ContextBecause of population migration from endemic areas and newly instituted blood bank screening, US clinicians are likely to see an increasing number of patients with suspected or confirmed chronic Trypanosoma cruzi infection (Chagas disease).ObjectiveTo examine the evidence base and provide practical recommendations for evaluation, counseling, and etiologic treatment of patients with chronic T cruzi infection.Evidence AcquisitionLiterature review conducted based on a systematic MEDLINE search for all available years through 2007; review of additional articles, reports, and book chapters; and input from experts in the field.Evidence SynthesisThe patient newly diagnosed with Chagas disease should undergo a medical history, physical examination, and resting 12-lead electrocardiogram (ECG) with a 30-second lead II rhythm strip. If this evaluation is normal, no further testing is indicated; history, physical examination, and ECG should be repeated annually. If findings suggest Chagas heart disease, a comprehensive cardiac evaluation, including 24-hour ambulatory ECG monitoring, echocardiography, and exercise testing, is recommended. If gastrointestinal tract symptoms are present, barium contrast studies should be performed. Antitrypanosomal treatment is recommended for all cases of acute and congenital Chagas disease, reactivated infection, and chronic T cruzi infection in individuals 18 years or younger. In adults aged 19 to 50 years without advanced heart disease, etiologic treatment may slow development and progression of cardiomyopathy and should generally be offered; treatment is considered optional for those older than 50 years. Individualized treatment decisions for adults should balance the potential benefit, prolonged course, and frequent adverse effects of the drugs. Strong consideration should be given to treatment of previously untreated patients with human immunodeficiency virus infection or those expecting to undergo organ transplantation.ConclusionsChagas disease presents an increasing challenge for clinicians in the United States. Despite gaps in the evidence base, current knowledge is sufficient to make practical recommendations to guide appropriate evaluation, management, and etiologic treatment of Chagas disease.

/pdf/evaluation-and-treatment-of-chagas-disease-in-the-united-3i0ib63hn5.pdf

Evaluation and treatment of chagas disease in the United States : A systematic review

BACKGROUND Chagas’ disease is an important health problem in Latin America, and cardiac involvement is associated with substantial morbidity and mortality. We developed a model to predict the risk of death in patients with Chagas’ heart disease. METHODS We retrospectively evaluated 424 outpatients from a regional Brazilian cohort. The association of potential risk factors with death was tested by Cox proportional-hazards analysis, and a risk score was created. The model was validated in 153 patients from a separate community hospital. RESULTS During a mean follow-up of 7.9 years, 130 patients in the development cohort died. Six independent prognostic factors were identified, and each was assigned a number of points proportional to its regression coefficient: New York Heart Association class III or IV (5 points), evidence of cardiomegaly on radiography (5 points), left ventricular systolic dysfunction on echocardiography (3 points), nonsustained ventricular tachycardia on 24-hour Holter monitoring (3 points), low QRS voltage on electrocardiography (2 points), and male sex (2 points). We calculated risk scores for each patient and defined three risk groups: low risk (0 to 6 points), intermediate risk (7 to 11 points), and high risk (12 to 20 points). In the development cohort, the 10-year mortality rates for these three groups were 10 percent, 44 percent, and 84 percent, respectively. In the validation cohort, the corresponding mortality rates were 9 percent, 37 percent, and 85 percent. The C statistic for the point system was 0.84 in the development cohort and 0.81 in the validation cohort. CONCLUSIONS A simple risk score was developed to predict death in Chagas’ heart disease and was validated in an independent cohort.

https://www.nejm.org/doi/pdf/10.1056/NEJMoa053241

Development and validation of a risk score for predicting death in Chagas' heart disease.

The intent of this American Heart Association (AHA) scientific statement is to summarize our current understanding of dilated cardiomyopathies. There is special emphasis on recent developments in diagnostic approaches and therapies for specific cardiomyopathies. Recommendations in this document are based on published studies, published practice guidelines from the American College of Cardiology (ACC)/AHA1 and other organizations,2,3 and the multidisciplinary expertise of the writing group. Existing evidence in epidemiology, classification, diagnosis, and management of specific cardiomyopathies is usually derived from nonrandomized observational studies, registries, case reports, or expert opinion based on clinical experience, not large-scale randomized clinical trials or systematic reviews. Therefore, in this document, rather than using the standard ACC/AHA classification schema of recommendations and level of evidence,4 we have included key management strategies at the end of each section and categorized our recommendations according to the level of consensus. Although the format of our recommendations might resemble the ACC/AHA classification of recommendations used in the ACC/AHA practice guidelines, because of the preponderance of expert opinion or level of evidence C evidence in our document, we elected to use different terminology to provide a distinction from the practice guidelines, in which stronger levels and quality of evidence with randomized clinical trials or meta-analyses are usually present.4 The levels of evidence follow the AHA and ACC methods of classifying the level of certainty of the treatment effect.4

The term dilated cardiomyopathy (DCM) refers to a spectrum of heterogeneous myocardial disorders that are characterized by ventricular dilation and depressed myocardial performance in the absence of hypertension, valvular, congenital, or ischemic heart disease.5

In clinical practice, the pathogenesis of heart failure (HF) has often been placed into 2 categories: ischemic and nonischemic cardiomyopathy. The term nonischemic cardiomyopathy has been interchangeably used with DCM. Although this …

Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association.

Chagas disease: an overview of clinical and epidemiological aspects.

Background— Chagas disease is a major cause of morbidity and mortality in Latin America. Knowledge of the predictors of prognosis can help clinical decision making by identifying patients’ level of risk. Methods and Results— We reviewed the published literature on prognostic factors in patients with Chagas disease by performing a PubMed search for articles published in any language between 1985 and February 2006 and hand searches of the reference lists of retrieved articles. Studies were selected if they included patients in the chronic phase of Chagas disease, analyzed a clearly defined outcome (all-cause mortality, sudden cardiac deaths, and/or cardiovascular deaths), and used multivariable regression models of prognosis. From 606 potentially relevant studies, 12 met the inclusion criteria: 8 clinic-based studies including 3928 patients and 4 hospital-based studies including 349 patients. Impaired left ventricular function by echocardiogram or cineventriculogram was found to be the most common and consi...

Predictors of mortality in chronic Chagas disease: a systematic review of observational studies.

Prognostic implications of clinical, electrocardiographic and hemodynamic findings in chronic Chagas' disease

Ventricular arrhythmias and left ventricular myocardial function in chronic chagasic patients.

Purpose To determine the prognostic significance of several parameters of left ventricular mechanics and of complex ventricular arrhythmias. Patients and methods 184 chronic chagasic and 85 primary dilated cardiomyopathy patients were submitted to non-invasive and invasive studies, including Holter monitoring and "M" mode echocardiogram and followed for a maximum of 8 years. Results Finding of a depressed left ventricle (LV) systolic function (% AC) was the most important independent prognostic factor in both groups of patients. The presence of complex ventricular arrhythmias had an additional, but very limited, independent prognostic importance, observed only in chagasic patients with depressed LV systolic function. When patients with similar degrees of left ventricular systolic dysfunction, inadequate hypertrophy or increased afterload were compared, chagasic patients had significantly worse prognosis than those with primary dilated cardiomyopathy. This is partly attributed to higher prevalence of complex ventricular arrhythmias. Conclusion The higher prevalence of complex ventricular arrhythmias in patients with chronic Chagas' disease may explain the prognostic differences between the groups.

[Ventricular mechanics and cardiac arrhythmias in patients with chagasic and primary dilated cardiomyopathy. Echo-electrocardiographic follow-up].

With the purpose of establishing clinical and paraclinical differences among chronic chagasic (MCh) and primary dilated cardiomyopathies (MCDP), 96 MCh and 104 MCDP patients with abnormal ECG were submitted to a study protocol which included clinical history, routine laboratory serology for Chagas' diseases, resting ECG, Chest-X-rays, and cardiac catheterisation. Patients with congestive heart failure (CHF) had common clinical and para-clinical findings. However, chagasic patients without CHF showed more prevalence of RBBB and LAH, complex ventricular arrhythmias and more left ventricular dilation while primary dilated cardiomyopathy patients with CHF had predominantly LBBB, simple ventricular arrhythmias, atrial fibrillation and less LV dilation than MCh patients. In order to establish the prognostic value of these findings and response to modern medical therapy, prospective studies on these two groups of patients are needed.

Lourdes Guerrero

Papers

Prognostic implications of clinical, electrocardiographic and hemodynamic findings in chronic Chagas' disease

Ventricular arrhythmias and left ventricular myocardial function in chronic chagasic patients.

[Ventricular mechanics and cardiac arrhythmias in patients with chagasic and primary dilated cardiomyopathy. Echo-electrocardiographic follow-up].

[Clinical and paraclinical differences between chronic Chagas' cardiomyopathy and primary dilated cardiomyopathies].

Diferencias clinicas y paraclinicas entre la miocardiopatia chagásica cronica y las miocardiopatias dilatadas primarias