Post on 12-Jan-2016
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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)
ClasificaciónClasificación de la Miocardiopatía Chagásica Crónica 113
Grupo Hallazgos
I
Serología PositivoSíntomas Asintomático
ECG NormalRadiografía de tórax Normal
II
Serología PositivoSíntomas Sin evidencia de ICC
ECG
A: alteraciones de condución
B: Arrítmias ventricularesC: Ambas ( A + B)
Radiografía de Tórax Diámetro < 0.55
III
Serología PositivoSíntomas Evidencia de ICC
ECG Patológico
Radiografía de TóraxCardiomegalia. Diámetro >
0. 55Storino 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 StudiesChronic Chagasic Cardiomyopathy
Primary Idiopathic Dilated
CardiomyopathySerology for T. cruzi Positive NegativeMean age 48 40Clinical Findings NYHA Class II 26% 60% Symptom that
predominatesDyspnea 64% Dyspnea 100%
ECG findings RBBB + LAFBLBBB or incomplete
LBBB Afib or Aflutter 2% 26%Chest x-ray with cardiomegaly
Extreme 10% Extreme: 53%
Holter monitoringPVC: 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
dilatation87% 100%
Left ventricular diastolic diameter
63 mm 67 mm
Ventricular Aneurysm 30% 0%
Gamma CameraRegional hypokinesia
38%Global Hypokinesia
54%
Need of Pacemaker13% for trifascicular
block13% for 3° AV block
Annual Mortality5.2% (17% for 5 year
mortality)13%
* 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)
CountryMaterial and
MethodOutcome 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 days51 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) Brazil
91 Chagasic patients41 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)Brazil
21 acute chagasic patients113 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 literatureConsidered 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 mice8 infected mice treated with Bz18 healthy mice
Decrease in the parasite loadDecrease in ECG alterationsDecrease 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)Argentina
566 patients from 30 to 50 years old283 treated for 30 days with Bz283 untreated
15% negative seroconversion Significantly less progression to the disease (p0.002) and ECG alterations (p0.001) than the untreated group.
Bz treatment is associated with a reduced risk for progression of ChrChC.
Fabbro et al 88 (2007) Argentina
Total 111 patients.57 untreated.54 treated.Santa Fe (Argentina)
37% seroconversion (cured)27.8% decreased titers35.2% remained positive with constant titersFavorable clinical evolution in the treated group
This study favors the treatment of chronic Chagas disease.
Bern et al (2007) United States
Review of the literature Refer to text
CONCLUSION 1Treatment 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