Chagas' cardiomyopathy: The economic burden of an expensive and neglected disease
Introduction
In times of economic crises around the world, the cost of disease knowledge is of utmost importance in order to plan healthcare actions. The importance of heart failure (HF) is that this disease continues to be among the most prevalent high mortality and morbidity diseases around world. Besides that, the need of resources for treating this disease requires significant proportion of overall healthcare budget in a lot of countries [1], [2], [3], [4], [5]. The so called “industrialized world” is more frequently used to dealing with an elderly population of patients whose diseases are mainly resulted from ischemic and hypertensive etiologies for HF [6]. Chagas' cardiomyopathy (CC) is a rising etiology for HF that previously was restricted to some countries of Latin America [7]. This disease results from a long term, chronic, systemic, parasitic infection caused by the protozoan Trypanosoma cruzi. It affects about 18 million people in Latin America [7]. Although it can be severe, acute cardiac form of the disease is not usually seen. The major problem happens in about 20–35% of the infected patients who develop the chronic disease that can primarily damage heart, digestive system, or both many years after the infection [8], [9]. Other complications are seen due to heart failure, mural thrombus, left ventricular apical aneurysm, and several types of cardiac arrhythmias, causing stroke [10]. Certainly, the cardiomyopathy, that evolutes to congestive heart failure is the worst condition and leads to high level of disabling sequelae. Early diagnose of the cardiac disease may not change the chronic evolution of the disease because at this phase drugs against the protozoan are not proven yet as effective to prevent the development of heart failure and/or arrhythmias. The world health organization (WHO) considers it a neglected tropical diseases according to the definition “…Chronically endemic and epidemic-prone tropical diseases, which have a very significant negative impact on the lives of poor populations [and] remain critically neglected in the global public health agenda” [11].
Due to national health authorities' control activities, the domestic and peridomestic cycles of transmission involving vectors, animal reservoirs and human in countries like Argentina, Chile, Brazil, and Uruguay were almost finished [7]. In the past, the lack of screening in blood banks was also an important form of contamination. However, many countries totally interrupted this kind of transmission in Latin America [7], [8].
Nowadays, the main reason for the spread of Chagas' disease is immigration that brought the parasite to North America and Europe [12], [13]. As the other neglected diseases, Chagas' disease has become an international health problem [11]. It needs to be cared for, not only in poor areas where basic health could prevent the epidemics but also in rich places where very sick patients demand for highly complex medical treatments [13], [14]. An example of this paradox is seen in many Sao Paulo cardiology centers that are located at a rich area of Brazil.
Nowadays, even with the reduction of cases described above, the chronic CC cases may cause a profound socio-economic impact. The reason for that is because many of the numerous infected people still may develop the disease. However the burden of this disease has not been well studied if compared to other causes of HF. Thus, we decided to focus on in-patients because the major part of resources to treat this disease is spent during these admissions. Our objective was to assess the cost burden of CC during acute decompensated HF (ADHF) admissions, and compare this cost to the other etiologies of HF.
Section snippets
Methods
By the end of 2006, after Ethical Commission Board approval (and complying with the Declaration of Helsinki) we started a five year follow-up of 577 consecutive adult patients admitted at a high complexity cardiology university hospital in the city of Sao Paulo, Brazil.
Patients with diagnosis of symptomatic heart failure due to either systolic or diastolic dysfunction that needed emergency or urgency care were enrolled in this study. All of the 577 records had the ADHF diagnosis confirmed, 58
Results
Non-chagasic patients were older and had more non-cardiac co-morbidities. Diabetes and renal dysfunction were more frequent in non-chagasic patients. Although coronary disease was more frequent in non-chagasic group, around 8% of the CC patients had history of coronary disease too. The prevalence of previous stroke was similar in both groups, but CC patients had more documented left ventricular clots. Comorbidity Charlson Index was higher in non-chagasic group. Regarding cardiac history, CC
Discussion
Our investigation provides data from a “real world” found in a university hospital in São Paulo, but may be taken as similar in many other cities in Brazil. High complexity is also a feature of this heart hospital. The reason for evaluating ADHF patients is because those admissions correspond to the main part of the resources used to treat HF patients.
The main attribute of our population is the severity of its sickness. The high rates of mortality in this population could be explained by the
References (32)
- et al.
2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation
J Am Coll Cardiol
(2009) - et al.
Chagas disease: a Latin American health problem becoming a world health problem
Acta Trop
(2010) - et al.
Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure
J Am Coll Cardiol
(2003) - et al.
Risk stratification in a Brazilian hospital-based cohort of 1220 outpatients with heart failure: role of Chagas' heart disease
Int J Cardiol
(2005) - et al.
High prevalence of renal dysfunction and its impact on outcome in 118,465 patients hospitalized with acute decompensated heart failure: a report from the ADHERE database
J Card Fail
(2007) - et al.
In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE)
J Am Coll Cardiol
(2005) - et al.
The paradox of survival results after heart transplantation for cardiomyopathy caused by Trypanosoma cruzi. First Guidelines Group for Heart Transplantation of the Brazilian Society of Cardiology
Ann Thorac Surg
(2001) - et al.
Hospitalizations after heart failure diagnosis a community perspective
J Am Coll Cardiol
(2009) - et al.
The Fourth INTERMACS Annual Report: 4,000 implants and counting
J Heart Lung Transplant
(2012) - et al.
Sociedasde Brasileira de Cardiologia. III Brazilian Guidelines on Chronic Heart Failure
Arq Bras Cardiol.
(2009)
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008
Eur Heart J
Lifetime risk for developing congestive heart failure. The Framingham Heart Study
Circulation
Heart failure: the commonest reason for hospital admission in Germany medical and economic perspectives
Dtsch Arztebl Int
Heart failure in the 21st century: is it a coronary artery disease problem or hypertension problem?
Cardiol Clin
Current epidemiological trends for Chagas disease in Latin America and future challenges in epidemiology, surveillance and health policy
Mem Inst Oswaldo Cruz
Chagas disease
Lancet
Cited by (0)
- 1
Heart Failure Department, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
- 2
This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
- 3
New Technologies Evaluation Department, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
- 4
Information Technology Department, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.