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Risk for CHD increases with Chagas disease
Early detection and monitoring of patients with Chagas disease may aid in treating these patients if they develop cardiac complications later in life, but more research is needed, according to an American Heart Association scientific statement published in Circulation.
Chagas disease is caused by the protozoan Trypanosoma cruzi, which is typically transmitted by about a dozen types of blood-sucking insects, according to the scientific statement. This disease also has the highest disease burden of any parasitic disease in the Western Hemisphere, including dilated cardiomyopathy with HF, stroke, ventricular arrhythmias and conduction disturbances, and other pulmonary or other systemic embolisms.
“This statement aims to increase global awareness among physicians who manage patients with Chagas disease outside of traditionally endemic environments,” Maria Carmo Pereira Nunes, MD, PhD, cardiologist at the Federal University of Minas Gerais in Belo Horizonte, Brazil, said in a press release. “This document will help health care providers and health systems outside of Latin America recognize, diagnose and treat Chagas disease and prevent further disease transmission.”
Cardiac inflammation
Acute Chagas disease results in inflammation of the heart, in addition to meninges, gastrointestinal tract, and central and peripheral nervous tissues. Cardiac enlargement involves all four chambers and may cause pericardial effusions.
The pathogenic of chronic Chagas heart disease is not completely understood, although two mechanisms — immune response from the parasite and autoreactivity from the infection — may initiate the disease state.
Most patients diagnosed with Chagas disease have loss of parasympathetic cardiac control before they develop myocardial dysfunction and may have impairment of coronary microcirculation control.
Microvascular deregulation may be caused by vascular endothelial cell damage, which is driven by the presence of the parasite or the immune system reaction.
Patients are typically asymptomatic throughout their life, although some may develop mild segmental wall motion abnormalities or conduction defects. Other patients may develop severe symptoms of thromboembolic phenomena, HF or ventricular arrhythmias that are life-threatening. Sudden cardiac death is also frequent in this patient population and manifests in the absence of symptoms of chronic Chagas cardiomyopathy.
Although predicting which patients will develop Chagas heart disease is a major topic of research, a common monitoring parameter is ECG. Research is also being performed to find an early serum biomarker. An increase in B-type natriuretic peptide has been shown to be an indicator of left ventricular systolic and diastolic dysfunction in patients with Chagas cardiomyopathy.
The majority of deaths in patients with Chagas disease is caused by Chagas cardiomyopathy. Chagas heart disease also manifests itself as arrythmias, HF and thromboembolism. Patients who are symptomatic typically present with those associated with HF, tachyarrhythmias, bradyarrhythmias, microvascular abnormalities and thromboembolic events.
“Early detection of Chagas disease is critical, allowing prompt introduction of therapy,” Nunes and colleagues wrote. “Moreover, identification of infection in blood and organs is crucial to evaluate suitability of a presumed donor for transfusion or transplantation.”
Monitoring patients
Patients should be assessed with ECG, Holter monitoring, chest X-ray, echocardiogram and stress test with ECG monitoring. Nuclear medicine tests can also provide information for these patients. Other tests that can be performed include cardiac MRI and cardiac catheterization.
Risk stratification scores should also be calculated in patients with Chagas disease, especially for stroke.
Patients who have Chagas heart disease can be treated with antitrypanosomal therapy. Antiarrhythmic drugs and implantable cardiac defibrillators can also be used in these patients, in addition to ablation therapy and pacemaker implantation. Warfarin has been indicated for patients with permanent or paroxysmal atrial fibrillation or LV systolic dysfunction.
“Although the pathogenesis of Chagas disease was first described > 100 years ago, it remains a largely neglected disease with insufficient diagnostic, therapeutic and prognostic advances,” Nunes and colleagues wrote. – by Darlene Dobkowski
Disclosures: Nunes reports no relevant financial disclosures. Please see the statement for all other authors’ relevant financial disclosures.