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1.
Infect Dis Clin North Am ; 33(1): 119-134, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30712757

RESUMO

American trypanosomiasis is caused by a parasite endemic of the Americas. Current migration has globalized Chagas disease. Acute infection usually resolves spontaneously. Nonetheless, 20% to 40% develop cardiomyopathy 20 to 30 years later. Progression to cardiomyopathy is devastatingly rapid, manifesting with heart failure and sudden death. Etiologic treatment is highly effective and recommended in those with acute infections, congenital infections, and parasite reactivation, and women of childbearing age, but in asymptomatic Trypanosoma cruzi carriers and patients with early cardiomyopathy remains controversial and under investigation. Progression of heart failure is rapid and accounts for most of the morbidity and related mortality.


Assuntos
Cardiomiopatia Chagásica/tratamento farmacológico , Cardiomiopatia Chagásica/mortalidade , Doença de Chagas/complicações , Doença de Chagas/tratamento farmacológico , Animais , Ensaios Clínicos como Assunto , Progressão da Doença , Vetores de Doenças , Humanos , Nitroimidazóis/uso terapêutico , Triatominae/parasitologia , Tripanossomicidas/uso terapêutico , Trypanosoma cruzi/isolamento & purificação
2.
J Am Coll Cardiol ; 72(21): 2567-2576, 2018 11 27.
Artigo em Inglês | MEDLINE | ID: mdl-30466514

RESUMO

BACKGROUND: Patients with chronic Chagas cardiomyopathy (CCC) have pronounced myocardial fibrosis, which may predispose to sudden cardiac death, despite well-preserved global left ventricular (LV) systolic function. Cardiac magnetic resonance can assess myocardial fibrosis by late gadolinium enhancement (LGE) sequences. OBJECTIVES: This prospective study evaluated if the presence of scar by LGE predicted hard adverse outcomes in a cohort of patients with CCC. METHODS: A prospective cohort of 140 patients with CCC (52.1% female; median age 57 years [interquartile range: 45 to 67 years]) were included. Cardiac magnetic resonance cine and LGE imaging were performed at enrollment with a 1.5-T scanner. The primary endpoint was the combination of cardiovascular death and sustained ventricular tachycardia. The secondary endpoint was the combination of cardiovascular death, sustained ventricular tachycardia, or cardiovascular hospitalization during follow-up. RESULTS: After a median of 34 months (interquartile range: 24 to 49 months) of follow-up, 11 cardiovascular deaths, 3 episodes of sustained ventricular tachycardia, and 20 cardiovascular hospitalizations were recorded. LGE scar was present in 71.4% of the patients, with the lateral, inferolateral, and inferior walls most commonly affected. Patients with positive LGE had lower LV ejection fraction and higher LV end-diastolic volume and LV mass than patients without LGE. No difference in other cardiovascular risk factors was noted. Patients with scar had higher event rates compared with those without scar for the primary (p = 0.043) and the secondary (p = 0.016) endpoint. In multivariable analysis, age and LGE area were related to primary outcome; age and lower LV ejection fraction were related to the secondary outcome. The pattern of LGE myocardial fibrosis was transmural, focal, or diffuse scar in approximately one-third of patients with positive LGE, and no pattern was specifically related to outcomes. CONCLUSIONS: In patients with CCC, presence of scar by LGE is common and is strongly associated with major adverse outcomes.


Assuntos
Cardiomiopatia Chagásica/diagnóstico por imagem , Cardiomiopatia Chagásica/mortalidade , Cicatriz/diagnóstico por imagem , Cicatriz/mortalidade , Ventrículos do Coração/diagnóstico por imagem , Adulto , Idoso , Doença Crônica , Estudos de Coortes , Eletrocardiografia/tendências , Feminino , Seguimentos , Humanos , Imagem Cinética por Ressonância Magnética/tendências , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Prognóstico , Estudos Prospectivos
3.
J Am Coll Cardiol ; 72(21): 2577-2587, 2018 11 27.
Artigo em Inglês | MEDLINE | ID: mdl-30466515

RESUMO

BACKGROUND: Myocardial fibrosis (MF) according to cardiac magnetic resonance (CMR) is a frequent finding in Chagas cardiomyopathy and has been associated with risk factors of poor outcome. OBJECTIVES: The goal of this study was to determine the prognostic value of MF in predicting combined hard events or all-cause mortality. METHODS: Patients with Chagas cardiomyopathy who had a previous CMR evaluation were included, and clinical follow-up was retrospectively obtained. The primary outcome was a combination of all-cause mortality, heart transplantation, antitachycardia pacing or appropriate shock from an implantable cardioverter-defibrillator, and aborted sudden cardiac death; the secondary outcome was all-cause mortality. RESULTS: A total of 130 patients were included; mean age was 53.6 ± 11.5 years, and 53.9% were female. The majority of patients reported no symptoms of heart failure or arrhythmia, but electrocardiographic and echocardiographic abnormalities were common. On CMR, left ventricular dilatation and dysfunction were frequent, and MF was found in 76.1%, with a mean mass of 15.2 ± 16.5 g. Over a median follow-up of 5.05 years, 58 (44.6%) patients reached the combined endpoint, and 45 (34.6%) patients died. MF was associated with the primary outcome as a continuous variable (adjusted hazard ratio: 1.031; 95% CI: 1.013 to 1.049; p = 0.001) and as a categorical variable (MF ≥12.3 g) (adjusted hazard ratio: 2.107; 95% CI: 1.111 to 3.994; p = 0.022), independently from the Rassi risk score. MF expressed as a continuous variable was also associated with all-cause mortality (adjusted hazard ratio: 1.028; 95% CI: 1.005 to 1.051; p = 0.017) independently from the Rassi risk score. CONCLUSIONS: MF is an independent predictor of adverse outcome in Chagas cardiomyopathy. Our data may support the use of CMR in better risk-stratifying this population and possibly guiding therapy.


Assuntos
Cardiomiopatia Chagásica/diagnóstico por imagem , Cardiomiopatia Chagásica/mortalidade , Miocárdio/patologia , Adulto , Idoso , Estudos de Coortes , Ecocardiografia/tendências , Feminino , Fibrose/diagnóstico por imagem , Fibrose/mortalidade , Seguimentos , Humanos , Imagem Cinética por Ressonância Magnética/tendências , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Tempo
4.
Cardiovasc Pathol ; 35: 23-28, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29747049

RESUMO

BACKGROUND: The risk of thromboembolic events is increased in patients with heart failure (HF); however, few studies have reported thromboembolic findings in HF patients who have undergone autopsy. METHODS AND RESULTS: We reviewed 1457 autopsies (January 2000/July 2006) and selected 595 patients with HF. We studied the occurrence of thromboembolic events in patients' autopsy reports. Mean age was 61.8±15.9 years; 376 (63.2%) were men and 219 (36.8%) women; left ventricular ejection fraction was 42.1±18.7%. HF etiologies were coronary artery disease in 235 (39.5%) patients, valvular disease in 121 (20.3%), and Chagas' disease in 81 (13.6%). The main cause of death was progressive HF in 253 (42.5%) patients, infections in 112 (18.8%), myocardial infarction in 86 (14.5%), and pulmonary embolism in 81 (13.6%). Altogether, 233 patients (39.2%) suffered 374 thromboembolic events. A thromboembolic event was considered the direct cause of death in 93 (24.9%) patients and related to death in 158 (42.2%). The most frequent thromboembolism was pulmonary embolism in 135 (36.1%) patients; in 81 events (60%), it was considered the cause of death. When we compared clinical characteristics of patients, sex (OR=1.511, CI 95% 1.066-2.143, P=.021) and Chagas disease (OR=2.362, CI 95% 1.424-3.918, P=.001) were independently associated with the occurrence of thromboembolisms. CONCLUSIONS: Thromboembolic events are frequent in patients with heart failure revealed at autopsy, and are frequently associated with the death process. Our findings warrant a high degree of suspicion for these occurrences, especially during the care of more susceptible populations, such as women and Chagas patients.


Assuntos
Insuficiência Cardíaca/patologia , Tromboembolia/patologia , Idoso , Autopsia , Causas de Morte , Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/patologia , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/patologia , Razão de Chances , Embolia Pulmonar/mortalidade , Embolia Pulmonar/patologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Tromboembolia/mortalidade
5.
Braz J Cardiovasc Surg ; 33(1): 82-88, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29617506

RESUMO

INTRODUCTION: Chagas disease represents an important health problem with socioeconomic impacts in many Latin-American countries. It is estimated that 20% to 30% of the people infected by Trypanosoma cruzi will develop chronic Chagas cardiomyopathy (CCC), which is generally accompanied by heart failure (HF). Cardiac resynchronization therapy (CRT) may be indicated for patients with HF and electromechanical dysfunctions. OBJECTIVE: The primary endpoint of this study was to analyze the response to CRT in patients with CCC, while the secondary endpoint was to estimate the survival rates of CRT responder patients. METHODS: This is an observational, cross-sectional and retrospective study. The records of 50 patients with CRT pacing devices implanted between June 2009 and March 2017 were analyzed. For statistical analyses, Pearson's correlation was used along with Student's t-test, and survival was analyzed using the Kaplan-Meier method. A P value of <0.05 was considered significant. RESULTS: Out of 50 patients, 56% were male, with a mean age of 63.4±13.3 years and an average CRT duration of 61.2±21.7 months. The mean QRS duration was 150.12±12.4 ms before and 116.04±2.2 ms after the therapy (P<0.001). The mean left ventricular ejection fractions (LVEF) were 29±7% and 39.1±12.2% before and after CRT, respectively (P<0.001). A total of 35 (70%) patients had a reduction of at least one New York Heart Association (NYHA) functional class after six months of therapy (P=0.014). The survival rate after 72 months was 45%. CONCLUSION: This study showed clinical improvement and a nonsignificant survival rate in patients with CCC after the use of CRT.


Assuntos
Terapia de Ressincronização Cardíaca/métodos , Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/terapia , Doença Crônica , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida
6.
Europace ; 20(11): 1813-1818, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29509903

RESUMO

Aims: Cardiac resynchronization therapy (CRT) is an established procedure for patients with heart failure. However, trials evaluating its efficacy did not include patients with chronic Chagas cardiomyopathy (CCC). We aimed to assess the role of CRT in a cohort of patients with CCC. Methods and results: This retrospective study compared the outcomes of CCC patients who underwent CRT with those of dilated (DCM) and ischaemic cardiomyopathies (ICM). The primary endpoint was all-cause mortality and the secondary endpoints were the rate of non-advanced New York Heart Association (NYHA) class 12 months after CRT and echocardiographic changes evaluated at least 6 months after CRT. There were 115 patients in the CCC group, 177 with DCM, and 134 with ICM. The annual mortality rates were 25.4%, 10.4%, and 11.3%, respectively (P < 0.001). Multivariate analysis adjusted for potential confounders showed that the CCC group had a two-fold [hazard ratio 2.34 (1.47-3.71), P < 0.001] higher risk of death compared to the DCM group. The rate of non-advanced NYHA class 12 months after CRT was significantly higher in non-CCC groups than in the CCC group (DCM 74.0% vs. ICM 73.9% vs. 56.5%, P < 0.001). Chronic Chagas cardiomyopathy and ICM patients had no improvement in the echocardiographic evaluation, but patients in the DCM group had an increase in left ventricular ejection fraction and a decrease in left ventricular end-diastolic diameter. Conclusion: This study showed that CCC patients submitted to CRT have worse prognosis compared to patients with DCM and ICM who undergo CRT. Studies comparing CCC patients with and without CRT are warranted.


Assuntos
Terapia de Ressincronização Cardíaca , Cardiomiopatia Chagásica , Brasil/epidemiologia , Terapia de Ressincronização Cardíaca/efeitos adversos , Terapia de Ressincronização Cardíaca/métodos , Cardiomiopatia Dilatada/diagnóstico , Cardiomiopatia Dilatada/mortalidade , Cardiomiopatia Dilatada/fisiopatologia , Cardiomiopatia Dilatada/terapia , Cardiomiopatia Chagásica/diagnóstico , Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/fisiopatologia , Cardiomiopatia Chagásica/terapia , Desfibriladores Implantáveis , Ecocardiografia/métodos , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Volume Sistólico
7.
Pacing Clin Electrophysiol ; 41(6): 583-588, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29578582

RESUMO

BACKGROUND: Chagas heart disease (CHD) is a dilated cardiomyopathy characterized by malignant ventricular arrhythmias and increased risk of sudden cardiac death (SCD). Much controversy exists concerning the efficacy of implantable cardioverter-defibrillator (ICDs) in CHD because of mixed results observed. We report our long-term experience with ICDs for secondary prevention in CHD, with the specific aim of assessing the results in groups with preserved or depressed global left ventricular function. METHODS: 111 patients (75 males; 60 ± 12 years) were followed for 1,948 ± 1,275 days after ICD. Time to death was the primary outcome; LVEF ≤ 45% the exposure; and age, gender, and ICD therapy delivery the potential confounders. We used time-to-event methods and Cox proportional models for analysis, censoring observations at time of death or at 5-year follow-up in survivors. RESULTS: Seventy-two percent of the patients presented at least one sustained ventricular arrhythmia requiring appropriate therapy, and only three patients received inappropriate therapy. Death occurred in 50 (45%) patients, with an annual mortality rate of 8.4%, mostly due to refractory heart failure or noncardiac causes. Unadjusted survival rates were significantly distinct between patients with left ventricular ejection fraction (LVEF) ≤ 45% (26 deaths), 50.5% (95% confidence interval [CI]: 36.2%-63.2%) when compared to patients with LVEF > 45% (10 deaths), 77.6% (95% CI: 62.3%-87.3%, P < 0.01). After adjusting for confounders, low LVEF (hazard ratio [HR]: 5.2, 95% CI: 2.3-11.6), age (HR: 1.04, 95% CI: 1.01-1.07), and female gender (HR: 3.97, 95% CI: 1.85-8.54) were independently associated with the outcome. CONCLUSIONS: ICDs successfully aborted life-threatening arrhythmias in CHD patients. Impaired left ventricular function predicted higher mortality in CHD patients with an ICD for secondary prevention of SCD.


Assuntos
Cardiomiopatia Chagásica/complicações , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Prevenção Secundária , Taquicardia Ventricular/prevenção & controle , Cardiomiopatia Chagásica/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taquicardia Ventricular/mortalidade , Resultado do Tratamento
8.
Int. j. cardiovasc. sci. (Impr.) ; 31(2): f:173-l:189, mar.-abr. 2018. ilus, tab, graf
Artigo em Português | LILACS | ID: biblio-882961

RESUMO

A cardiomiopatia crônica da doença de Chagas (CCDC) é resultante de miocardite fibrosante focal de baixa intensidade, mas incessante, causada pela infecção persistente do T cruzi, associada à inflamação mediada por mecanismos imunes adversos. Cerca de 30% dos infectados desenvolvem, ao longo da vida, a forma crônica cardíaca da doença de Chagas com manifestação clínica proteiforme, que pode incluir morte súbita, sintomas e sinais de insuficiência cardíaca, eventos cardioembólicos, arritmia e sintomas anginoides. A morte súbita e a progressão da insuficiência cardíaca (IC) são os mecanismos mais comuns de óbito nesta condição. Os aspectos prognósticos mais relevantes são sintomas de IC avançada (CF III/IV da NYHA), cardiomegalia, disfunção sistólica do VE e taquicardia ventricular não sustentada. A prevenção dos eventos cardioembólicos é aspecto importante no manejo dos pacientes com CCDC. Agentes anticoagulantes orais devem ser indicados para pacientes com risco elevado, conforme a presença de um conjunto de fatores de risco: disfunção sistólica do VE, aneurisma apical, alteração da repolarização ventricular ao ECG e idade avançada. O tratamento da IC na CCDC segue os mesmos princípios aplicados à IC secundária à cardiomiopatia dilatada de outras etiologias


Assuntos
Humanos , Masculino , Feminino , Cardiomiopatias/mortalidade , Cardiomiopatia Chagásica/mortalidade , Doença de Chagas/epidemiologia , Doença de Chagas/mortalidade , Morte Súbita , Ecocardiografia/métodos , Eletrocardiografia Ambulatorial/métodos , Eletrocardiografia/métodos , Espectroscopia de Ressonância Magnética/métodos , Valva Mitral , Valva Tricúspide , Trypanosoma cruzi/parasitologia
9.
PLoS Negl Trop Dis ; 12(2): e0006207, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29432453

RESUMO

AIMS: Explore the association between clinical findings and prognosis in patients with acute decompensated heart failure (ADHF) and analyze the influence of etiology on clinical presentation and prognosis. METHODS AND RESULTS: Prospective cohort of 500 patients admitted with ADHF from Aug/2013-Feb/2016; patients were predominantly male (61.8%), median age was 58 (IQ25-75% 47-66 years); etiology was dilated cardiomyopathy in 141 (28.2%), ischemic heart disease in 137 (27.4%), and Chagas heart disease in 113 (22.6%). Patients who died (154 [30.8%]) or underwent heart transplantation (53[10.6%]) were younger (56 years [IQ25-75% 45-64 vs 60 years, IQ25-75% 49-67], P = 0.032), more frequently admitted for cardiogenic shock (20.3% vs 6.8%, P<0.001), had longer duration of symptoms (14 days [IQ25-75% 4-32.8 vs 7.5 days, IQ25-75% 2-31], P = 0.004), had signs of congestion (90.8% vs 76.5%, P<0.001) and inadequate perfusion more frequently (45.9% vs 28%, P<0.001), and had lower blood pressure (90 [IQ25-75% 80-100 vs 100, IQ25-75% 90-120], P<0.001). In a logistic regression model analysis, systolic blood pressure (P<0.001, OR 0.97 [95%CI 0.96-0.98] per mmHg) and jugular distention (P = 0.004, OR 1.923 [95%CI 1.232-3.001]) were significant. Chagas patients were more frequently admitted for cardiogenic shock (15%) and syncope/arrhythmia (20.4%). Pulmonary congestion was rare among Chagas patients and blood pressure was lower. The rate of in-hospital death or heart transplant was higher among patients with Chagas (50.5%). CONCLUSIONS: A physical exam may identify patients at higher risk in a contemporaneous population. Our findings support specific therapies targeted at Chagas patients in the setting of ADHF.


Assuntos
Cardiomiopatia Chagásica/patologia , Insuficiência Cardíaca/patologia , Função Ventricular , Idoso , Cardiomiopatia Chagásica/mortalidade , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Análise de Sobrevida
10.
Pacing Clin Electrophysiol ; 41(3): 238-245, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29315657

RESUMO

BACKGROUND: It has been difficult to prove that "catecholamine-induced cardiomyopathy" contributes to the mechanism of sudden cardiac death in Chagas heart disease. Also, it is almost impossible to rule out the possibility that it is not involved in the process. More importantly, the vagal-cholinergic pathway in the ventricle plays a direct role in the prevention of the initiation of complex ventricular arrhythmias, including nonsustained ventricular tachycardia, ventricular fibrillation responsible for sudden death. OBJECTIVE: To determine frequency of parasympathetic autonomic indices among the different groups of risk of cardiovascular death when stratified by Rassi score. METHODS: Patients with Chagas heart disease were selected and divided into three risk groups by Rassi score. A fourth group, non-Chagas group, was of similar age and gender. All were subjected to analysis of heart rate variability during controlled breathing (RSA) and tilt table passive test (tilt test). High frequency and low frequency/high frequency ratio were calculated and presented by box-plot. Also, t-test was used to compare the two groups. RESULTS: It was observed that the parasympathetic and sympathetic component were affected, when the risk group increased the response was worsened to the stimulus (RSA or Tilt). Also, the low-risk group was jeopardized, when compared to the non-Chagas group. CONCLUSION: The loss of parasympathetic modulation was present in all Rassi risk groups, including the low risk, indicating that a morphological change of the myocardium represents a detectable neurofunctional change.


Assuntos
Sistema Nervoso Autônomo/fisiopatologia , Cardiomiopatia Chagásica/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Cardiomiopatia Chagásica/mortalidade , Feminino , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Teste da Mesa Inclinada
11.
Int J Cardiol ; 250: 260-265, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29079412

RESUMO

BACKGROUND: Chronic Chagas cardiomyopathy (CCC) is the most serious and frequent manifestation of Chagas disease. Conduction abnormalities and bradycardia requiring pacemaker are common. The aim of this study was to determine the rate and predictors of death in CCC patients with pacemaker. METHODS: In this single-center prospective cohort study we assessed the outcome of 396 CCC patients with pacemaker, followed-up for at least 24months. All patients underwent a clinical and device assessment, 12-lead electrocardiography and echocardiography. RESULTS: During the median follow-up of 1.9years (Interquartile range 1.6-2.4), there were 65 (16.4%) deaths, yielding an annual mortality rate of 8.6%. The major cause was sudden death (33.8%), followed by heart failure (HF), 32.3%. All the investigated variables were examined as potential predictors of death. The final multivariate logistic regression model included five independent variables: advanced HF functional class (OR [odds ratio] 6.71; 95% confidence interval [95% CI] 1.95-23.2; P=0.003), renal disease (OR 5.71; 95% CI 1.80-18.0; P=0.003), QRS ≥150ms (OR 2.80; 95% CI 1.08-7.27; P=0.034), left atrial enlargement (OR 2.75; 95% CI 1.09-6.95; P=0.032) and left ventricular ejection fraction ≤43% (OR 2.31; 95% CI 1.07-4.97; P=0.032). The model had good discrimination, confirmed by bootstrap validation (optimism-adjusted c-statistic of 0.78) and the calibration curve showed a proper calibration (slope=0.972). CONCLUSIONS: CCC patients with pacemaker have a high annual mortality rate despite that the pacemaker related variables were not predictors of death. The independent predictors of death can help us to identify the poor prognosis patients.


Assuntos
Cardiomiopatia Chagásica/diagnóstico , Cardiomiopatia Chagásica/mortalidade , Marca-Passo Artificial/tendências , Idoso , Doença Crônica , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Valor Preditivo dos Testes , Estudos Prospectivos
12.
Am J Cardiol ; 121(3): 364-369, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-29191568

RESUMO

We sought to investigate the prognostic value of the electrocardiogram (ECG) electrical axes (P wave, T wave and QRS) as predictors of mortality in the 14-year follow-up of the prospective cohort of all residents ≥60 years living in the southeastern Brazilian city of Bambuí, a population with high prevalence of Chagas disease (ChD). Baseline ECG axes were automatically measured with normal values defined as follows: P-wave axis 0° to 75°, QRS axis -30° to 90°, and T axis 15° to 75°. Participants underwent annual follow-up visits and death was verified using death certificates. Cox proportional hazards regression was used to assess the prognostic value of ECG axes for all-cause mortality, after adjustment for potential confounders. From 1,742 qualifying residents, 1,462 were enrolled, of whom 557 (38.1%) had ChD. Mortality rate was 51.9%. In multivariable adjusted models, abnormal P-wave axis was associated with a 48% (hazard ratio [HR] = 1.48 [95% confidence interval (CI) 1.16-1.88]) increased mortality risk in patients with ChD and 43% (HR = 1.43 [CI 1.13-1.81]) in patients without ChD. Abnormal QRS axis was associated with a 34% (HR = 1.34 [CI 1.04-1.73]) increased mortality risk in patients with ChD, but not in individuals without ChD. Similarly, in the ChD group, abnormal T-wave axis was associated with a 35% (HR = 1.35 [CI 1.07-1.71]) increased mortality, but not in patients without ChD. In conclusion, abnormal P-wave, QRS, and T-wave axes were associated with increased all-cause mortality in patients with ChD. Abnormal P-wave axis was associated with mortality also among those without ChD, being the strongest predictor among ECG variables.


Assuntos
Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/fisiopatologia , Idoso , Brasil , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Prognóstico , Fatores de Risco
13.
Rev Port Cardiol ; 36(12): 927-934, 2017 Dec.
Artigo em Inglês, Português | MEDLINE | ID: mdl-29223851

RESUMO

BACKGROUND: Anaerobic threshold (AT) is recognized as objective and direct measurement that reflects variations in metabolism of skeletal muscles during exercise. Its prognostic value in heart diseases of non-chagasic etiology is well established. However, the assessment of risk of death in Chagas heart disease is relatively well established by Rassi score. But, the added value that AT can bring to Rassi score has not been studied yet. OBJECTIVES: To assess whether AT presents additional effect to Rassi score in patients with chronic Chagas' heart disease. METHODS: Prospective research of dynamic cohort by review of 150 medical records of patients. Were selected for cohort 45 medical records of patients who underwent cardiopulmonary exercise testing between 1996-1997 and followed until September 2015. Data analysis to detect association between studied variables can be seen using a logistic regression model. The suitability of the models was verified using ROC curves and the coefficient of determination R2. RESULTS: 8 patients (17.78%) died by September 2015, with 7 of them (87.5%) from cardiovascular causes, of which 4 (57.14%) were considered on high risk by Rassi score. With Rassi score as independent variable, and death being the outcome, we obtained an area under the curve (AUC)=0.711, with R2=0.214. Instituting AT as independent variable, we found AUC=0.706, with R2=0.078. When we define Rassi score and AT as independent variables, it was obtained AUC=0.800 and R2=0.263. CONCLUSION: when AT is included in logistic regression, it increases by 5% the explanation (R2) to the death estimation.


Assuntos
Limiar Anaeróbio , Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/fisiopatologia , Modelos Estatísticos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Saúde da População Urbana
14.
Circ Heart Fail ; 10(11)2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29141857

RESUMO

BACKGROUND: Chagas' disease is an important cause of cardiomyopathy in Latin America. We aimed to compare clinical characteristics and outcomes in patients with heart failure (HF) with reduced ejection fraction caused by Chagas' disease, with other etiologies, in the era of modern HF therapies. METHODS AND RESULTS: This study included 2552 Latin American patients randomized in the PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) and ATMOSPHERE (Aliskiren Trial to Minimize Outcomes in Patients With Heart Failure) trials. The investigator-reported etiology was categorized as Chagasic, other nonischemic, or ischemic cardiomyopathy. The outcomes of interest included the composite of cardiovascular death or HF hospitalization and its components and death from any cause. Unadjusted and adjusted Cox proportional hazards models were performed to compare outcomes by pathogenesis. There were 195 patients with Chagasic HF with reduced ejection fraction, 1300 with other nonischemic cardiomyopathy, and 1057 with ischemic cardiomyopathy. Compared with other etiologies, Chagasic patients were more often female, younger, and had lower prevalence of hypertension, diabetes mellitus, and renal impairment (but had higher prevalence of stroke and pacemaker implantation) and had worse health-related quality of life. The rates of the composite outcome were 17.2, 12.5, and 11.4 per 100 person-years for Chagasic, other nonischemic, and ischemic patients, respectively-adjusted hazard ratio for Chagasic versus other nonischemic: 1.49 (95% confidence interval, 1.15-1.94; P=0.003) and Chagasic versus ischemic: 1.55 (1.18-2.04; P=0.002). The rates of all-cause mortality were also higher. CONCLUSIONS: Despite younger age, less comorbidity, and comprehensive use of conventional HF therapies, patients with Chagasic HF with reduced ejection fraction continue to have worse quality of life and higher hospitalization and mortality rates compared with other etiologies. CLINICAL TRIAL REGISTRATION: PARADIGM-HF: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01035255; ATMOSPHERE: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00853658.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Cardiomiopatia Chagásica/complicações , Insuficiência Cardíaca/tratamento farmacológico , Idoso , Amidas/uso terapêutico , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Fármacos Cardiovasculares/efeitos adversos , Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/virologia , Feminino , Fumaratos/uso terapêutico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/virologia , Hospitalização , Humanos , Estimativa de Kaplan-Meier , América Latina , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Volume Sistólico/efeitos dos fármacos , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda/efeitos dos fármacos
15.
Arq Bras Cardiol ; 108(3): 246-254, 2017 Mar.
Artigo em Português, Inglês | MEDLINE | ID: mdl-28443956

RESUMO

BACKGROUND: Prognostic factors are extensively studied in heart failure; however, their role in severe Chagasic heart failure have not been established. OBJECTIVES: To identify the association of clinical and laboratory factors with the prognosis of severe Chagasic heart failure, as well as the association of these factors with mortality and survival in a 7.5-year follow-up. METHODS: 60 patients with severe Chagasic heart failure were evaluated regarding the following variables: age, blood pressure, ejection fraction, serum sodium, creatinine, 6-minute walk test, non-sustained ventricular tachycardia, QRS width, indexed left atrial volume, and functional class. RESULTS: 53 (88.3%) patients died during follow-up, and 7 (11.7%) remained alive. Cumulative overall survival probability was approximately 11%. Non-sustained ventricular tachycardia (HR = 2.11; 95% CI: 1.04 - 4.31; p<0.05) and indexed left atrial volume ≥ 72 mL/m2 (HR = 3.51; 95% CI: 1.63 - 7.52; p<0.05) were the only variables that remained as independent predictors of mortality. CONCLUSIONS: The presence of non-sustained ventricular tachycardia on Holter and indexed left atrial volume > 72 mL/m2 are independent predictors of mortality in severe Chagasic heart failure, with cumulative survival probability of only 11% in 7.5 years.


Assuntos
Cardiomiopatia Chagásica/complicações , Cardiomiopatia Chagásica/mortalidade , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Adulto , Fatores Etários , Função do Átrio Esquerdo/fisiologia , Pressão Sanguínea/fisiologia , Volume Cardíaco/fisiologia , Cardiomiopatia Chagásica/fisiopatologia , Creatinina/sangue , Métodos Epidemiológicos , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Sódio/sangue , Volume Sistólico/fisiologia , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Fatores de Tempo , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Teste de Caminhada
16.
Int. j. cardiovasc. sci. (Impr.) ; 30(2): f:145-l:156, mar.-abr. 2017. ilus, tab, graf
Artigo em Português | LILACS | ID: biblio-833920

RESUMO

Fundamento: A doença de Chagas é um problema de saúde global, sendo necessário o desenvolvimento de novos protocolos terapêuticos. Nosso grupo demonstrou recentemente que o nifurtimox associado ao dipiridamol tem efeitos curativos em camundongos com doença de Chagas aguda. Neste estudo, avaliamos o efeito deste protocolo terapêutico em camundongos chagásicos com insuficiência cardíaca. Objetivo: Avaliar se o nifurtimox e o dipiridamol são úteis no tratamento de resgate em camundongos com miocardite chagásica aguda com insuficiência cardíaca. Métodos: Foram divididos em três grupos 42 camundongos com miocardite chagásica aguda e insuficiência cardíaca congestiva: Controle Chagas (n = 11); Nif-Dip, tratados com nifurtimox e dipiridamol (n = 14); e Nif-Dip-Insuficiência Cardíaca, tratados com nifurtimox e dipiridamol, associados com digoxina, furosemida e captopril (n = 17). As doses de nifurtimox e dipiridamol foram de 40 e 30mg/kg/dia, respectivamente, durante 6 semanas. Os camundongos foram submetidos a avaliações clínicas, eletrocardiográficas, hemoparasitológicas e histopatológicas. Resultados: Observou-se menor mortalidade no Grupo Nif-Dip (n = 4; 28,57%) em relação ao Controle Chagas (n = 6; 54,54%) e ao Nif-Dip-Insuficiência Cardíaca (n = 9; 52,9%). Clinicamente, os camundongos tratados com nifurtimox e dipiridamol aumentaram o peso corporal e melhoraram a insuficiência cardíaca, sem mostrar esplenomegalia. Nestes grupos, foram erradicadas as parasitemias e os parasitas teciduais; a fibrose, a miocitólise, o infiltrado de células inflamatórias e os mastócitos diminuíram. Os distúrbios de repolarização, os intervalos QRS e o QT prolongados, o aumento da amplitude da onda S e a dissociação atrioventricular foram revertidos pelo tratamento. Conclusão: O tratamento com nifurtimox e dipiridamol pode ser usado no resgate em camundongos com doença chagásica aguda grave, já que o nifurtimox teve atividade tripanocida, e o dipiridamole potenciou seu efeito. O dipiridamol seria útil na insuficiência cardíaca chagásica


Background: Chagas disease is a global health problem; therefore, the development of new therapeutic protocols is necessary. Our group recently demonstrated that nifurtimox associated with dipyridamole has curative effects in mice with acute Chagas disease. In this study, we assess the effect of this therapeutic protocol in chagasic mice with heart failure. Objective: To evaluate whether nifurtimox and dipyridamole are useful to rescue mice with severe acute chagasic myocarditis with heart failure. Methods: 42 mice with acute chagasic myocarditis and congestive heart failure were divided into three groups: control chagas (n = 11), Nif-Dip treated with nifurtimox and dipyridamole (n = 14) and Nif-Dip-heart failure treated with nifurtimox and dipyridamole associated with digoxin, furosemide, and captopril (n = 17). Nifurtimox and dipyridamole doses were 40 and 30 mg/kg/day, respectively, for 6 weeks. Mice underwent clinical, electrocardiographic, hemoparasitological and histopathological assessments. Results: Lower mortality in Nif-Dip (28.57%; n = 4) compared to control chagas (54.54%; n = 6) and Nif-Dip-heart failure (52.9%; n = 9) was observed. Clinically, nifurtimox and dipyridamole-treated mice increased body weight and improved heart failure without splenomegaly. In these groups, parasitemia and tissue parasites were eradicated; fibrosis, myocytolysis, inflammatory cell infiltrate and mast cells decreased. Repolarization disorders, prolonged QRS and QT intervals, increase of S wave amplitude and atrioventricular dissociation were reversed by the treatment. Conclusion: Nifurtimox with dipyridamole can rescue NMRI mice from severe acute chagas disease, as nifurtimox showed trypanocidal activity and dipyridamole potentiated its effect. Dipyridamole would be useful in chagasic heart failure


Assuntos
Animais , Camundongos , Ratos , Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/fisiopatologia , Doença de Chagas/mortalidade , Doença de Chagas/fisiopatologia , Dipiridamol/administração & dosagem , Dipiridamol/uso terapêutico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Camundongos , Nifurtimox/administração & dosagem , Nifurtimox/uso terapêutico , Análise de Variância , Doença Crônica , Protocolos Clínicos/normas , Eletrocardiografia/métodos , Modelos Animais , Mortalidade , Estatística como Assunto/métodos
17.
Int J Cardiol ; 227: 577-582, 2017 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-27839809

RESUMO

BACKGROUND/OBJECTIVES: Up 30 to 40% of Chagas patients exhibit cardiomyopathy with different degrees of cardiac involvement. Biomarkers may help in differentiation of the severity of Chagas cardiomyopathy (CCM). This study sought to examine the diagnostic value of a panel of biomarkers to distinguish the severity of (CCM). METHODS: 100 patients with CCM were included in this cross-sectional study. Based on electrocardiogram and echocardiogram, CCM patients were classified in three stages according to disease's severity. Levels of high-sensitivity cardiac troponin T (Hs-cTnT), N-terminal pro B-type natriuretic peptide (NT-proBNP), galectin-3 (Gal-3), neutrophil gelatinase-associated lipocalin (NGAL), soluble ST2 (sST2) and cystatin-c (Cys-c) were measured. Logistic regression models were used to assess the association between levels of natural log-transformed values of biomarkers and stages C/D versus B. We also calculated the area under curve (AUC) for each of the models. RESULTS: In models adjusted for age, sex, body mass index, kidney function and medication use, increased levels of NT-proBNP (per 1 unit natural log-transformed values, odds ratio (OR)=5.55; 95CI%:1.65-18.72) and Hs-cTnT (per 1 unit natural log-transformed values, OR=7.11; 95CI%:1.41-35.90) showed significant association with the severity of CCM per 1 unit increase of biomarkers. The accuracy of NT-proBNP and Hs-cTnT for diagnosis of the severity of CCM was high: AUC of 0.968 and 0.956 respectively. No significant difference was found in the AUC between NT-proBNP and Hs-cTnT. No association was found between Gal-3, NGAL, sST2 and Cys-C and severity of CCM. CONCLUSIONS: NT-proBNP and Hs-cTnT have both same diagnostic value in distinguishing severity of CCM.


Assuntos
Cardiomiopatia Chagásica/sangue , Cardiomiopatia Chagásica/mortalidade , Eletrocardiografia , Galectina 3/sangue , Peptídeo Natriurético Encefálico/sangue , Troponina T/sangue , Adulto , Fatores Etários , Idoso , Área Sob a Curva , Biomarcadores/sangue , Cardiomiopatia Chagásica/tratamento farmacológico , Cardiomiopatia Chagásica/fisiopatologia , Estudos Transversais , Cistatina C/sangue , Progressão da Doença , Feminino , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fragmentos de Peptídeos/sangue , Projetos Piloto , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Taxa de Sobrevida
18.
Artigo em Inglês | MEDLINE | ID: mdl-27993857

RESUMO

Current treatments for chronic Chagas cardiomyopathy, a disease with high mortality rates and caused by the protozoan Trypanosoma cruzi, are unsatisfactory. Myocardial inflammation, including endothelial activation, is responsible for the structural and functional damage seen in the chronic phase. The clinical efficacy of benznidazole could be improved by decreasing chronic inflammation. Statins, which have anti-inflammatory properties, may improve the action of benznidazole. Here, the action of simvastatin in a murine model of chronic Chagas cardiomyopathy and the link with the production of the proresolving eicosanoid 15-epi-lipoxin A4, produced by 5-lipoxygenase, are evaluated. Simvastatin decreased the expression of the adhesion molecules E-selectin, intracellular adhesion molecule type 1 (ICAM-1), and vascular cell adhesion molecule type 1 (VCAM-1) in T. cruzi-infected mice. However, when this drug was administered to 5-lipoxygenase-deficient mice, the anti-inflammatory effect was not observed unless exogenous 15-epi-lipoxin A4 was administered. Thus, in chronic Chagas disease, 5-epi-lipoxin A4 induced by simvastatin treatment could improve the pathophysiological condition of patients by increasing the trypanocidal action of benznidazole.


Assuntos
Anticolesterolemiantes/farmacologia , Cardiomiopatia Chagásica/tratamento farmacológico , Nitroimidazóis/farmacologia , Parasitemia/tratamento farmacológico , Sinvastatina/farmacologia , Tripanossomicidas/farmacologia , Animais , Araquidonato 5-Lipoxigenase/deficiência , Araquidonato 5-Lipoxigenase/genética , Cardiomiopatia Chagásica/metabolismo , Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/parasitologia , Doença Crônica , Modelos Animais de Doenças , Quimioterapia Combinada , Selectina E/genética , Selectina E/metabolismo , Endotélio/efeitos dos fármacos , Endotélio/metabolismo , Endotélio/parasitologia , Regulação da Expressão Gênica , Humanos , Molécula 1 de Adesão Intercelular/genética , Molécula 1 de Adesão Intercelular/metabolismo , Lipoxinas/antagonistas & inibidores , Lipoxinas/metabolismo , Lipoxinas/farmacologia , Masculino , Camundongos , Camundongos Endogâmicos BALB C , Camundongos Knockout , Miocárdio/metabolismo , Miocárdio/patologia , Parasitemia/metabolismo , Parasitemia/mortalidade , Parasitemia/parasitologia , Análise de Sobrevida , Trypanosoma cruzi/efeitos dos fármacos , Trypanosoma cruzi/crescimento & desenvolvimento , Trypanosoma cruzi/patogenicidade , Molécula 1 de Adesão de Célula Vascular/genética , Molécula 1 de Adesão de Célula Vascular/metabolismo
19.
Microbes Infect ; 18(11): 675-686, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27416748

RESUMO

Chagasic cardiomyopathy, which is seen in Chagas disease, is the most severe and life-threatening manifestation of infection by the kinetoplastid Trypanosoma cruzi. Adipose tissue and diet play a major role in maintaining lipid homeostasis and regulating cardiac pathogenesis during the development of Chagas cardiomyopathy. We have previously reported that T. cruzi has a high affinity for lipoproteins and that the invasion rate of this parasite increases in the presence of cholesterol, suggesting that drugs that inhibit cholesterol synthesis, such as statins, could affect infection and the development of Chagasic cardiomyopathy. The dual epidemic of diabetes and obesity in Latin America, the endemic regions for Chagas disease, has led to many patients in the endemic region of infection having hyperlipidemia that is being treated with statins such as atorvastatin. The current study was performed to examine mice fed on either regular or high fat diet for effects of atorvastatin on T. cruzi infection-induced myocarditis and to evaluate the effect of this treatment during infection on adipose tissue physiology and cardiac pathology. Atorvastatin was found to regulate lipolysis and cardiac lipidopathy during acute T. cruzi infection in mice and to enhance tissue parasite load, cardiac LDL levels, inflammation, and mortality in during acute infection. Overall, these data suggest that statins, such as atorvastatin, have deleterious effects during acute Chagas disease.


Assuntos
Anticolesterolemiantes/administração & dosagem , Atorvastatina/administração & dosagem , Cardiomiopatia Chagásica/mortalidade , Dieta Hiperlipídica/efeitos adversos , Animais , Anticolesterolemiantes/efeitos adversos , Atorvastatina/efeitos adversos , Modelos Animais de Doenças , Masculino , Camundongos Endogâmicos C3H , Análise de Sobrevida , Resultado do Tratamento
20.
Arq Bras Cardiol ; 107(2): 99-100, 2016 Aug.
Artigo em Inglês, Português | MEDLINE | ID: mdl-27411097

RESUMO

BACKGROUND: The outcome of Chagas disease patients after receiving implantable cardioverter defibrillator (ICD) is still controversial. OBJECTIVE: To compare clinical outcomes after ICD implantation in patients with chronic Chagas cardiomyopathy (CCC) and ischemic heart disease (IHD). METHODS: Prospective study of a population of 153 patients receiving ICD (65 with CCC and 88 with IHD). The devices were implanted between 2003 and 2011. Survival rates and event-free survival were compared. RESULTS: The groups were similar regarding sex, functional class and ejection fraction. Ischemic patients were, on average, 10 years older than CCC patients (p < 0.05). Patients with CCC had lower schooling and monthly income than IHD patients (p < 0.05). The number of appropriate therapies was 2.07 higher in CCC patients, who had a greater incidence of appropriate shock (p < 0.05). Annual mortality rate and electrical storm incidence were similar in both groups. There was no sudden death in CCC patients, and only one in IHD patients. Neither survival time (p = 0.720) nor event-free survival (p = 0.143) significantly differed between the groups. CONCLUSION: CCC doubles the risk of receiving appropriate therapies as compared to IHD, showing the greater complexity of arrhythmias in Chagas patients.


Assuntos
Cardiomiopatia Chagásica/terapia , Desfibriladores Implantáveis/estatística & dados numéricos , Isquemia Miocárdica/terapia , Adulto , Idoso , Cardiomiopatia Chagásica/mortalidade , Estudos de Coortes , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/mortalidade , Estudos Prospectivos , Taxa de Sobrevida , Resultado do Tratamento
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