive screening tests for T. cruzi, but negative for other infectious agents screened by blood banks. These records were matched with a random sample 1: 4 donors who showed negative results to all the screening tests. Participants were interviewed to know their socio-demographic aspects and to get a perception of their health status. Physical exams were performed and blood samples were taken for laboratory tests. Frequencies and proportions of participants were reported. Hypothesis testing of no differences between the two groups using the Chi square test was performed, showing a 5% level of alpha significance. Resultados: The sample included 2132 blood donors between May 2000 and March 2004. By using serological tests, it was identified that 488 (22.9%) were seropositive and 1644 (77.1%) were seronegative. Seropositive donors were older people who belonged to a low socio-economic level and had no health insurance. They also had a better perception of their health compared to seronegative donors (p <0.05). The perception of how the three evaluated systems worked (cardiovascular, urinary and gastrointestinal) showed no statistically significant differences between the two groups. Conclusions: The study findings allow us to infer that seropositive blood donors for T. cruzi could be considered as asymptomatic carriers without clinical evidence of cardiomyopathy.

Para identificar o deterioro clínico dos indivíduos soropositivos para a doença de Chagas Ú necessério acompanhar a evolução de indivíduos com infecção estabelecida pelo Trypanosoma cruzi (T. cruzi), livres de sinais e sintomas de cardiomiopatia numa linha de base. Objetivo: Fazer uma comparação entre os doadores dos bancos de sangue de Bucaramanga com sorologia positiva e negativa para T. cruzi. Metodologia: A amostra consistiu de doadores elegíveis com rastreamento positivo para T. cruzi, porém negativo para outros agentes infecciosos selecionados pelos bancos de sangue. Esses registros foram emparelhados com uma amostra aleatória de 1: 4 com testes negativos a todos os testes da triagem de doadores. Os participantes foram entrevistados para se conhecer aspectos sociodemográficos e perceber seus aspectos de saúde, foi realizado um exame físico e foram coletadas amostras de sangue para exames de laboratório. Relataram-se as frequéncias e proporções de participantes. Foi feito um teste de hipóteses de não diferenças entre os dois grupos com o teste do chi-quadrado, com um nível alfa de significãncia de 5%. Resultados: A mostra consistiu em 2132 doadores de sangue incluídos entre maio de 2000 e marþo de 2004. Pela prova sorol¾gica identificaram-se 488 (22.9%) soropositivos y 1644 (77.1%) soronegativos. Os Soropositivos foram maiores de 18 anos, tinham indicadores socioeconómicos menos favoróveis, menor inscrição no seguro social com o regime contributivo e melhor percepção da sua saúde em relação aos soronegativos (p <0,05). Estatisticamente não se observaram diferenças significativas quanto Ó percepção do funcionamento dos trés sistemas avaliados (cardiovascular, gastrointestinal e urinário) em ambos os grupos. Concluções: resultados do estudo permitem concluir que os doadores soropositivos para T. cruzi no sangue poderiam ser vistos como portadores assintomáticos, sem evidência clínica de cardiomiopatia.

The Epidemiology, Clinical Manifestations, and Management of Chagas Heart Disease.

Chagas disease results from infection by the protozoan parasite Trypanosoma cruzi and is endemic in Latin America. T cruzi is most commonly transmitted through the feces of an infected triatomine, but can also be congenital, via contaminated blood transfusion or through direct oral contact. In the acute phase, the disease can cause cardiac derangements such as myocarditis, conduction system abnormalities, and/or pericarditis. If left untreated, the disease advances to the chronic phase. Up to one-half of these patients will develop a cardiomyopathy, which can lead to cardiac failure and/or ventricular arrhythmias, both of which are major causes of mortality. Diagnosis is confirmed by serologic testing for specific immunoglobulin G antibodies. Initial treatment consists of the antiparasitic agents benznidazole and nifurtimox. The treatment of Chagas cardiac disease comprises standard medical therapy for heart failure and amiodarone for ventricular arrhythmias, with consideration for implantable cardioverter-defibrillator. Chagas disease causes the highest infectious burden of any parasitic disease in the Western Hemisphere, and increased awareness of this disease is essential to improve diagnosis, enhance management, and reduce spread.

Role of cardiac magnetic resonance imaging in assessment of nonischemic cardiomyopathies.

Diagnosis of nonischemic cardiomyopathy is a challenging process that influences patient morbidity and mortality. Currently, the well known World Health Organization classification has been revisited by an American Heart Association expert consensus panel. The contemporary classification is compatible with the rapid evolution in molecular genetics and evolving diagnostic tools such as cardiac magnetic resonance imaging (MRI). Magnetic resonance imaging is a robust diagnostic tool that offers various techniques to assess the function, morphology, perfusion, and scarring of myocardial tissue thus providing better understanding of the underlying causes of nonischemic cardiomyopathies. In this review, we discuss the current role of cardiac MRI in the evaluation of nonischemic cardiomyopathy, in the context of the current American Heart Association classification of these disorders.

[How much does the medical treatment of chronic Chagas cardiopathy cost? Direct costs in a cardiology hospital]. / Cuánto cuesta la atención de la cardiopatía chagásica crónica? Costos directos en un hospital de cardiología.

OBJECTIVE: To estimate health care costs of patients with chronic Chagasic cardiomyopathy (CCC) in a cardiovascular referral center (Instituto Nacional de Cardiología I. Chávez). MATERIAL AND METHODS: In a retrospective study, 13 clinical charts of CCC patients treated in the hospital during 1998 were reviewed. Diagnostic and therapeutic procedures and patients admission were identify as well as health care costs, which were drawn from the hospital costs system. RESULTS: 62% of the cases were admitted to the hospital through the out-patient facilities. All the patients had a health care subsidy of 15 to 55% allocated to the institutional budget. Health care costs were calculated for minimal, average, and maximum scenarios, according to the patient's clinical stage and the price of medical equipment used (low, medium, and high). Most of the health care costs are due to the use of high cost diagnostic equipment (33 a 58%) and hospital stay (including the emergency room) (19 a 28%). CONCLUSION: This is the first approximation to the economic study of Chagas disease in Mexico, providing foundations for further studies on health economics and quality care of CCC, and suggests that prevention should be enhanced.

Cuánto cuesta la atención de la cardiopatía chagásica crónica? Costos directos en un hospital de cardiología / How much does the medical treatment of chronic Chagas cardiopathy cost? Direct costs in a cardiology hospital

OBJECTIVE: To estimate health care costs of patients with chronic Chagasic cardiomyopathy (CCC) in a cardiovascular referral center (Instituto Nacional de CardiologÝa I. Chßvez). MATERIAL AND METHODS: In a retrospective study, 13 clinical charts of CCC patients treated in the hospital during 1998 were reviewed. Diagnostic and therapeutic procedures and patients admission were identify as well as health care costs, which were drawn from the hospital costs system. RESULTS: 62 of the cases were admitted to the hospital through the out-patient facilities. All the patients had a health care subsidy of 15 to 55 allocated to the institutional budget. Health care costs were calculated for minimal, average, and maximum scenarios, according to the patient's clinical stage and the price of medical equipment used (low, medium, and high). Most of the health care costs are due to the use of high cost diagnostic equipment (33 a 58) and hospital stay (including the emergency room) (19 a 28). CONCLUSION: This is the first approximation to the economic study of Chagas disease in Mexico, providing foundations for further studies on health economics and quality care of CCC, and suggests that prevention should be enhanced.

Atención del paciente infectado por el Trypanosoma cruzi en el sistema de salud: aspectos operativos y laborales / Management and care of Trypanosoma cruzi infected patients in health services: operative and laboral procedures

El texto se ha preparado vom vistas a la atención del chagásico en Latino América, en donde se estima que hay entre 16 y 18 millones de indivíduos infectados. La expectativa en las dos próximas décadas senala para el progresivo control de la transmisión, restando para los programas de la lucha contra la enfermedad, la consolidación de una vigilancia epidemiológica efectiva, así como la atención médica y social al infectado. Las formas clínicas agudas tiendem a desaparecer y la atención será cada vez más dirigida hacia los indivíduos en la forma indeterminada y/o con formas cronicas cardíacas y digestivas iniciales, especialmente detectados en serologias de bancos de sangre. El diagnóstico clínico debe hacerse principalmente por la red básica de salud(atención primaria), correspondiendo a la confirmación diagnóstica y a la determinación de la fase, de la forma y de la gravedad de la enfermedad. De manera general,un buen diagnóstico clínico auxiliado por un electrocardiograma ey radiografias para corazón (tórax simple), esófago (tiempo de retención) y colon (enema) ya es suficiente para la definición en más del 90 por cento de los casos cronicos...

Normas para atención médica del infectado chagásico / Standards of medical attention to the chagasic infected

Un grupo de expertos e investigadores del Programa Nacional de Investigación elaboraron normas de atención médica para el infectado chagásico, formulando recomendaciones para la anámnesis, el examen físico, de laboratorio (inmunodiagnóstico y de análisis clínicos), electrocardiográficos y radiográficos; para el control del recién nacido hijo de madre chagásica; el tratamiento etiológico con nifurtimox y benznidazol (administración, dosificación, precauciones, signos de intolerancia a estas drogas, y contraindicaciones); y otros exámenes complementarios para pacientes con enfermedad de Chagas aguda, crónico, congénito, o con cardiomiopatía chagásica o que presentan trastornos cardiovasculares. También se dan normas para el control de doadores de sangre, a seguir en bancos de sangre, para la detección de Chagas transfusional. Finalmente, se da la orientación laboral para el paciente, según sea el grado de infección en que se encuentre