Manoel Otávio da Costa Rocha UNIVERSIDADE FEDERAL DE MINAS GERAIS - FACULDADE DE MEDICINA PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA SAÚDE: INFECTOLOGIA.

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Manoel Otávio da Costa Rocha UNIVERSIDADE FEDERAL DE MINAS GERAIS - FACULDADE DE MEDICINA PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA SAÚDE: INFECTOLOGIA E MEDICINA TROPICAL

Morbidity and prognostic factors in chronic Chagas cardiopathy Medical and Social Relevance  Clinical importance of cardiac form  High morbidity and lethality  Few specific studies concerning its management

Peculiarities  Low socioeconomic status (Lopes et al., 1995)  Advanced stimulus conduction disorders  Increased frequency of PVCs and worse prognosis (Guerrero et al., 1985)  Intracardiac nervous system denervation (Oliveira, 1985)  Myocardial fibrosis (Barreto et al., 1997)  Ventricular aneurysms (Bestetti & Muccillo, 1997)  Thromboembolism (Carod-Artal et al., 2005) Morbidity and prognostic factors in chronic Chagas cardiopathy

What is the incidence of ischemic cerebrovascular events in patients with Chagas cardiomyopathy? What is the effect of the left ventricular ejection fraction on the risk for ischemic cerebrovascular events? Morbidity and prognostic factors in chronic Chagas cardiopathy

Thromboembolism Morbidity and prognostic factors in chronic Chagas cardiopathy J Neurol Sci. 2009;278:96-101

Thromboembolism Morbidity and prognostic factors in chronic Chagas cardiopathy J Neurol Sci. 2009;278:96-101

Thromboembolism Variable Patients without events n(%) Patients with previous stroke/TIA n(%) p value NYHA classes I-II133(76)29(74).720 Anticoagulation therapy32 (18)21 (54)<.001 LVEF36.7 ± ± Apical aneurysms67 (39)28 (72)<.001 Apical thrombus16(9)14(36)<.001 Baseline Characteristics of a Cohort of 213 Patients with Chagas Cardiomyopathy Morbidity and prognostic factors in chronic Chagas cardiopathy J Neurol Sci. 2009;278:96-101

Thromboembolism Morbidity and prognostic factors in chronic Chagas cardiopathy J Neurol Sci. 2009;278:96-101

Thromboembolism Variable Hazard ratio Beta coeffcient 95%CIp value LVEF ≤ 35% LA vol index (ml/m 2 ) Predictors of ischemic cerebrovascular events in the multivariate analysis Morbidity and prognostic factors in chronic Chagas cardiopathy J Neurol Sci. 2009;278:96-101

Thromboembolism Morbidity and prognostic factors in chronic Chagas cardiopathy J Neurol Sci. 2009;278:96-101

Thromboembolism Morbidity and prognostic factors in chronic Chagas cardiopathy J Neurol Sci. 2009;278:96-101

How is the right ventricle affected in Chagas cardiopathy? Morbidity and prognostic factors in chronic Chagas cardiopathy

Right ventricular involvement Morbidity and prognostic factors in chronic Chagas cardiopathy J Am Soc Echocardiogr. 2002;15:

Right ventricular involvement VariableControlChagasicp S (cm/s)14.5 ± ± IVCTr(ms)90.2 ± ± e’(cm/s)18.8 ± ± a’(cm/s)14.1 ± ± e’/a’ (cm/s)1.4 ± ± Comparison of Doppler tissue imaging in the right ventricle free wall between 12 control participants and 18 chagasic patients with normal echocardiogram s, Systolic flow velocity wave; IVCTr, regional isovolumic contraction time; e, early expansion velocity wave; a, late expansion velocity wave. Morbidity and prognostic factors in chronic Chagas cardiopathy J Am Soc Echocardiogr. 2002;15:

Right ventricular involvement Morbidity and prognostic factors in chronic Chagas cardiopathy J Am Soc Echocardiogr. 2002;15:

Right ventricular involvement Morbidity and prognostic factors in chronic Chagas cardiopathy Int J Cardiol. 2004;94:79-85

Right ventricular involvement Morbidity and prognostic factors in chronic Chagas cardiopathy Int J Cardiol. 2004;94:79-85

Right ventricular involvement Morbidity and prognostic factors in chronic Chagas cardiopathy Int J Cardiol. 2004;94:79-85

Right ventricular involvement Association between maximal velocity of the tricuspid regurgitation jet and involvement of the right ventricle Morbidity and prognostic factors in chronic Chagas cardiopathy Int J Cardiol. 2004;94:79-85 p < Max Vel TR (cm/s) Right ventricle

` Right ventricular involvement Association between left ventricular diastolic diameter and the degree of right ventricular involvement 1: normal 2: mildly enlarged 3: moderately enlarged 4: severely enlarged Morbidity and prognostic factors in chronic Chagas cardiopathy RV LVd n= 43 n= 15 n= 9 n= 7 Int J Cardiol. 2004;94:79-85 p<0.002 (mm)

What are the prognostic consequences of right ventricular involvement in chronic Chagas cardiopathy ? Morbidity and prognostic factors in chronic Chagas cardiopathy

Right ventricular involvement Morbidity and prognostic factors in chronic Chagas cardiopathy Int J Cardiol. 2008;127:372-9

Right ventricular involvement Morbidity and prognostic factors in chronic Chagas cardiopathy Int J Cardiol. 2008;127:372-9

Total Survivors (n=114) Non- survivors (n=44) Hazard Ratio (95% CI)p Age (years)48.5 ± ± ± (0.98–1.03)0.834 Male gender (n/%) 99 (63) 71 (62)28 (64)0.96 (0.51–1.79)0.895 NYHA class III–IV (n/%) 33 (21) 13 (11%)20 (45%)2.79 (2.03–3.83)0.001 Systolic BP (mm Hg) ± ± ± (0.95–0.98)0.002 Syncope (n/%)34 (22%) 18 (16%)16 (36%)1.91 (1.32–2.76)0.001 PVC (n/%)76 (48) 50 (44)26 (59)1.93 (1.33–2.79)0.001 LA diameter (mm)43.1 ± ± ± ( 1.08–1.16)0.001 LVDd/BSA (mm/m2)38.5 ± ± ± (1.12–1.23)0.001 LVEF (%)36.9 ± ± ± (0.87–0.92)0.001 LV Tei index0.71 ± ± ± (6.56–100.5)0.001 E/A ratio1.6 ± ± ± (1.43–2.49)0.001 Right ventricular involvement Baseline characteristics of the patients and parameters predictors of death in the univariate analysis Morbidity and prognostic factors in chronic Chagas cardiopathy Int J Cardiol. 2008;127:372-9

Hazard Ratio(95% CI)p NYHA classes III-IV LVEF (%) RV Tei index Right ventricular involvement Multivariate analysis of clinical and Doppler echocardiographic variables predicting death in Chagas cardiomyopathy Morbidity and prognostic factors in chronic Chagas cardiopathy Int J Cardiol. 2008;127:372-9

Right ventricular involvement Morbidity and prognostic factors in chronic Chagas cardiopathy Int J Cardiol. 2008;127:372-9

Does Chagas etiology imply a poorer prognosis when compared to other cardiomyopathies? Morbidity and prognostic factors in chronic Chagas cardiopathy

Chagasic vs. Idiopathic Without known etiology Ischemic heart disease excluded by angiography HF: 38 Sudden death: 35 Thromboembolism: 4 Non-cardiac death: 3 Dilatation with ventricular dysfunction Dilated cardiomyopathy n=169 Chagasic n=125 Follow-up mean: 44 ± 30 months Deaths 80 Idiopathic n=44 Two positive serum test (IIF, IH, ELISA) Morbidity and prognostic factors in chronic Chagas cardiopathy

Chagasic vs. Idiopathic VariableHRIC 95% P NYHA class III-IV – LV EF – RV Tei index – LA volume – Chagas etiology – Morbidity and prognostic factors in chronic Chagas cardiopathy Independent predictors of cardiac events in cohort of 169 patients with dilated cardiomyopathy

Chagasic vs. Idiopathic Morbidity and prognostic factors in chronic Chagas cardiopathy p=0.001 p<0.001

Chagasic vs. Idiopathic Chagas cardiomyopathy was associated with worse survival when compared to IDC, independent of other clinical factors and echocardiographic parameters of poor prognosis in HF Morbidity and prognostic factors in chronic Chagas cardiopathy

Chagasic vs. Idiopathic p<0.001 Morbidity and prognostic factors in chronic Chagas cardiopathy

Clinical relevance What can be done? Morbidity and prognostic factors in chronic Chagas cardiopathy Multicentric studies Risk stratification Identification of high-risk patients Identification of measures that could modify cardiac damage, functional heart impairment and prognosis

Thank you!