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More effective prediction of mortality in Chagas heart disease patients? Importance of cardiopulmonary stress testing
Cardiopatia chagásica: predição mais eficaz de morte nestes doentes? Importância da prova de esforço cardiopulmonar
Luís Martins Brízida
Hospital Amadora-Sintra Prof. Doutor Fernando Fonseca, Serviço de Cardiologia, Unidade Cuidados Intensivos Cardíacos (UCIC), Amadora, Portugal
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Importance of cardiopulmonary stress testing" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "935" "paginaFinal" => "936" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Luís Martins Brízida" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Luís Martins" "apellidos" => "Brízida" "email" => array:1 [ 0 => "brizidaluis@yahoo.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Amadora-Sintra Prof. Doutor Fernando Fonseca, Serviço de Cardiologia, Unidade Cuidados Intensivos Cardíacos (UCIC), Amadora, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Cardiopatia chagásica: predição mais eficaz de morte nestes doentes? Importância da prova de esforço cardiopulmonar" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chagas disease, an infection caused by a protozoan parasite, <span class="elsevierStyleItalic">Trypanosoma cruzi</span>, is a major public health problem with a considerable global disease burden and costs. It is the third most prevalent serious parasitic infection worldwide after malaria and schistosomiasis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The disease is endemic in South America and incidence is high, with around 11 million infected individuals,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> despite efforts to fight the disease that have included extensive campaigns to eradicate the disease's insect vectors.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Large-scale migrations have enabled Chagas disease to cross borders and to spread worldwide. Since it can also be transmitted by blood transfusions and organ transplantation, it has become necessary to screen blood donors,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> particularly in the USA, where there are large immigrant populations, and in Europe, especially in Spain and Portugal, but also in other countries.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Cardiac involvement is found in 25-30% of cases,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> and it is reported that a third of infected patients in Brazil have Chagas cardiomyopathy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Prognosis is heavily dependent on the development of heart disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The mechanisms responsible for Chagas cardiomyopathy have been thoroughly studied. Three main processes are involved: inflammation, cell death and fibrosis. Various explanations have been put forward for this cardiomyopathy, including the neurogenic theory (development of parasympathetic disautonomy leading to sympathetic predominance and catecholamine toxicity), microvascular dysfunction, autoimmune reactions, and immune responses to surviving parasites, with lymphocyte infiltration into cardiac tissues.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3</span></a> These mechanisms lead to dilated cardiomyopathy and ventricular arrhythmias that may be malignant, sudden death, heart failure and thromboembolic phenomena.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Sudden death can occur in asymptomatic patients in the latent stage of the disease and is due to tachyarrhythmias – ventricular tachycardia and/or ventricular fibrillation – or more rarely bradyarrhythmias – complete atrioventricular block, asystole and sinus node disease. The incidence of sudden death is high; it is the cause of death in Chagas heart disease in 55-65% of cases.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The importance of sudden death in Chagas disease has prompted efforts to predict which individuals are at greater risk through the use of risk scores, enabling a more aggressive and interventionist approach to these patients.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The best-known is the Rassi score, described and validated in a paper by Anis Rassi and Maurício Scanavacca's group, published in the <span class="elsevierStyleItalic">NEJM</span> in 2006. It classified patients into three risk groups (low, intermediate and high) on the basis of six parameters: functional class, cardiomegaly, wall motion abnormalities, ventricular tachycardia on Holter, low QRS voltage, and male gender. Patients classified as high-risk should receive more aggressive, invasive treatment, particularly implantation of a cardioverter-defibrillator.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The authors of the study published in this issue of the <span class="elsevierStyleItalic">Journal</span>,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Silva et al. from Rio de Janeiro, aim to improve the discriminatory and predictive value of the Rassi score by introducing a new parameter, the anaerobic threshold, as assessed by cardiopulmonary exercise testing. They retrospectively studied 150 patients with evidence of Chagas cardiomyopathy, 45 of whom had undergone cardiopulmonary exercise testing with a cycle ergometer ramp protocol.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Their results show that introducing the anaerobic threshold as a parameter into a logistic regression model together with the Rassi score increased the score's predictive power for estimating mortality risk by 5%. The study population was a low-risk one, with little cardiac involvement, but even so the finding that reduced anaerobic threshold was associated with increased mortality risk is a significant one for this new parameter.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The authors explain their finding of the discriminatory power of this parameter in low-risk populations as being due to the detection of early impairment of right ventricular function and left ventricular diastolic function, parameters that have previously been described as indicating risk, before the eventual appearance of systolic dysfunction and left ventricular dilatation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">They highlight the importance of the anaerobic threshold and of functional capacity for the detection and assessment of early cardiac impairment in Chagas disease, and their significant clinical value.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Brízida LM. Cardiopatia chagásica: predição mais eficaz de morte nestes doentes? Importância da prova de esforço cardiopulmonar. Rev Port Cardiol. 2017;36:935–936.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on Chagas disease on the first centennial of its discovery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.J. Marin-Neto" 1 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 5 | 9 |
| 2024 October | 31 | 30 | 61 |
| 2024 September | 35 | 24 | 59 |
| 2024 August | 37 | 27 | 64 |
| 2024 July | 37 | 29 | 66 |
| 2024 June | 31 | 24 | 55 |
| 2024 May | 37 | 27 | 64 |
| 2024 April | 27 | 24 | 51 |
| 2024 March | 32 | 27 | 59 |
| 2024 February | 33 | 23 | 56 |
| 2024 January | 21 | 18 | 39 |
| 2023 December | 18 | 21 | 39 |
| 2023 November | 25 | 22 | 47 |
| 2023 October | 20 | 18 | 38 |
| 2023 September | 19 | 20 | 39 |
| 2023 August | 27 | 21 | 48 |
| 2023 July | 18 | 5 | 23 |
| 2023 June | 29 | 10 | 39 |
| 2023 May | 33 | 30 | 63 |
| 2023 April | 17 | 4 | 21 |
| 2023 March | 46 | 29 | 75 |
| 2023 February | 27 | 23 | 50 |
| 2023 January | 25 | 14 | 39 |
| 2022 December | 37 | 25 | 62 |
| 2022 November | 38 | 33 | 71 |
| 2022 October | 38 | 25 | 63 |
| 2022 September | 22 | 41 | 63 |
| 2022 August | 30 | 27 | 57 |
| 2022 July | 33 | 37 | 70 |
| 2022 June | 27 | 34 | 61 |
| 2022 May | 19 | 33 | 52 |
| 2022 April | 27 | 30 | 57 |
| 2022 March | 24 | 35 | 59 |
| 2022 February | 27 | 42 | 69 |
| 2022 January | 29 | 25 | 54 |
| 2021 December | 15 | 26 | 41 |
| 2021 November | 29 | 42 | 71 |
| 2021 October | 29 | 44 | 73 |
| 2021 September | 21 | 34 | 55 |
| 2021 August | 28 | 37 | 65 |
| 2021 July | 12 | 26 | 38 |
| 2021 June | 22 | 17 | 39 |
| 2021 May | 25 | 45 | 70 |
| 2021 April | 55 | 45 | 100 |
| 2021 March | 64 | 24 | 88 |
| 2021 February | 59 | 24 | 83 |
| 2021 January | 36 | 13 | 49 |
| 2020 December | 44 | 26 | 70 |
| 2020 November | 31 | 11 | 42 |
| 2020 October | 19 | 12 | 31 |
| 2020 September | 54 | 8 | 62 |
| 2020 August | 22 | 5 | 27 |
| 2020 July | 36 | 12 | 48 |
| 2020 June | 44 | 9 | 53 |
| 2020 May | 28 | 3 | 31 |
| 2020 April | 30 | 17 | 47 |
| 2020 March | 56 | 14 | 70 |
| 2020 February | 52 | 32 | 84 |
| 2020 January | 37 | 10 | 47 |
| 2019 December | 38 | 8 | 46 |
| 2019 November | 36 | 5 | 41 |
| 2019 October | 53 | 7 | 60 |
| 2019 September | 11 | 9 | 20 |
| 2019 August | 27 | 6 | 33 |
| 2019 July | 48 | 15 | 63 |
| 2019 June | 26 | 17 | 43 |
| 2019 May | 32 | 3 | 35 |
| 2019 April | 25 | 18 | 43 |
| 2019 March | 39 | 12 | 51 |
| 2019 February | 37 | 12 | 49 |
| 2019 January | 20 | 12 | 32 |
| 2018 December | 30 | 13 | 43 |
| 2018 November | 30 | 9 | 39 |
| 2018 October | 30 | 20 | 50 |
| 2018 September | 36 | 15 | 51 |
| 2018 August | 27 | 6 | 33 |
| 2018 July | 16 | 4 | 20 |
| 2018 June | 35 | 7 | 42 |
| 2018 May | 28 | 15 | 43 |
| 2018 April | 39 | 13 | 52 |
| 2018 March | 76 | 12 | 88 |
| 2018 February | 77 | 20 | 97 |
| 2018 January | 94 | 42 | 136 |
| 2017 December | 47 | 21 | 68 |
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