Prevalence and clinical course of patients with chronic heart failure secondary to chronic Chagas heart disease associated with obstructive coronary artery disease.

BACKGROUND: The prevalence and the outcomes of patients with chronic Chagas heart disease with obstructive coronary artery disease (CCHD-CAD) and chronic heart failure (CHF) with precordial chest pain are unsettled. Accordingly, the aim of this study was to determine the prevalence and clinical course of patients with CHF secondary to CCHD-CAD. METHODS: Patients with positive serology for Chagas disease and systolic CHF were included; those with precordial chest pain and at least two risk factors for CAD underwent coronary arteriogram. RESULTS: In total 262 patients were included in the investigation; 234 (89%) had CHF secondary to CCHD alone, and 28 (11%) with CHF secondary to CCHD-CAD, as observed at coronary arteriogram. The survival probability of patients with CHF secondary to CCHD alone at 12, 24, 36, 48 and 72 mo was 79%, 64%, 54%, 44% and 33%, respectively, whereas survival probability for patients with CHF secondary to CCHD-CAD at 12, 24, 36, 48 and 72 mo was 96%, 80%, 71%, 66% and 57%, respectively (p=0.04). CONCLUSIONS: In patients with CCHD with CHF, the prevalence of CAD of 11% is not neglectable in those with precordial chest pain. The outcome for patients with precordial chest pain with CHF secondary to CCHD-CAD is better than that observed in patients with CHF secondary to CCHD alone.

Does left ventricular reverse remodeling influence long-term outcomes in patients with Chagas cardiomyopathy?

BACKGROUND: The impact of left ventricular reverse remodeling (LVRR) on the prognosis of Chagas cardiomyopathy is unknown. The aim of this study was to determine whether the presence of LVRR can predict mortality in these patients. METHODS: From January 2000 to December 2010, the medical charts of 159 patients were reviewed. LVRR was defined as an increase of left ventricular ejection fraction (LVEF) and a decrease of left ventricular end-diastolic diameter (LVDD) by two-dimensional echocardiography. No patient underwent cardiac resynchronization therapy or required mechanical ventricular assistance. RESULTS: At baseline, median (25th-75th) LVDD was 64 mm (59-70), and median LVEF was 33.2% (26.4-40.1). LVRR was detected in 24.5% of patients in a 40-month (26-64) median follow-up. In the LVRR group, LVDD decreased from 64 mm (59-68) to 60 mm (56-65; p < 0.001), and LVEF increased from 31.3% (24.1-39.0) to 42.5% (32.2-47.7; p < 0.001). However, LVRR was not associated with heart failure hospitalization, cardiogenic shock, heart transplantation, or mortality (p > 0.05 for all comparisons). The Cox proportional hazard model analysis identified only cardiogenic shock (hazard ratio [HR]: 2.41; 95% confidence interval [CI]: 1.51-3.85; p < 0.001) and serum sodium level (HR: 0.91; 95% CI: 0.86-0.96; p < 0.001) as independent predictors of all-cause mortality. CONCLUSIONS: Left ventricular reverse remodeling occurs in one quarter of patients with Chagas cardiomyopathy and have no impact on the outcomes of patients with this condition.

The use of the CALL Risk Score for predicting mortality in Brazilian heart failure patients.

AIMS: This study aimed to develop and validate a simple method for predicting long-term all-cause mortality in ambulatory patients with chronic heart failure (CHF) residing in an area where Chagas disease is endemic, which will be important not only for patients living in Latin America but also to those living in developed non-endemic countries. METHODS AND RESULTS: A total of 677 patients with a wide spectrum of aetiologies for left ventricular systolic dysfunction and receiving optimized evidence-based treatment for CHF were prospectively followed for approximately 11 years. We established a risk score using Cox proportional hazard regression models. After multivariable analysis, four variables were independently associated with mortality and included in the CALL Risk Score: Chagas cardiomyopathy aetiology alone [hazard ratio, 3.36; 95% confidence interval (CI), 2.61-4.33; P < 0.001], age ≥60 years (hazard ratio, 1.36; 95% CI, 1.06-1.74; P = 0.016), left anterior fascicular block (hazard ratio, 1.64; 95% CI, 1.27-2.11; P < 0.001), and left ventricular ejection fraction <40% (hazard ratio, 1.73; 95% CI, 1.30-2.28; P < 0.001). The internal validation considered the bootstrapping, a resampling technique recommended for prediction model development. Hence, we established a scoring system attributing weights according to each risk factor: 3 points for Chagas cardiomyopathy alone, 1 point for age ≥60 years, and 2 points each for left anterior fascicular block and left ventricular ejection fraction <40%. Three risk groups were identified: low risk (score ≤2 points), intermediate risk (score of 3 to 5 points), and high risk (score ≥6 points). High-risk patients had more than two-fold increase in mortality (26.9 events/100 patient-years) compared with intermediate-risk patients (10.1 events/100 patient-years) and almost seven-fold increase compared with low-risk patients (4.3 events/100 patient-years). The CALL Risk Score data sets from the development and internal validation cohorts both displayed suitable discrimination c-index of 0.689 (95% CI, 0.688-0.690; P < 0.001) and 0.687 (95% CI, 0.686-0.688; P < 0.001), respectively, and satisfactory calibration [Greenwood-Nam-D'Agostino test (8) = 7.867; P = 0.447] and [Greenwood-Nam-D'Agostino test (8) = 10.08; P = 0.273], respectively. CONCLUSIONS: The CALL Risk Score represents a simple and validated method with a limited number of non-invasive variables that successfully predicts long-term all-cause mortality in a real-world cohort of patients with CHF. Patients with CHF stratified as high risk according to the CALL Risk Score should be monitored and aggressively managed, including those with CHF secondary to Chagas disease.

Prognostic Significance of Chronic Kidney Disease (CKD-EPI Equation) and Anemia in Patients with Chronic Heart Failure Secondary to Chagas Cardiomyopathy.

BACKGROUND: Few studies regarding chronic kidney disease (CKD) and anemia have been conducted in patients with Chagas cardiomyopathy (CC). We evaluated the risk prediction performance of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and anemia in CC patients. METHODS: From 2000 to 2010, a total of 232 patients were studied in a single-center retrospective study. CKD was defined as creatinine clearance <60 mL/min/1.73 m2 according to CKD-EPI equation. Anemia was defined as hemoglobin <12 g/dL (women) and <13 g/dL (men). Cox proportional hazards models were used to establish predictors for death. RESULTS: At baseline, 98 individuals (42.2%) had criteria for CKD and 41 (17.7%) for anemia. During follow-up, 136 patients (58.6%) died. Independently, CKD and anemia were not associated with all-cause mortality. However, when they coexisted, an additional risk was attributed for these patients. Cox proportional hazard models analysis identified systolic blood pressure (hazard ratio, 0.99; 95% confidence interval (CI), 0.98 to 1.00; P=0.015), implantable cardioverter-defibrillator (hazard ratio, 0.48; 95% CI, 0.27 to 0.85; P=0.012), left anterior fascicular block (hazard ratio, 1.52; 95% CI, 1.08 to 2.13; P=0.017), left ventricular end-diastolic diameter (hazard ratio, 1.04; 95% CI, 1.02 to 1.06; P < 0.001), and serum sodium (hazard ratio, 0.95; 95% CI, 0.92 to 0.99; P=0.020) as independent predictors for death. CONCLUSIONS: CKD and anemia are not independent predictors for long-term mortality in CC patients. However, the prognosis is poorer in individuals with both comorbidities.

Outcome of Chagas cardiomyopathy in comparison to ischemic cardiomyopathy.

BACKGROUND: Chagas cardiomyopathy and ischemic heart disease (IHD) are frequent causes of chronic systolic heart failure (CHF) in areas where the former is endemic. Nonetheless, a specific comparison of outcome and role of etiology of CHF failure has not been performed in patients with both conditions. METHODS: Two-hundred twenty two patients with Chagas cardiomyopathy and 79 with IHD with CHF were included in the study. A Cox proportional hazards model was used to establish independent predictors of mortality for the studied population. Survival analysis was performed with the Kaplan-Meir product limit method. RESULTS: In the multivariable model, Beta-Blocker therapy [(hazard ratio (HR)=0.36; 95% confidence interval (CI) 0.24 to 0.52; p<0.005)], Chagas etiology of CHF (HR=3.6; 95% CI 2.0 to 6.5; p<0.005), serum sodium levels (HR=0.95; 95% CI 0.91 to 0.98; p<0.005), digoxin use (HR=2.1; 95% CI 1.19 to 3.80, p=0.01), and spironolactone use (HR=1.7; 95% CI 1.10 to 2.80; p=0.02) were determined independent predictors of all-cause mortality for this cohort. Probability of survival at 12, 24, 36, 48, and 60 months was 92%, 92%, 88%, 81%, and 78%, respectively, in IHD patients, and 79%, 61%, 49%, 41%, and 35%, respectively, in Chagas cardiomyopathy patients (p<0.005). CONCLUSION: Outcome in patients with chronic systolic heart failure secondary to Chagas cardiomyopathy is poorer than that seen in those with IHD.

Effects of B-Blockers on outcome of patients with Chagas' cardiomyopathy with chronic heart failure.

BACKGROUND: A few studies have shown a beneficial effect of B-Blocker therapy on cardiac function and functional status in patients with chronic heart failure secondary to Chagas' cardiomyopathy. METHODS: The medical charts of patients routinely followed from January, 2000 to January, 2007 were reviewed to collect clinical, standard laboratory tests, 12-lead electrocardiogram, chest X-Ray, and Doppler echochardiogram variables. A Cox proportional hazards model was used to establish independent predictors of all-cause mortality for patients with Chagas' cardiomyopathy with chronic heart failure. RESULTS: A total of 231 consecutive patients were enrolled in the study. Median follow up was 19 (7, 46) months. Twenty (9%) patients underwent heart transplantation and 120 (52%) died during the investigation. Left ventricular systolic dimension (hazard ratio=1.04; 95% confidence interval=1.02 to 1.06; p<0.005) and need of inotropic support (hazard ratio=1.80; 95% confidence interval 1.2 to 2.60; p=0,03), were positively associated, whereas B-Blocker therapy (HR=0.34; 95% confidence interval 0.23 to 0.51; p<0.0005) was negatively associated with mortality. Mortality was significantly lower in patients taking in comparison to those not taking B-Blockers. Patients taking a mean daily dose of carvedilol>or=to 9.375mg had a marked decrease in mortality in comparison to those not on carvedilol therapy. CONCLUSION: B-Blockers are effective, not detrimental, and may improve survival in Chagas' disease patients with chronic heart failure. A randomized trial is necessary to confirm these findings.

Comparison of outcome between Chagas cardiomyopathy and idiopathic dilated cardiomyopathy.

BACKGROUND: Little is known about the outcome of patients with Chagas cardiomyopathy in comparison to that of patients with idiopathic dilated cardiomyopathy in the contemporary era. OBJECTIVE: To compare the outcome of chagasic patients with chronic systolic heart failure secondary to Chagas cardiomyopathy with that observed in patients with IDC in the contemporary era. METHODS: A total of 352 patients (246 with Chagas cardiomyopathy, 106 with idiopathic dilated cardiomyopathy) prospectively followed at our Institution from January, 2000 to January, 2008 were included. All patients received standard contemporary medical therapy. RESULTS: In Cox proportional hazards model multivariate analysis, digoxin use (Hazard Ratio=3.17; 95% Confidence Interval 1.62 to 6.18; p=0.001), need of inotropic support (Hazard Ratio=2.08; 95% Confidence Interval 1.43 to 3.02; p<0.005), left ventricular ejection fraction (Hazard Ratio=0.97; 95% Confidence Interval 0.95 to 0.99; p<0.005), and Chagas cardiomyopathy etiology (Hazard Ratio=3.29; 95% Confidence Interval 1.89 to 5.73; p<0.005) were positively associated with mortality, whereas beta-blocker therapy (Hazard Ratio=0.39; 95% Confidence Interval 0.26 to 0.56; p<0.005) was negatively associated with mortality. Survival probability for patients with Chagas cardiomyopathy at 8, 24, and 49 months was 83%, 61%, and 41%, respectively, and for patients with idiopathic dilated cardiomyopathy 97%, 92%, and 82%, respectively (p<0.005). CONCLUSION: In the current era of heart failure therapy, patients with Chagas cardiomyopathy have a poorer outcome in comparison to patients with idiopathic dilated cardiomyopathy.

Prognostic significance of anemia in patients with chronic systolic heart failure secondary to Chagas' cardiomyopathy.

The purpose of this study was to evaluate the prognostic significance of anemia on outcome of patients with chronic systolic heart failure secondary to Chagas' cardiomyopathy, as no previous study has previously addressed this question. One-hundred-eight-six patients followed for chronic systolic heart failure secondary to Chagas' cardiomyopathy at our Institution from January 2000 to December 2008 were studied. Forty-nine (26%) patients were found to have anemia; 37 (20%) were men and 12 (6%) were women. Mean hemoglobin level was 14.1±1.2g/L in patients with no anemia and 11.5±1.2g/L in patients with anemia. On a Cox proportional hazards multivariate analysis, anemia was a predictor of all-cause mortality neither in the univariate nor in the multivariate analysis. Mean serum sodium (Hazard ratio=0.92; Beta-coefficient=-0.09; 95% confidence interval 0.89-0.96; p value<0.005), and Beta-Blocker therapy (Hazard ratio=0.40; 95% confidence interval 0.26-0.61; p value<0.005) were retained as independent predictors of mortality for patients with Chagas' cardiomyopathy with chronic heart failure. Probability of survival for patients with anemia, however, was significantly lower in patients with anemia in comparison to patients with no anemia, mainly in patients with advanced heart failure. Anemia is not an independent predictor of all-cause mortality in patients with Chagas' cardiomyopathy with chronic systolic heart failure. Probability of survival is poorer in patients with anemia than in those without.

Predictors of all-cause mortality in chronic Chagas' heart disease in the current era of heart failure therapy.

BACKGROUND AND AIMS: We sought to identify predictors of all-cause mortality for Chagas' disease patients with chronic systolic heart failure because they are virtually lacking in the current era of heart failure therapy. METHODS AND RESULTS: This study focus on 127 patients with the diagnosis of chronic systolic heart failure secondary to Chagas' cardiomyopathy. Mean follow up was 25+/-19 months. Sixty-three (50%) patients died during the study period. Cox regression analysis showed lack of B-blocking agent use (p=0.002, hazard ratio=0.30, 95% Confidence Interval 0.14 to 0.64), serum sodium levels (p=0.01, hazard ratio=0.93, 95% Confidence Interval 0.87 to 0.98), left ventricular ejection fraction (p=0.02, hazard ratio=0.96, 95% Confidence Interval 0.93 to 0.99), digoxin treatment (p=0.04, hazard ratio=8.47, 95% Confidence Interval 1.13 to 62.52) and New York Heart Association Class IV on admission (p=0.034, hazard ratio=1.92, 95% Confidence Interval 1.02 to 3.51) independent predictors of all-cause mortality. CONCLUSION: Lack of B-blocking agent use, serum sodium levels, left ventricular ejection fraction, digoxin treatment and New York Heart Association Class IV are independent predictors of all-cause mortality for patients with chronic heart failure secondary to Chagas' cardiomyopathy in the current era of heart failure therapy.

Comparação do desfecho entre a cardiopatia chagásica e a miocardiopatia dilatada idiopática / Comparison of outcome between Chagas cardiomyopathy and idiopathic dilated cardiomyopathy

FUNDAMENTO: Pouco se sabe sobre o desfecho dos pacientes com cardiopatia chagásica, em comparação aos pacientes com miocardiopatia dilatada idiopática na era contemporânea. OBJETIVO: Comparar o desfecho dos pacientes chagásicos com insuficiência cardíaca sistólica crônica decorrente da cardiopatia chagásica ao observado em pacientes com MDI na era contemporânea. MÉTODOS: Foi incluído um total de 352 pacientes (246 com cardiomiopatia chagásica e 106 com miocardiopatia dilatada idiopática), seguidos prospectivamente em nossa Instituição, de janeiro de 2000 a janeiro de 2008. Todos os pacientes receberam tratamento clínico contemporâneo padrão. RESULTADOS: Na análise multivariada com o modelo de risco proporcional de Cox, o uso da digoxina (relação de risco = 3,17; intervalo de confiança de 95 por cento, de 1,62 a 6,18; p = 0,001) necessitou de suporte inotrópico (relação de risco = 2,08; intervalo de confiança de 95 por cento, de 1,43 a 3,02; p < 0,005). A fração de ejeção do ventrículo esquerdo (relação de risco = 0,97; intervalo de confiança de 95 por cento, de 0,95 a 0,99; p < 0,005) e a etiologia da cardiopatia chagásica (relação de risco = 3,29; intervalo de confiança de 95 por cento, de 1,89 a 5,73; p < 0,005) foram associadas positivamente à mortalidade, enquanto a terapia com betabloqueadores (relação de risco = 0,39; intervalo de confiança de 95 por cento, de 0,26 a 0,56; p < 0,005) foi associada negativamente à mortalidade. A probabilidade de sobrevida para pacientes com cardiomiopatia chagásica em oito, 24 e 49 meses foi de 83 por cento, 61 por cento e 41 por cento, respectivamente. Já para pacientes com cardiomiopatia dilatada idiopática, foi de 97 por cento, 92 por cento e 82 por cento, respectivamente (p < 0,005). CONCLUSÃO: Na era atual do tratamento da insuficiência cardíaca, os pacientes com cardiomiopatia chagásica têm um desfecho pior em comparação aos pacientes com cardiomiopatia dilatada idiopática.

BACKGROUND: Little is known about the outcome of patients with Chagas cardiomyopathy in comparison to that of patients with Idiopathic Dilated Cardiomyopathy in the contemporary era. OBJECTIVE: To compare the outcome of chagasic patients with chronic systolic heart failure secondary to Chagas cardiomyopathy with that observed in patients with IDC in the contemporary era. METHODS: A total of 352 patients (246 with Chagas cardiomyopathy, 106 with Idiopathic Dilated Cardiomyopathy) prospectively followed at our Institution from January, 2000 to January, 2008 were included. All patients received standard contemporary medical therapy. RESULTS: In Cox proportional hazards model multivariate analysis, digoxin use (Hazard Ratio=3.17; 95 percent Confidence Interval 1.62 to 6.18; p=0.001), need of inotropic support (Hazard Ratio=2.08; 95 percent Confidence Interval 1.43 to 3.02; p<0.005), left ventricular ejection fraction (Hazard Ratio=0.97; 95 percent Confidence Interval 0.95 to 0.99; p<0.005), and Chagas cardiomyopathy etiology (Hazard Ratio=3.29; 95 percent Confidence Interval 1.89 to 5.73; p<0.005) were positively associated with mortality, whereas Beta-Blocker therapy (Hazard Ratio=0.39; 95 percent Confidence Interval 0.26 to 0.56; p<0.005) was negatively associated with mortality. Survival probability for patients with Chagas cardiomyopathy at 8, 24, and 49 months was 83 percent, 61 percent, and 41 percent, respectively, and for patients with Idiopathic Dilated cardiomyopathy 97 percent, 92 percent, and 82 percent, respectively (p<0.005). CONCLUSION: In the current era of heart failure therapy, patients with Chagas cardiomyopathy have a poorer outcome in comparison to patients with Idiopathic Dilated Cardiomyopathy.