Arq Bras CardiolabcArquivos Brasileiros de CardiologiaArq. Bras. Cardiol.0066-782X1678-4170Sociedade Brasileira de Cardiologia - SBC4wZSrKQQYxHskdvwJ7yJNPfS0066-782X20250005002070020710.36660/abc.20250332abc.20250332MinieditorialInsuficiência Cardíaca por Doença de Chagas: Desafio ainda a Ser Vencido no Século 210000-0002-2263-4261SaraivaRoberto M.1PortelaLuciana F.1CostaAndréa R.1Fundação Oswaldo CruzInstituto Nacional de Infectologia Evandro ChagasRio de JaneiroRJBrasilInstituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ – BrasilRoberto M. Saraiva • Fundacao Oswaldo Cruz - Instituto Nacional de Infectologia Evandro Chagas – Av, Brasil, 4365. CEP 21040-360, Rio de Janeiro, RJ - Brasil E-mail: roberto.saraiva@ini.fiocruz.br, robertomsaraiva@gmail.com14072025202512205e20250332060520251405202514052025This is an open-access article distributed under the terms of the Creative Commons Attribution LicensePalavras-chaveDoença de ChagasInsuficiência CardíacaPrognóstico
Embora os novos casos de doença de Chagas (DC) tenham diminuído nas últimas décadas por meio do controle da transmissão vetorial e transfusional, cerca de 3,7 milhões de brasileiros ainda vivem cronicamente afetados por essa doença.1 Como cerca de 30 a 40% dessa população apresenta a forma cardíaca (CCC), e a insuficiência cardíaca (IC) está presente em cerca de 10% dos portadores de CCC,2 a DC é uma das principais causas de IC em países endêmicos, variando de 4% a 50%.2-4 O artigo de Silva et al. acrescenta importantes informações epidemiológicas atualizadas: 8,7% dos pacientes admitidos por IC aguda em um grande registro multicêntrico brasileiro entre 2011 e 2018 apresentavam CCC.5 Portanto, mesmo atualmente, ainda é imperativo incluir DC na investigação diagnóstica de pacientes com IC de etiologia desconhecida. Outro aspecto importante da IC por DC é que ela apresenta maior mortalidade4,6,7 e incidência de AVC4 do que a IC relacionada a outras etiologias. O artigo de Silva et al. confirmou que, entre aqueles admitidos por IC aguda, os pacientes com DC apresentaram uma maior taxa de morte ou transplante cardíaco durante a internação hospitalar e maior incidência cumulativa de morte após 3, 6 e 12 meses após a alta.5
O pior desfecho na DC pode estar relacionado a características específicas da doença, incluindo miocardite fibrosante progressiva com aumento cumulativo da fibrose miocárdica ao longo do tempo,8 fenômenos cardioembólicos mais frequentes,4 arritmias com risco de vida mais frequentes e pior hemodinâmica e função sistólica do ventrículo esquerdo (VE).9 De fato, Silva et al. descreveram uma menor pressão arterial sistólica e fração de ejeção do VE entre pacientes com DC.5 Outro aspecto descrito por Silva et al. é que sinais de IC direita foram mais frequentes em pacientes com CCC.5
Apesar do pior prognóstico da IC relacionada a DC, faltam estudos específicos sobre a previsão de um novo caso de IC ou sobre o tratamento específico da IC em pacientes com DC. Um estudo recente revelou que a maioria dos preditores tradicionais de novos casos de IC não foram associados a novos casos em pacientes com CCC. Ao mesmo tempo, parâmetros ecocardiográficos, incluindo função sistólica e diastólica do VE e parâmetros derivados do strain, podem ser bons preditores de novos casos de IC em CCC.10 Portanto, muitos desafios ainda precisam ser superados para reverter o excesso de mortalidade relacionado à CCC. Esses desafios incluem o baixo financiamento público e privado para ensaios clínicos multicêntricos para investigar novos medicamentos, dispositivos cardíacos e abordagens não farmacológicas para CCC e para avaliar novos tratamentos antiparasitários que poderiam melhorar a progressão da DC, ausência de treinamento contínuo para profissionais de saúde e políticas públicas insuficientes visando diagnóstico e tratamento precoces, entre outros.11
Insuficiência Cardíaca Aguda em Pacientes com Cardiomiopatia Chagásica: Resultados do I Registro Brasileiro de Insuficiência Cardíaca (BREATHE)
ReferênciasLaportaGZLimaMMCostaVMLimaMMNetoPalmeiraSLRodovalhoSREstimation of Prevalence of Chronic Chagas Disease in Brazilian MunicipalitiRev Panam Salud Publica202448e2810.26633/RPSP.2024.281 Laporta GZ, Lima MM, Costa VM, Lima MM Neto, Palmeira SL, Rodovalho SR, et al. Estimation of Prevalence of Chronic Chagas Disease in Brazilian Municipaliti. Rev Panam Salud Publica. 2024;48:e28. doi: 10.26633/RPSP.2024.28.MartinezFPernaEPerroneSVLiprandiASChagas Disease and Heart Failure: An Expanding Issue WorldwideEur Cardiol2019142828810.15420/ecr.2018.30.22 Martinez F, Perna E, Perrone SV, Liprandi AS. Chagas Disease and Heart Failure: An Expanding Issue Worldwide. Eur Cardiol. 2019;14(2):82-8. doi: 10.15420/ecr.2018.30.2.EcheverríaLESaldarriagaCRivera-ToquicaAAGómez-OchoaSACadena-BonfantiAJZarama-MárquezMHCharacterization of Patients with Heart Failure of Chagas Etiology in Colombia: An Analysis Based on the Colombian Registry of Heart Failure (RECOLFACA)Curr Probl Cardiol2023481210196410196410.1016/j.cpcardiol.2023.1019643 Echeverría LE, Saldarriaga C, Rivera-Toquica AA, Gómez-Ochoa SA, Cadena-Bonfanti AJ, Zarama-Márquez MH, et al. Characterization of Patients with Heart Failure of Chagas Etiology in Colombia: An Analysis Based on the Colombian Registry of Heart Failure (RECOLFACA). Curr Probl Cardiol. 2023;48(12):101964. doi: 10.1016/j.cpcardiol.2023.101964.Cerqueira-SilvaTGonçalvesBMPereiraCBPortoLMMarquesMESantosLSChagas Disease is an Independent Predictor of Stroke and Death in a Cohort of Heart Failure PatientsInt J Stroke202217218018810.1177/174749302110062844 Cerqueira-Silva T, Gonçalves BM, Pereira CB, Porto LM, Marques ME, Santos LS, et al. Chagas Disease is an Independent Predictor of Stroke and Death in a Cohort of Heart Failure Patients. Int J Stroke. 2022;17(2):180-8. doi: 10.1177/17474930211006284.Barros e SilvaPGMAlbuquerqueDCLopesRDNogueiraPRFreitasAFJrAcute Heart Failure in Patients with Chagas Cardiomyopathy: Results of the I Brazilian Heart Failure Registry (BREATHE)Arq Bras Cardiol20251225e20240555https://doi.org/10.36660/abc.20240555i5 Barros e Silva PGM, Albuquerque DC, Lopes RD, Nogueira PR, Freitas Jr AF, et al. Acute Heart Failure in Patients with Chagas Cardiomyopathy: Results of the I Brazilian Heart Failure Registry (BREATHE). Arq Bras Cardiol. 2025; 122(5):e20240555. DOI: https://doi.org/10.36660/abc.20240555i.FreitasHFChizzolaPRPaesATLimaACMansurAJRisk Stratification in a Brazilian Hospital-Based Cohort of 1220 Outpatients with Heart Failure: Role of Chagas’ Heart DiseaseInt J Cardiol2005102223924710.1016/j.ijcard.2004.05.0256 Freitas HF, Chizzola PR, Paes AT, Lima AC, Mansur AJ. Risk Stratification in a Brazilian Hospital-Based Cohort of 1220 Outpatients with Heart Failure: Role of Chagas’ Heart Disease. Int J Cardiol. 2005;102(2):239-47. doi: 10.1016/j.ijcard.2004.05.025.BoasLGCVBestettiRBOtavianoAPCardinalliANetoNogueiraPROutcome of Chagas Cardiomyopathy in Comparison to Ischemic CardiomyopathyInt J Cardiol2013167248649010.1016/j.ijcard.2012.01.0337 Boas LGCV, Bestetti RB, Otaviano AP, Cardinalli-Neto A, Nogueira PR. Outcome of Chagas Cardiomyopathy in Comparison to Ischemic Cardiomyopathy. 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Arq Bras Cardiol. 2023;120(6):e20230269. doi: 10.36660/abc.20230269.CunhaDMDMedianoMFFRimoloLDSMCostaARDiogoDBSangenisLHCPredictors of Incident Heart Failure in Patients with Chronic Chagas Disease CardiomyopathyEchocardiography2025425e7016310.1111/echo.7016310 Cunha DMD, Mediano MFF, Rimolo LDSM, Costa AR, Diogo DB, Sangenis LHC, et al. Predictors of Incident Heart Failure in Patients with Chronic Chagas Disease Cardiomyopathy. Echocardiography. 2025;42(5):e70163. doi: 10.1111/echo.70163.MedianoMFFSaraivaRMMolinaIMendesFSNSAddressing Challenges and Advancing Treatment Strategies for Chagas CardiomyopathyLancet20244041045691591710.1016/S0140-6736(24)00751-711 Mediano MFF, Saraiva RM, Molina I, Mendes FSNS. Addressing Challenges and Advancing Treatment Strategies for Chagas Cardiomyopathy. Lancet. 2024;404(10456):915-7. doi: 10.1016/S0140-6736(24)00751-7.10.36660/abc.20250332iShort EditorialAcute Heart Failure Due to Chagas Disease: Still a Challenge in the 21st Century0000-0002-2263-4261SaraivaRoberto M.1PortelaLuciana F.1CostaAndréa R.1Rio de JaneiroRJBrazilInstituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ – BrazilRoberto M. Saraiva • Fundacao Oswaldo Cruz - Instituto Nacional de Infectologia Evandro Chagas – Av, Brasil, 4365. Postal Code 21040-360, Rio de Janeiro, RJ - Brazil E-mail: roberto.saraiva@ini.fiocruz.br, robertomsaraiva@gmail.comKeywordsChagas DiseaseHeart FailurePrognosis
Although new Chagas disease (CD) cases have decreased in the last decades through control of vector-borne and blood transfusion transmission, around 3,7 million Brazilians still live chronically affected by this disease.1 As around 30-40% of this population presents the cardiac form (CCC), and heart failure (HF) is present in about 10% of those with CCC,2 CD is a major cause of HF in endemic countries, ranging from 4% to 50%.2-4 The paper by Silva et al. adds important updated epidemiological information that 8.7% of the patients admitted due to acute HF in a large Brazilian multicenter registry between 2011 and 2018 had CCC.5 Therefore, even nowadays, it is still imperative to include CD in the diagnosis workup of patients with HF of unknown etiology. Another important aspect of the HF due to CD is that it presents higher mortality4,6,7 and stroke incidence4 than HF related to other etiologies. The paper by Silva et al confirmed that among those admitted due to acute HF, patients with CD had a higher rate of the composite of death or heart transplant during hospital stay and a higher cumulative incidence of death after 3, 6, and 12 months after discharge.5
The worst outcome in CD may be related to specific characteristics of the disease, including a progressive fibrosing myocarditis with a cumulative increase in myocardial fibrosis over time,8 more frequent cardioembolic phenomena,4 more frequent life-threatening arrhythmias, and worse hemodynamics and left ventricular (LV) systolic function.9 In fact, Silva et al. described a lower systolic blood pressure and LV ejection fraction among patients with CD.5 Another aspect described by Silva et al is that signs of right-sided HF were more frequent in patients with CCC.5
Although the worst outcome, specific studies on predicting incident HF or addressing HF treatment specifically in patients with CD are lacking. A recent study revealed that most traditional incident HF predictors were not associated with incident HF in patients with CCC. At the same time, echocardiographic parameters, including LV systolic and diastolic function and strain-derived parameters, can be good predictors of incident HF in CCC.10 Therefore, many challenges are still to be overcome in order to reverse the excess in mortality related to CCC. Those challenges include low public and private funding for multicenter clinical trials to investigate new drugs, cardiac devices, and non-pharmacological approaches for CCC and to evaluate new anti-parasitic treatments that could ameliorate CD progression, absence of continuous training for health-care professionals, and insufficient public policies targeting early diagnosis and treatment, among others.11
Acute Heart Failure in Patients with Chagas Cardiomyopathy: Results of the I Brazilian Heart Failure Registry (BREATHE)