Miocardiopatía chagásica Dr Miocardiopatía chagásica Dr. José Milei VI Cátedra de Medicina Interna – Hospital de Clínicas – UBA Director del Instituto de Investigaciones Cardiológicas (ININCA) UBA-CONICET

Miocarditis crónica más frecuente del mundo Enfermedad parasitaria que más muertes causa en Latino América según la OMS. La enfermedad de Chagas continúa siendo un riesgo para la salud de aproximadamente 28 millones de personas, la mayoría latinoamericanos (OMS, 2005)

Clasificación de la Miocardiopatía Chagásica Crónica 113 Grupo Hallazgos I Serología Positivo Síntomas Asintomático ECG Normal Radiografía de tórax II Sin evidencia de ICC A: alteraciones de condución B: Arrítmias ventriculares C: Ambas ( A + B) Radiografía de Tórax Diámetro < 0.55 III Evidencia de ICC Patológico Cardiomegalia. Diámetro > 0. 55 Storino RA, Milei J et al, Clasificación Clínica de la miocardiopatía chagásica crónica e historia natural. Medicina (Bs. As) 1985;63:160

Una disociación A-V con unas ondas P claramente distinguibles e independientes de un ritmo QRS. Ondas P asociadas con complejos QRS alternantes que se identifica mejor en la derivación V1, se debe a un bloqueo retrógrado 2:1. Una relación de tipo 1:1 entre ondas P y los complejos QRS, con un intervalo RP corto. Disociación A-V, un impulso sinusal adecuadamente sincronizado de forma fortuita puede fusionarse con un complejo QRS ancho debido a la TV y producir un único ciclo de un complejo QRS alterado (habitualmente estrechado). Una duración del complejo QRS mayor de 0.14 segundos, como causa de la taquiarritmia con complejos QRS anchos. Complejos QRS coincidentemente positivos o negativos a lo largo de las derivaciones precordiales desde V1 a V6.

Pericardial effusion in chagasic myocarditis Apical aneurysm

Diagnóstico diferencial entre la ChrChC y DCM * Clinical Studies Chronic Chagasic Cardiomyopathy Primary Idiopathic Dilated Cardiomyopathy Serology for T. cruzi Positive Negative Mean age 48 40 Clinical Findings NYHA Class II 26% 60% Symptom that predominates Dyspnea 64% Dyspnea 100% ECG findings RBBB + LAFB LBBB or incomplete LBBB Afib or Aflutter 2% Chest x-ray with cardiomegaly Extreme 10% Extreme: 53% Holter monitoring PVC: 48% SB: 28% PVC: 50% Afib: 33% Heart Sounds High pitched holosystolic murmur: 46% S3: 31% High pitched holosystolic murmur: 58% S3: 75% Echocardiogram Left ventricular dilatation 87% 100% Left ventricular diastolic diameter 63 mm 67 mm Ventricular Aneurysm 30% 0% Gamma Camera Regional hypokinesia 38% Global Hypokinesia 54% Need of Pacemaker 13% for trifascicular block 13% for 3° AV block Annual Mortality 5.2% (17% for 5 year mortality) 13% Diagnóstico diferencial entre la ChrChC y DCM * * Storino RA, Milei J. Enfermedad de Chagas. Buenos Aires: Mosby-Doyma; 1994

Progresión de la enfermedad Storino RA, Milei J et al. Enfermedad de Chagas: Doce años de seguimiento en área urbana. Revista Argentina de Cardiología 1992;60:205-216

Tratamiento del Chagas Crónico* Author (year) Country Material and Method Outcome of treated group Conclusion de Andrade et al94 (1996) Brazil 129 seropositive children from 7 to 12 years old (resulted from screening of 1990 schoolchildren) 64 treated with benznidazole. 65 untreated Negative seroconversion in 55.8% Authors recommend the treatment of seropositive children. Sosa Estani et al 95 (1998) Argentina 106 children from 6 to 12 years old 55 treated with Bz for 60 days 51 untreated Negative serconversion in 62% 4.7% of the treated group had a positive xenodiagnosis versus a 51.2% in the placebo group. Infected children may successfully be treated with Bz. Lauria Pires et al92 (2000) 91 Chagasic patients 41 uninfected patients 100% of treated patients showed presence of the parasite by PCR. Not significant difference in between treated and untreated patients concerning ECG alterations and parasitemia levels. Treatment of chronic Chagas with nitroderivatives is unsatisfactory and cannot be recommended Cançado 86 (2002) 21 acute chagasic patients 113 chronic chagasic patients Cure in 8% of chronic chagasic patients and 76% of acute cases. Authors consider that Bz should be used in the treatment of chronic patients. Reyes et al 90 (2005) Review of the literature Considered a single double blind randomized clinical trial and 5 case control or case series. Treatment of chronic Chagas with these drugs is not sufficiently well supported. García et al 89 (2005) 8 infected mice 8 infected mice treated with Bz 18 healthy mice Decrease in the parasite load Decrease in ECG alterations Decrease in myocarditis Authors emphasize the importance of Bz in chronic chagasic patients in order to decrease or retard the development of ChrChC. Viotti et al 93 (2006) 566 patients from 30 to 50 years old 283 treated for 30 days with Bz 283 untreated 15% negative seroconversion Significantly less progression to the disease (p0.002) and ECG alterations (p0.001) than the untreated group. Bz treatment is associated with a reduced risk for progression of ChrChC. Fabbro et al 88 (2007) Total 111 patients. 57 untreated. 54 treated. Santa Fe (Argentina) 37% seroconversion (cured) 27.8% decreased titers 35.2% remained positive with constant titers Favorable clinical evolution in the treated group This study favors the treatment of chronic Chagas disease. Bern et al (2007) United States Refer to text

CONCLUSION 1 Treatment should always be offered (strength of recommendation graded A) in acute T cruzi infection, in early congenital T cruzi infection, children up to 18 years old with chronic T cruzi infection and in reactivated T cruzi infection in patients with HIV/AIDS or other immunosupression. Bern C, et al. Evaluation and Treatment of Chagas Disease in the United States. JAMA 2007;298(18):2171-81

CONCLUSION 2 Treatment must be discouraged in chronic chagasic cardiomyopathy because of the low chance of parasitological and serological cure, with dubious clinical benefits and intense side effects. Lack of randomized controlled clinical studies An important issue is the difficulty in evaluating the effectiveness of treatment, as the infection is very complex itself. It “would be” of utmost importance to conduct further studies to solve the controversy, employing non-invasive methods to better understand the cardiovascular status in chagasic patients and PCR methods to establish (or not) parasitological cure. Milei J. Treatment of chronic Chagas’ disease with current anti-parasitic drugs. World Congress of Cardiology 2008