Prevalence of Chagas Disease in a U.S. Population of Latin American Immigrants with Conduction Abnormalities on Electrocardiogram

Chagas Disease: Epidemiology, Diagnosis, and Treatment

PURPOSE OF REVIEW

This review seeks to describe the updates in the literature - particularly with regards to the epidemiology and diagnosis of Chagas disease. Additionally, this paper describes updates to the antiparasitic treatment for Chagas disease.

RECENT FINDINGS

With regards to changing epidemiology, autochthonous cases are being found within the USA in addition to Latin America. Additionally, there appears to be more intermixing of discrete typing units-meaning, they are not confined to specific geographic regions. Screening for Chagas disease is recommended in persons who lived in areas with endemic Chagas, persons wtih family member diagnosed with Chagas Disease, persons who have lived in homes of natural material in Latin America, and persons with history of kissing bug bites. Treatment for the parasitic infection remains limited to benznidazole and nifurtimox, and the role of these treatments in Chagas cardiomyopathy has not yet been definitively defined. Finally, indications for and management of heart transplant in the setting of Chagas disease are discussed.

FUTURE RESEARCH

Use of antiparasitics during chronic chagas disease should be further explored. Additionally, future research identifying other markers of infection would be valuable to defining cure from infection.

Clinical Characteristics and Outcomes of Chagas Disease in the United States: A Multicenter Retrospective Analysis

Chagas disease affects approximately 300,000 patients in the United States. We evaluated a multicenter U.S.-based network to obtain clinical characteristics and outcomes of chronic Chagas disease by disease forms. This was a U.S.-based, multicenter, population-based, retrospective cohort study. We queried TriNetX, a global research network, to identify patients with dual-positive IgG serology for Trypanosoma cruzi. We captured outcomes of interest for up to 5 years. We found 429 patients with evidence of dual-positive T. cruzi IgG out of 19,831 patients with an available test result from 31 U.S. medical centers. The positive proportion for those tested was 2.2%, up to 4.6% among Hispanics. We found a prevalence of a positive Chagas serology of 0.02% among Hispanics. Cardiomyopathy risk reached an annual rate of 1.3% during the initial 5 years of follow-up among patients with the indeterminate form. We found no new events for pulmonary embolism, sudden death, or left ventricular aneurysms at 5 years. Annual risks for arrhythmias and stroke for chronic Chagas cardiomyopathy (CCC) were 1.6% and 0.8%, respectively. The yearly mortality and hospitalization rates for CCC were 2.7% and 17.1%, respectively. Only 13 patients had a documented antitrypanosomal therapy course within 6 months after diagnosis. Of those receiving treatment, 10 patients received benznidazole and three nifurtimox. Chagas disease screening in patients from endemic areas living in the United States remains crucial. Chronic Chagas cardiomyopathy carries a considerable disease burden, translating into increased morbidity and mortality and an enlarging medical health service utilization.

Platinum and Palladium Organometallic Compounds: Disrupting the Ergosterol Pathway in Trypanosoma cruzi

Current treatment for Chagas' disease is based on two drugs, Nifurtimox and Benznidazol, which have limitations that reduce the effectiveness and continuity of treatment. Thus, there is an urgent need to develop new, safe and effective drugs. In previous work, two new metal-based compounds with trypanocidal activity, Pd-dppf-mpo and Pt-dppf-mpo, were fully characterized. To unravel the mechanism of action of these two analogous metal-based drugs, high-throughput omics studies were performed. A multimodal mechanism of action was postulated with several candidates as molecular targets. In this work, we validated the ergosterol biosynthesis pathway as a target for these compounds through the determination of sterol levels by HPLC in treated parasites. To understand the molecular level at which these compounds participate, two enzymes that met eligibility criteria at different levels were selected for further studies: phosphomevalonate kinase (PMK) and lanosterol 14-α demethylase (CYP51). Molecular docking processes were carried out to search for potential sites of interaction for both enzymes. To validate these candidates, a gain-of-function strategy was used through the generation of overexpressing PMK and CYP51 parasites. Results here presented confirm that the mechanism of action of Pd-dppf-mpo and Pt-dppf-mpo compounds involves the inhibition of both enzymes.

Seroprevalence of Chagas Disease among People of Latin American Descent Living in Suffolk County, Long Island, New York

This cross-sectional study estimated a one-time point seroprevalence rate of Chagas disease among people of Latin American descent in Suffolk County, Long Island, New York. Subjects who met the inclusion criteria were screened using the Chagas Detect Plus Rapid Test (InBios, Seattle, WA) with confirmation via Trypanosoma cruzi enzyme immunoassay and T. cruzi immunoblot assay. Administration of a questionnaire regarding demographics and risk factors followed. A seroprevalence rate of 10.74% was found. Identified risk factors included prior residence in a palm leaf house (odds ratio [OR], 10.42; P = 0.003; 95% CI, 2.18-49.76), residence in a house with triatomines (OR, 9.03; P = 0.006; 95% CI, 1.90-42.88), and history of triatomine bite (OR, 9.52; P = 0.009; 95% CI, 1.75-51.77). Our findings emphasize the importance of this frequently underdiagnosed disease and help highlight the importance of early screening among high-risk populations.

A Case of Chagas Cardiomyopathy in Western Virginia: Worlds Away?

Chagas cardiomyopathy, caused by the parasite Trypanosoma cruzi, is a significant cause of cardiac pathology worldwide. Though most frequently observed in Latin America, Chagas disease is present in the United States and should be considered in patients with heart block or other cardiac abnormalities and previous travel to or residence in endemic areas. Here we describe a new diagnosis of Chagas cardiomyopathy in a patient residing in Virginia with a previous residence in Mexico.

Chagas Heart Disease: Beyond a Single Complication, from Asymptomatic Disease to Heart Failure

Chagas cardiomyopathy (CC), caused by the protozoan Trypanosoma cruzi, is an important cause of cardiovascular morbidity and mortality in developing countries. It is estimated that 6 to 7 million people worldwide are infected, and it is predicted that it will be responsible for 200,000 deaths by 2025. The World Health Organization (WHO) considers Chagas disease (CD) as a Neglected Tropical Disease (NTD), which must be acknowledged and detected in time, as it remains a clinical and diagnostic challenge in both endemic and non-endemic regions and at different levels of care. The literature on CC was analyzed by searching different databases (Medline, Cochrane Central, EMBASE, PubMed, Google Scholar, EBSCO) from 1968 until October 2022. Multicenter and bioinformatics trials, systematic and bibliographic reviews, international guidelines, and clinical cases were included. The reference lists of the included papers were checked. No linguistic restrictions or study designs were applied. This review is intended to address the current incidence and prevalence of CD and to identify the main pathogenic mechanisms, clinical presentation, and diagnosis of CC.

Transplantation for chagas' disease: closing the knowledge gap

PURPOSE OF THE REVIEW

This review examines the most recent literature on the epidemiology and treatment of Chagas Disease and the risk of Chagas Disease Reactivation and donor-derived disease in solid organ transplant recipients.

RECENT FINDINGS

Chagas disease is caused by infection with the parasite Trypansoma cruzi . In nonendemic countries the disease is seen primarily in immigrants from Mexico, Central America and South America where the disease is endemic. Benznidazole or nifurtimox can be used for treatment. Posaconazole and fosravuconazole did not provide any additional benefit compared to benznidazole alone or in combination. A phase 2 randomized controlled trial suggests that shorter or reduced dosed regimes of benznidazole could be used. Based on a large randomized controlled trial, benznidazole is unlikely to have a significant preventive effect for established Chagas cardiomyopathy. Transplantation has become the treatment of choice for individuals with refractory Chagas cardiomyopathy. Cohort studies show similar posttransplant outcomes for these patients compared to other indications. Transplant candidates and donors with chronic T. cruzi infection are at risk for Chagas disease reactivation and transmitting infection. Screening them via serology is the first line of prevention. Recipients with chronic infection and those receiving organs from infected donors should undergo sequential monitoring with polymerase chain reaction for early detection of reactivation and preemptive treatment with antitrypanosomal therapy.

SUMMARY

Patients with chronic T. cruzi infection can be safely transplanted and be noncardiac organ donors.

Recommendations for Screening and Diagnosis of Chagas Disease in the United States

BACKGROUND

Chagas disease affects an estimated 326 000-347 000 people in the United States and is severely underdiagnosed. Lack of awareness and clarity regarding screening and diagnosis is a key barrier. This article provides straightforward recommendations, with the goal of simplifying identification and testing of people at risk for US healthcare providers.

METHODS

A multidisciplinary working group of clinicians and researchers with expertise in Chagas disease agreed on 6 main questions, and developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, after reviewing the relevant literature on Chagas disease in the United States.

RESULTS

Individuals who were born or resided for prolonged time periods in endemic countries of Mexico and Central and South America should be tested for Trypanosoma cruzi infection, and family members of people who test positive should be screened. Women of childbearing age with risk factors and infants born to seropositive mothers deserve special consideration due to the risk of vertical transmission. Diagnostic testing for chronic T. cruzi infection should be conducted using 2 distinct assays.

CONCLUSIONS

Increasing provider-directed screening for T. cruzi infection is key to addressing this neglected public health challenge in the United States.

Multiple Strokes in a Latin American Patient

We present a case of a recent immigrant from El Salvador without past medical history who presented to our hospital with symptoms concerning for acute stroke. Brain magnetic resonance imaging (MRI) with gadolinium confirmed an acute stroke along with multiple prior infarcts involving different vascular beds. Head magnetic resonance arteriogram did not reveal any occlusions/stenosis or aneurysmal changes. His subsequent extensive evaluation included an electrocardiogram (ECG) that revealed bifascicular block and echocardiography that suggested an apical aneurysm, but images were limited to assess. To further assess the likelihood of cardiac embolism, he underwent cardiac MRI with gadolinium, which confirmed the apical aneurysm. Because of his country of origin and classic ECG and echo findings, Chagas disease was suspected, and both commercial ELISA and confirmatory ELISA and TESA blots were positive. This is both a classic presentation of Chagas cardiomyopathy and an important reminder that Chagas disease should be considered in the differential diagnosis of cardioembolic stroke in Latin American immigrants from an endemic country.

Chagas Disease: Implementation of Screening to Benefit Mother and Infant

Pregnancy-based screening would identify women with Chagas disease, allowing for treatment of Trypanosoma cruzi-infected women and infants to prevent potentially fatal Chagas cardiomyopathy.

"You Don't Have a Normal Life": Coping with Chagas Disease in Los Angeles, California

Chagas disease is the neglected tropical disease of greatest public health impact in the United States, where it affects over 300,000 people. Diverse barriers limit healthcare access for affected people; fewer than 1% have obtained testing or treatment. We interviewed 50 people with Chagas disease in Los Angeles, California, and administered a cultural consensus analysis questionnaire. Participants were asked about their experiences and perceptions of Chagas disease, access to healthcare, and strategies for coping with the disease. In participants' narratives, the physical and emotional impacts of the disease were closely interwoven. Participant explanatory models highlight difficulties in accessing care, despite a desire for biomedical treatment. Obtaining testing and treatment for Chagas disease poses substantial challenges for US patients.

CRISPRing protozoan parasites to better understand the biology of diseases

Precise gene editing techniques are paramount to gain deeper insights into the biological processes such as host-parasite interactions, drug resistance mechanisms, and gene-function relationships. Discovery of CRISPR-Cas9 system has spearheaded mechanistic understanding of protozoan parasite biology as evident from the number of reports in the last decade. Here, we have described the use of CRISPR-Cas9 in understanding the biology of medically important protozoan parasites such as Plasmodium, Leishmania, Trypanosoma, Babesia and Trichomonas. In spite of intrinsic difficulties in genome editing in these protozoan parasites, CRISPR-Cas9 has acted as a catalyst for faster generation of desired transgenic parasites. Modifications in the CRISPR-Cas9 system for improving the efficiency have been useful in better understanding the molecular mechanisms associated with repair of double strand breaks in the parasites. Moreover, improvement in reagents used for CRISPR mediated gene editing have been instrumental in addressing the issue of non-specificity and toxicity for therapeutic use. These application-based modifications may help in further increasing the efficiency of gene editing in protozoan parasites.

Recognition and screening for Chagas disease in the USA

Chagas disease (CD), caused by the protozoan Trypanosoma cruzi, is a public health concern, mainly among countries in South and Central America. However, despite the large number of immigrants from endemic countries living in the USA, awareness of CD is poor in the medical community, and therefore it is significantly underdiagnosed. To avoid the catastrophic cardiac complications of CD and to prevent maternal-fetal transmission, widespread educational programs highlighting the need for diagnosis are urgently needed.

Early impairment of myocardial deformation assessed by regional speckle-tracking echocardiography in the indeterminate form of Chagas disease without fibrosis detected by cardiac magnetic resonance

Chagas disease (CD) will account for 200,000 cardiovascular deaths worldwide over the next 5 years. Early detection of chronic Chagas cardiomyopathy (CCC) is a challenge. We aimed to test if speckle-tracking echocardiography (STE) can detect incipient myocardial damage in CD. METHODS: Among 325 individuals with positive serological tests, 25 (age 55±12yrs) were selected to compose the group with indeterminate form of Chagas disease (IFCD), based on stringent criteria of being asymptomatic and with normal EKG/X-ray studies. This group was compared with a group of 20 patients with CCC (55±11yrs) and a group of 20 non-infected matched control (NC) subjects (48±10yrs). CD patients and NC were submitted to STE and CD patients were submitted to cardiac magnetic resonance (CMR) with late gadolinium administration to detect cardiac fibrosis by the late enhancement technique. Global longitudinal strain (GLS), circumferential (GCS) and radial strain (GRS) were defined as the average of segments measured from three apical view (GLS) and short axis views (GRS and GCS). Regional left ventricular (LV) longitudinal strain (Reg LS) was measured from each of the 17 segments. Twist was measured as systolic peak difference between basal and apical rotation and indexed to LV length to express torsion. RESULTS: STE global indices (GLS, GCS, twist and torsion) were reduced in CCC vs NC (GLS: -14±6.3% vs -19.3±1.6%, p = 0.001; GCS: -13.6±5.2% vs -17.3 ±2.8%; p = 0.008; twist: 8±7° vs 14±7°, p = 0.01 and torsion: 0.96±1°/cm vs 1.9±1°/cm, p = 0.005), but showed no differences in IFCD vs NC. RegLS was reduced in IFCD vs NC in four LV segments: basal-inferior (-16.3±3.3% vs -18.6±2.2%, p = 0.013), basal inferoseptal (-13.1±3.4 vs -15.2±2.7, p = 0.019), mid-inferoseptal (-17.7±3.2 vs -19.4±2, p = 0.032) and mid-inferolateral (-15.2±3.5 vs -17.8±2.8, p = 0.014). These abnormalities in RegLS occurred in the absence of myocardial fibrosis detectable with CMR in nearly 92% of subjects with IFCD, while myocardial fibrosis was present in 65% with CCC. CONCLUSION: RegLS detects early regional impairment of myocardial strain that is independent from fibrosis in IFCD subjects.

Regional longitudinal strain is reduced in IFCD before significant fibrosis. As CD progresses to CF, global STE measurements of left ventricle (GLS, GCS, twist and torsion) and GLS of right ventricle are reduced.

Early abnormal strain pattern of CD comprises inferior, septoinferior and inferolateral segments of LV. Recognizing the regional strain pattern of Chagas cardiomyopathy may help identifying the disease even at early stages.

Clinical Presentations of Chagas Cardiomyopathy

Chronic Chagas cardiomyopathy (CCC) is the most common cause of nonischemic cardiomyopathy in endemic Latin American countries. Immigrants to the United States suffer from this disease, but it is underrecognized. We describe the three hallmark clinical presentations: stroke, ventricular arrhythmias, and heart failure, which should prompt suspicion for CCC.

Chagas heart disease: A contemporary review

Chagas disease is caused by a parasite infection endemic of the Americas. Traditionally observed in rural areas of Latin America, current migration trends have turned Chagas disease into a global epidemic. Acute infection is rarely severe and once it resolves, some patients can develop cardiomyopathy as part of the chronic form many years later. Multiple factors related with both the host and the parasite determine the susceptibility and progression to cardiomyopathy. Current imaging techniques are able to identify cardiac autonomic denervation, perfusion abnormalities, and myocardial fibrosis at an early of stage before the development of symptoms. The prognosis of patients with Chagasic cardiomyopathy remains poor and life-threatening ventricular arrhythmias can occur at an early stage. Treatment of chronic Chagas cardiomyopathy is challenging with a great need for more studies in the field.

Use of tissue doppler imaging for the early detection of myocardial dysfunction in patients with the indeterminate form of Chagas disease

INTRODUCTION:

Chagas disease is one of the most common diseases in Latin America and heart involvement is the main cause of death. This study aimed to determine differences in tissue Doppler imaging (TDI) parameters in the assessment left and right ventricular function in patients with the indeterminate form of Chagas disease compared to those in healthy controls.

METHODS:

We compared 194 patients with the indeterminate form of Chagas disease to 72 age-matched healthy individuals. We considered p-values <0.05 to be statistically significant.

RESULTS:

TDI analysis of the right ventricular (RV) showed lengthened isovolumic relaxation time (IRT) and higher RV index of myocardial performance (RIMP) and left ventricle (LV) index of myocardial performance (LIMP) in the Chagas group than in the control group, indicating RV and LV systolic and diastolic myocardial damage. TDI analysis of the myocardial velocities of the interventricular septum and the lateral wall of the LV also showed a systolic and diastolic myocardial damage.

CONCLUSIONS:

The study results demonstrated early LV systolic and diastolic myocardial damage in the RV and LV in patients with the indeterminate form of Chagas disease by TDI. These early findings of RV and LV dysfunction may help identify patients who will progress to heart failure during the disease course. TDI should be included in initial patient evaluations because it allows adequate follow-up and treatment.

Translating Chagasic dilating cardiomyopathy to surgical therapies: An under published global challenge

Chagas disease is a neglected parasitic anthropozoonosis of the Americas linked to social deprivation with no hope of eradication in the future. Having been the most common non-ischemic cause of dilating cardiomyopathy in Latin America, it now spreads beyond the geographical boundaries of its vector via imported and autochthonous transmission. We review the evidence on surgery in Chagasic heart failure and offer a brief narrative on the main aspects of translational management. There is very limited literature on surgery for Chagasic heart failure, especially assist devices and transplantation. This may be attributed to the often unsurmountable economic burden of this single-system parasymphatholytic heart failure to young sufferers who commonly have very limited access to the aforementioned procedures. Chagasic heart failure offers a so far neglected translational model of parasymphatholytic non-ischemic cardiac failure.

Chagas Disease in the United States: a Public Health Approach

Trypanosoma cruzi is the etiological agent of Chagas disease, usually transmitted by triatomine vectors. An estimated 20 to 30% of infected individuals develop potentially lethal cardiac or gastrointestinal disease. Sylvatic transmission cycles exist in the southern United States, involving 11 triatomine vector species and infected mammals such as rodents, opossums, and dogs. Nevertheless, imported chronic T. cruzi infections in migrants from Latin America vastly outnumber locally acquired human cases. Benznidazole is now FDA approved, and clinical and public health efforts are under way by researchers and health departments in a number of states. Making progress will require efforts to improve awareness among providers and patients, data on diagnostic test performance and expanded availability of confirmatory testing, and evidence-based strategies to improve access to appropriate management of Chagas disease in the United States.

Evaluation and Management of Congenital Chagas Disease in the United States

Chagas disease is underappreciated as a health concern in the United States. Approximately 40 000 women of childbearing age living in the United States have chronic Chagas disease. Most of them are unaware that they have an infection that is transmissible to their offspring. The estimated US maternal-to-infant transmission rate of Trypanosoma cruzi is 1% to 5%. Ten percent to 40% of neonates with congenital T cruzi infection have clinical signs consistent with a congenital infection but no findings are unique to Chagas disease. If left untreated, 20% to 40% of infants with Chagas disease will later develop potentially fatal cardiac manifestations. Molecular testing can confirm the diagnosis in neonates. Treatment is well tolerated in infancy and usually results in cure. Screening of at-risk women during pregnancy can identify maternal infection and allow early assessment and treatment for congenital T cruzi infection.

State-of-the-art CRISPR/Cas9 Technology for Genome Editing in Trypanosomatids

CRISPR/Cas9 technology has revolutionized biology. This prokaryotic defense system against foreign DNA has been repurposed for genome editing in a broad range of cell tissues and organisms. Trypanosomatids are flagellated protozoa belonging to the order Kinetoplastida. Some of its most representative members cause important human diseases affecting millions of people worldwide, such as Chagas disease, sleeping sickness and different forms of leishmaniases. Trypanosomatid infections represent an enormous burden for public health and there are no effective treatments for most of the diseases they cause. Since the emergence of the CRISPR/Cas9 technology, the genetic manipulation of these parasites has notably improved. As a consequence, genome editing is now playing a key role in the functional study of proteins, in the characterization of metabolic pathways, in the validation of alternative targets for antiparasitic interventions, and in the study of parasite biology and pathogenesis. In this work we review the different strategies that have been used to adapt the CRISPR/Cas9 system to Trypanosoma cruzi, Trypanosoma brucei, and Leishmania spp., as well as the research progress achieved using these approaches. Thereby, we will present the state-of-the-art molecular tools available for genome editing in trypanosomatids to finally point out the future perspectives in the field.

Progression of Baseline Electrocardiogram Abnormalities in Chagas Patients Undergoing Antitrypanosomal Treatment

Background

The objective of the study was to better understand the impact of antitrypanosomal treatment on the evolution of Chagas-related, prognostically important electrocardiogram (ECG) abnormalities.

Methods

Initial and posttreatment ECGs were obtained in a prospective cohort of Chagas patients treated with nifurtimox or benznidazole and compared to an untreated cohort. Electrocardiogram disease progression was compared in those with and without baseline abnormalities pre- and posttherapy.

Results

Fifty-nine patients were recruited in the treatment arm and followed for an average of 3.9 years. There were no differences between ECG groups with regards to follow-up, age, baseline ejection fraction, or therapy. In the treated cohort, 0 of 30 patients with normal ECGs developed an abnormal ECG compared with 7 of 29 patients with baseline ECG abnormalities who developed new ECG abnormalities (P = .005). In an untreated cohort of 30 patients, 3 of 7 with normal ECGs developed an abnormality compared with 14 of 23 patients with baseline abnormalities (P = .67). Untreated patients had a higher likelihood of developing new EKG abnormalities (56.7% vs 11.9%, P < .001) despite shorter follow-up, and in a multivariate analysis adjusting for baseline EKG status across both treated and untreated cohorts, treated patients were still less likely to have progression of their EKG disease (odds ratio = 0.13, P < .001). The corrected QT (QTc) interval was not significantly affected by either study medication (415 vs 421 ms, initial vs posttreatment QTc; P = .06).

Conclusions

Over an average follow-up of 3.9 years, treated patients with normal baseline ECGs did not have significant changes during a course of treatment; however, those with baseline abnormal ECGs had significant progression of their conduction system disease despite treatment, and those without treatment also experienced a progression of ECG disease. These preliminary results suggest that Chagas patients with normal ejection fraction and normal ECG may benefit the most from antitrypanosomal treatment.

Relevance of Trypanothione Reductase Inhibitors on Trypanosoma cruzi Infection: A Systematic Review, Meta-Analysis, and In Silico Integrated Approach

Due to the rudimentary antioxidant defenses in Trypanosoma cruzi, disruptors of redox balance are promising candidates for new antitrypanosomal drugs. We developed an integrated model based on systematic review, meta-analyses, and molecular modeling to evaluate the effect of trypanothione reductase (TR) inhibitors in T. cruzi infections. Our findings indicated that the TR inhibitors analyzed were effective in reducing parasitemia and mortality due to Trypanosoma cruzi infection in animal models. The most investigated drugs (clomipramine and thioridazine) showed no beneficial effects on the occurrence of infection-related electrocardiographic abnormalities or the affinity and density of cardiac β-adrenergic receptors. The affinity between the tested ligands and the active site of TR was confirmed by molecular docking. However, the molecular affinity score was unable to explain TR inhibition and T. cruzi death in vitro or the antiparasitic potential of these drugs when tested in preclinical models of T. cruzi infection. The divergence of in silico, in vitro, and in vivo findings indicated that the anti-T. cruzi effects of the analyzed drugs were not restricted to TR inhibition. As in vivo studies on TR inhibitors are still scarce and exhibit methodological limitations, mechanistic and highly controlled studies are required to improve the quality of evidence.

Electrocardiographic abnormalities in Chagas disease in the general population: A systematic review and meta-analysis

BACKGROUND

Chagas disease (CD) is a major public health concern in Latin America and a potentially serious emerging threat in non-endemic countries. Although the association between CD and cardiac abnormalities is widely reported, study design diversity, sample size and quality challenge the information, calling for its update and synthesis, which would be very useful and relevant for physicians in non-endemic countries where health care implications of CD are real and neglected. We performed to systematically review and meta-analyze population-based studies that compared prevalence of overall and specific ECG abnormalities between CD and non-CD participants in the general population.

METHODS

Six databases (EMBASE, Ovid Medline, Web of Science, Cochrane Central, Google Scholar and Lilacs) were searched systematically. Observational studies were included. Odds ratios (OR) were computed using random-effects model.

RESULTS

Forty-nine studies were selected, including 34,023(12,276 CD and 21,747 non-CD). Prevalence of overall ECG abnormalities was higher in participants with CD (40.1%; 95%CIs=39.2-41.0) compared to non-CD (24.1%; 95%CIs=23.5-24.7) (OR=2.78; 95%CIs=2.37-3.26). Among specific ECG abnormalities, prevalence of complete right bundle branch block (RBBB) (OR=4.60; 95%CIs=2.97-7.11), left anterior fascicular block (LAFB) (OR=1.60; 95%CIs=1.21-2.13), combination of complete RBBB/LAFB (OR=3.34; 95%CIs=1.76-6.35), first-degree atrioventricular block (A-V B) (OR=1.71; 95%CIs=1.25-2.33), atrial fibrillation (AF) or flutter (OR=2.11; 95%CIs=1.40-3.19) and ventricular extrasystoles (VE) (OR=1.62; 95%CIs=1.14-2.30) was higher in CD compared to non-CD participants.

CONCLUSIONS

This systematic review and meta-analysis provides an update and synthesis in this field. This research of observational studies indicates a significant excess in prevalence of ECG abnormalities (40.1%) related to T. cruzi infection in the general population from Chagas endemic regions, being the most common ventricular (RBBB and LAFB), and A-V B (first-degree) node conduction abnormalities as well as arrhythmias (AF or flutter and VE). Also, prevalence of ECG alterations in children was similar to that in adults and suggests earlier onset of cardiac disease.

Chronic Chagas Heart Disease Management: From Etiology to Cardiomyopathy Treatment

Trypanosoma cruzi (T. cruzi) infection is endemic in Latin America and is becoming a worldwide health burden. It may lead to heterogeneous phenotypes. Early diagnosis of T. cruzi infection is crucial. Several biomarkers have been reported in Chagas heart disease (ChHD), but most are nonspecific for T. cruzi infection. Prognosis of ChHD patients is worse compared with other etiologies, with sudden cardiac death as an important mode of death. Most ChHD patients display diffuse myocarditis with fibrosis and hypertrophy. The remodeling process seems to be associated with etiopathogenic mechanisms and neurohormonal activation. Pharmacological treatment and antiarrhythmic therapy for ChHD is mostly based on results for other etiologies. Heart transplantation is an established, valuable therapeutic option in refractory ChHD. Implantable cardioverter-defibrillators are indicated for prevention of secondary sudden cardiac death. Specific etiological treatments should be revisited and reserved for select patients. Understanding and management of ChHD need improvement, including development of randomized trials.

Imaging Diagnosis of Right Ventricle Involvement in Chagas Cardiomyopathy

Right ventricle (RV) is considered a neglected chamber in cardiology and knowledge about its role in cardiac function was mostly focused on ventricular interdependence. However, progress on the understanding of myocardium diseases primarily involving the RV led to a better comprehension of its role in health and disease. In Chagas disease (CD), there is direct evidence from both basic and clinical research of profound structural RV abnormalities. However, clinical detection of these abnormalities is hindered by technical limitations of imaging diagnostic tools. Echocardiography has been a widespread and low-cost option for the study of patients with CD but, when applied to the RV assessment, faces difficulties such as the absence of a geometrical shape to represent this cavity. More recently, the technique has evolved to a focused guided RV imaging and myocardial deformation analysis. Also, cardiac magnetic resonance (CMR) has been introduced as a gold standard method to evaluate RV cavity volumes. CMR advantages include precise quantitative analyses of both LV and RV volumes and its ability to perform myocardium tissue characterization to identify areas of scar and edema. Evolution of these cardiac diagnostic techniques opened a new path to explore the pathophysiology of RV dysfunction in CD.