Elsevier

Cardiology Clinics

Volume 35, Issue 1, February 2017, Pages 31-47
Cardiology Clinics

Chagas Cardiomyopathy: Clinical Presentation and Management in the Americas

https://doi.org/10.1016/j.ccl.2016.08.013Get rights and content

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Key points

  • The diagnosis and treatment of Chagas disease require specific knowledge about the acute and chronic forms of the disease.

  • The initial Chagas infection is typically asymptomatic but after a decade or longer, approximately 30% of people will progress to a chronic cardiac form of Chagas cardiomyopathy with symptoms including heart failure, arrhythmias, and thromboembolism.

  • Death is often premature and sudden due to arrhythmias or progressive heart failure.

  • Prevention of infection through vector

Epidemiology

Chagas disease is a disease of poverty. It is on the World Health Organization’s (WHO) list of 17 neglected tropical diseases because it shares similar characteristics, such as particular geographic dispersion affecting populations with poor socioeconomic status; high morbidity and consequent mortality with significant socioeconomic impact; biomedical and psychosocial barriers to diagnosis, treatment, and control; and limited availability of resources and political priority. It is endemic to

Pathogenesis

The pathogenesis of Chagas heart disease involves a complex interaction of different processes (Fig. 2),17 related to tissue damage due to parasite persistence, inflammation, autoimmunity, fibrosis, dysautonomia, and microvascular changes.18, 19 After the acute, febrile phase, the T cruzi parasite hides in target tissues (namely the cardiac and digestive system muscles) and enters the chronic phase, almost always without clinical manifestations. However, a low-grade inflammation persists during

Clinical aspects of Chagas disease

Chagas disease presents classically as 2 different phases: acute and chronic. Each phase has different clinical characteristics, diagnostic criteria, and treatment. The most common symptoms in the various Chagas disease phases are listed in Table 1.

Diagnosis

The diagnosis of acute Chagas disease is made by the detection of the parasite in blood samples or by seroconversion. Enzyme-linked immunosorbent assay (ELISA), indirect immunofluorescence (IIF), indirect hemagglutination (IHA) test, and parasite polymerase chain reaction (PCR) are the most widely available tests. There are also rapid diagnostic tests that can directly detect the causative parasite, T cruzi.60 In the chronic phase, the parasitemia burden is lower and diagnosis often requires

Treatment

Treatment during the acute phase is recommended and associated with a near 100% cure rate with antitrypanosomal therapy.61 Currently available regimens include benznidazole and nifurtimox. Benznidazole 5 mg/kg per day (maximum 300 mg/24 hours) is given in 2 to 3 divided daily oral doses for 60 days in chronic cases (10 mg/kg per day in acute cases). In children younger than 12 years, the recommended dose is 8 to 10 mg/kg per day in 3 to 4 daily oral doses for 60 days. The side effect of

Prevention

Despite the enormous benefit of preventive therapy on the control of many neglected tropical diseases, unfortunately it does not work for Chagas disease. The most effective approaches are vector control programs in endemic areas, which require retaining political interest, public health resources, and financial commitments, as well as active surveillance and control programs. For nonvectoral transmission, maintaining universal screening for blood donors and organ transplantation donors and

Prognosis

Deaths are rare in the acute phase and most deaths attributable to Chagas disease result from downstream cardiovascular sequelae. Sudden death accounts for approximately 55% to 65% of deaths in patients with chronic Chagas and is likely underestimated due to underreporting, particularly in rural areas.13 It is more common in those with severe underlying heart disease and is precipitated by intense exercise. The main causes are VT or ventricular fibrillation, complete atrioventricular block, or

Summary

Chagas cardiomyopathy is a chronic condition and remains a significant cause of morbidity and mortality in Latin America. The diagnosis and treatment require specific knowledge about the acute and chronic forms of the disease. Chronic Chagas cardiomyopathy manifests as disorders of the heart’s conduction system, heart failure, or pulmonary or cerebrovascular embolisms, leading to premature mortality and perpetuates the cycle of poverty in those affected. A strong surveillance system is required

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      Citation Excerpt :

      CD is asymptomatic in the vast majority of patients during the acute phase, but chronic infection will manifest as a multisystem disease affecting mainly the cardiovascular and digestive systems. Chagas cardiomyopathy is the leading cause of nonischemic cardiomyopathy (NICM) in Latin America and affects around 30% of infected patients.1,2 The foremost characteristics are a diffuse myocarditis with focal fibrosis, mainly located in the apex and basal segments of the posterior and inferior wall, as well as left ventricular hypertrophy.

    View all citing articles on Scopus

    Disclosures: The authors have nothing to disclose.

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