Biomarkers, new imaging parameters prognostic of CV event-free survival in Chagas disease
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Key takeaways:
- 2D strain, 3D-derived parameters, BNP and positive T. cruzi PCR predicted poor survival in chronic Chagas disease.
- Prognostic value was independent of age, sex, 2D echo indexes, hypertension and more.
Researchers in Brazil identified new echocardiographic parameters and biomarkers prognostic of poor cardiac event-free survival among patients with chronic Chagas disease, which affects up to 7 million worldwide.
Markers included global left atrial strain, left ventricular global circumferential strain, LV torsion, 3D LV end-diastolic volume, brain natriuretic peptide (BNP) and positive Trypanosoma cruzi polymerase chain reaction (PCR), according to findings published in the Journal of the American Heart Association.
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“Chronic Chagas heart disease is an important cause of hospital admission due to decompensated HF, sudden cardiac arrest, arrhythmias needing cardiac device implantation, and stroke in endemic areas. Thus, Chagas disease is still considered one of the main challenges of global health, causing > 7,000 deaths per year, and the parasitic disease with the highest economic and health burden in the Western Hemisphere,” Veronica G. Mendes, PhD, of the Clinical Research Laboratory in Chagas Disease at the Evandro Chagas National Institute of Infectious Diseases in Rio de Janeiro, and colleagues wrote.
Chagas disease in South America and globally
According to a prior report published in Circulation in 2016, Chagas disease is caused by a parasite called T. cruzi, which is transmitted by biting insects called triatomine bugs or “kissing bugs.” According to the CDC, kissing bugs are nocturnal insects typically found in the southern U.S., Mexico, Central America and South America that feed on the blood of mammals.
WHO has labeled Chagas disease as endemic in areas of 21 Latin American countries, with an estimated 6 million to 7 million people worldwide infected with T. cruzi.
“Detection of the parasite in the bloodstream has been implicated in a worse clinical form and prognosis, both by hemoculture and molecular methods,” the researchers wrote. “However, few studies have explored in the same cohort the prognostic value of biomarkers and new echocardiographic techniques against traditional 2D Doppler echocardiographic parameters to try to understand if the addition of such tools to the patients’ workup would add to prognosis prediction in Chagas disease.”
Prediction of CV event-free survival
Therefore, Mendes and colleagues conducted the present single-center prospective study to identify biomarkers prognostic of worsening cardiac involvement in chronic Chagas disease. Biomarkers of interest included echocardiographic analyses of left atrial, LV and right ventricular strain; 3D analyses of left atrial and LV volume; cardiac troponin I, BNP, transforming growth factor-beta 1, tumor necrosis factor and matrix metalloproteinases; and T. cruzi PCR.
Chronic Chagas disease can present in four clinical forms, according to the study:
- The indeterminate form can last for years and affects 60% to 70% of the patients.
- The cardiac form — Chagas cardiomyopathy — has the worst prognosis.
- The digestive form is characterized by dilated esophagus and/or colon.
- The “cardio-digestive” form is when cardiac and digestive forms are present in the same patient.
The analysis included 361 patients with chronic Chagas disease (mean age, 61 years; 58% men). Overall, 27.1% of patients presented with the indeterminate form of Chagas disease, 56.6% with cardiac form, 3.6% with digestive form and 12.7% with cardio-digestive form.
The primary endpoint was a composite of Chagas-related mortality, heart transplant, HF hospitalization or new cardiac device insertion.
During an average of 4.9 years follow-up, the composite primary endpoint occurred in 79 patients.
The researchers reported that independent predictors of poor CV outcomes in chronic Chagas disease included LV end-diastolic volume (HR = 1.01; 95% CI, 1-1.02; P = .02), peak negative global atrial strain (HR = 1.08; 95% CI, 1-1.17; P = .04), LV global circumferential strain (HR = 1.12; 95% CI, 1.04-1.21; P = .003), LV torsion (HR = 0.55; 95% CI, 0.35-0.81; P = .003), BNP (HR = 2.03; 95% CI, 1.23-3.34; P = .005), and positive T. cruzi PCR (HR = 1.8; 95% CI, 1.12-2.91; P = .01).
“Left ventricular systolic and left atrial contractile strain parameters, 3-dimensional left ventricular volume, brain natriuretic peptide, and a positive T. cruzi quantitative polymerase chain reaction are predictors of survival free of cardiovascular events in chronic Chagas disease and represent potential tools to be incorporated in models of risk prediction in Chagas disease,” the researchers wrote. “The independent value of a positive T. cruzi quantitative polymerase chain reaction for cardiovascular outcome prediction suggests the importance of parasite persistence in Chagas disease pathophysiology and the need for further studies on trypanocidal treatment in chronic Chagas disease.”
References:
- Chagas disease (American trypanosomiasis). www.who.int/health-topics/chagas-disease#tab=tab_1. Accessed June 23, 2023.
- Kuehn BM. Circulation. 2016;doi:10.1161/CIRCULATIONAHA.116.024839.
- Parasites - American Trypanosomiasis (also known as Chagas Disease). www.cdc.gov/parasites/chagas/gen_info/vectors/index.html. Page last reviewed April 3, 2023. Accessed June 23, 2023.
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