Review articleA rationale approach for mortality risk stratification in Chagas' heart disease
Introduction
Chagas' disease is one of the greatest health problems faced by many Latin American countries, in regions ranging from the southern United States to Argentina [1]. Cardiac disease is by far the most important clinicopathologic consequence of this disease [2]. Consequently, the social impact is very great [3]. On the other hand, as recently stressed by Factor [4]“…the similarity of Chagas' disease to other dilated congestive cardiomyopathies, particularly those due to viral etiology, should make awareness of this South and Central American disease relevant to investigators outside endemic areas. Finally, with travel facilitated by international jets, and immigration necessitated by economic, political, and social upheaval, it is mandatory that cardiovascular pathologists become more aware of this condition”.
Conventional therapy, similar to that for general congestive heart failure and cardiac arrhythmias, has been shown useful to ameliorate symptoms in chagasic patients. However, to this point, there have been no scientific guidelines for the specific treatment of patients with chronic chagasic cardiomyopathy. This may be accounted by the fact that only recently independent predictors of mortality for patients with Chagas' cardiomyopathy have been settled.
This review provides an overview of clinicopathological aspects of chronic Chagas' heart disease, and a comprehensive view of predictors of mortality for chagasic patients with Chagas' cardiopathy in an attempt to help physicians with the management of their patients.
Section snippets
Clinicopathologic aspects of chronic Chagas' heart disease
Chagas' disease is characterized by three phases: acute, indeterminate, and chronic 5, 6. The heart is the most severely and frequently involved organ. The degree of cardiac involvement during the acute phase varies from mild (asymptomatic or olygosymptomatic) to severe. The later involvement may be fatal, but this complication is infrequent and occurs in only 3–5% of the cases. Chronic Chagas' heart disease is the most serious and frequent manifestation of Chagas' disease, affecting about 10
Longitudinal studies
Several longitudinal studies have been conducted on unselected populations in different areas where Chagas' disease is endemic in an attempt to establish predictors of mortality for patients with Chagas' cardiomyopathy. Such studies have taken into consideration clinical, radiological and electrocardiographic findings. Neither echocardiographic studies, which could determine indices of myocardial contractility and myocardial chamber dimensions, nor 24-h Holter monitoring, which could assess the
Conclusions
On the basis of the facts outlined above, a rationale approach for stratifying chagasic patients according to risk factors for mortality is proposed (Fig. 4). In general unselected populations living in areas where the disease is endemic, a simple resting ECG should be performed in all patients with a positive serological test for Chagas' disease. Patients in NYHA class II or greater and asymptomatic patients who present abnormalities related to pathological Q waves and/or intraventricular
Acknowledgements
The authors wish to thank Maria Elena Riul, Lı́gia Santoro, Monica Abreu, Maria O. Rossi, and Júlio Matos for their excellent technical assistance. Professor Marcos A. Rossi is Senior Investigator of the Conselho Nacional de Desenvolvimento Cientı́fico e Tecnológico (CNPq). Supported in part by a grant to Professor Rossi from Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP 95/1634-3).
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