Mode of Death on Chagas Heart Disease: Comparison with Other Etiologies. A Subanalysis of the REMADHE Prospective Trial

Abstract

BackgroundSudden death has been considered the main cause of death in patients with Chagas heart disease. Nevertheless, this information comes from a period before the introduction of drugs that changed the natural history of heart failure. We sought to study the mode of death of patients with heart failure caused by Chagas heart disease, comparing with non-Chagas cardiomyopathy.Methods and resultsWe examined the REMADHE trial and grouped patients according to etiology (Chagas vs non-Chagas) and mode of death. The primary end-point was all-cause, heart failure and sudden death mortality; 342 patients were analyzed and 185 (54.1%) died. Death occurred in 56.4% Chagas patients and 53.7% non-Chagas patients. The cumulative incidence of all-cause mortality and heart failure mortality was significantly higher in Chagas patients compared to non-Chagas. There was no difference in the cumulative incidence of sudden death mortality between the two groups. In the Cox regression model, Chagas etiology (HR 2.76; CI 1.34–5.69; p = 0.006), LVEDD (left ventricular end diastolic diameter) (HR 1.07; CI 1.04–1.10; p<0.001), creatinine clearance (HR 0.98; CI 0.97–0.99; p = 0.006) and use of amiodarone (HR 3.05; CI 1.47–6.34; p = 0.003) were independently associated with heart failure mortality. LVEDD (HR 1.04; CI 1.01–1.07; p = 0.005) and use of beta-blocker (HR 0.52; CI 0.34–0.94; p = 0.014) were independently associated with sudden death mortality.ConclusionsIn severe Chagas heart disease, progressive heart failure is the most important mode of death. These data challenge the current understanding of Chagas heart disease and may have implications in the selection of treatment choices, considering the mode of death.Trial RegistrationClinicalTrails.gov NCT00505050 (REMADHE)

Decompensated chagasic heart failure versus non-chagasic heart failure at a tertiary care hospital: Clinical characteristics and outcomes

“…These authors also found reduced mortality from cerebrovascular accident, other non-cardiac causes of death and longer hospital stay while comparing chagasic and non-chagasic heart diseases patients. 16 In more severe cases of Chagas disease, the only treatment capable of modifying the natural history of disease is a heart transplant. Fiorelli et al conducted a review of 107 transplant patients with a focus on disease reactivation, rejection, and mortality.…”

Chagas disease: morbidity profile in an endemic area of Northeastern Brazil

“…In this context, CCC is associated with a worse prognosis and a survival rate that is one-half of the rates for cardiomyopathies of non-infl ammatory etiology (e.g., dilated cardiomyopathy and ischemic heart disease) (46) . Studies in Brazil and Venezuela have also reported that higher functional classes are associated with higher mortality rates among patients with CCC (47) (48) , with sudden death, heart failure, and ischemic stroke being the main mechanisms of death in patients with ChD (49) (50) . Our findings regarding electrocardiographic changes, such as RBBB and LAFB, are in agreement with the previous studies and are the most characteristic changes of the disease in endemic areas (51) .…”

The treatment of chronic heart failure secondary to Chagas cardiomyopathy in the contemporary era

“…45 Third, SCD affects mainly Chagas disease patients with mild to moderate CHF. 21 Fourth, activation of the sympathetic nervous system appears to occur first before that of the Renin-Aldosterone system. 49 Fifth, the probability that a Betablocker reaches the target dose following a targeted dose of ACEI is low.…”

“…16 Autopsy studies have revealed that pulmonary embolism may be found in up to 37% of patients who died of CHF secondary to Chagas cardiomyopathy. 20 Intractable pump failure appears to be the most important cause of death in patients with Chagas disease heart failure, mainly in those with advanced forms of the disease, 21 affecting up to 43% of patients with this condition.…”