Andre Pires Antunes

Ten-Year Incidence of Chagas Cardiomyopathy Among Asymptomatic Trypanosoma cruzi–Seropositive Former Blood Donors

Background— Very few studies have measured disease penetrance and prognostic factors of Chagas cardiomyopathy among asymptomatic Trypanosoma cruzi–infected persons. Methods and Results— We performed a retrospective cohort study among initially healthy blood donors with an index T cruzi–seropositive donation and age-, sex-, and period-matched seronegatives in 1996 to 2002 in the Brazilian cities of São Paulo and Montes Claros. In 2008 to 2010, all subjects underwent medical history, physical examination, ECGs, and echocardiograms. ECG and echocardiogram results were classified by blinded core laboratories, and records with abnormal results were reviewed by a blinded panel of 3 cardiologists who adjudicated the outcome of Chagas cardiomyopathy. Associations with Chagas cardiomyopathy were tested with multivariate logistic regression. Mean follow-up time between index donation and outcome assessment was 10.5 years for the seropositives and 11.1 years for the seronegatives. Among 499 T cruzi seropositives, 120 (24%) had definite Chagas cardiomyopathy, and among 488 T cruzi seronegatives, 24 (5%) had cardiomyopathy, for an incidence difference of 1.85 per 100 person-years attributable to T cruzi infection. Of the 120 seropositives classified as having Chagas cardiomyopathy, only 31 (26%) presented with ejection fraction <50%, and only 11 (9%) were classified as New York Heart Association class II or higher. Chagas cardiomyopathy was associated (P<0.01) with male sex, a history of abnormal ECG, and the presence of an S3 heart sound. Conclusions— There is a substantial annual incidence of Chagas cardiomyopathy among initially asymptomatic T cruzi–seropositive blood donors, although disease was mild at diagnosis.

Electrocardiographic Abnormalities in Trypanosoma cruzi Seropositive and Seronegative Former Blood Donors

Background Blood donor screening leads to large numbers of new diagnoses of Trypanosoma cruzi infection, with most donors in the asymptomatic chronic indeterminate form. Information on electrocardiogram (ECG) findings in infected blood donors is lacking and may help in counseling and recognizing those with more severe disease. Objectives To assess the frequency of ECG abnormalities in T.cruzi seropositive relative to seronegative blood donors, and to recognize ECG abnormalities associated with left ventricular dysfunction. Methods The study retrospectively enrolled 499 seropositive blood donors in São Paulo and Montes Claros, Brazil, and 483 seronegative control donors matched by site, gender, age, and year of blood donation. All subjects underwent a health clinical evaluation, ECG, and echocardiogram (Echo). ECG and Echo were reviewed blindly by centralized reading centers. Left ventricular (LV) dysfunction was defined as LV ejection fraction (EF)<0.50%. Results Right bundle branch block and left anterior fascicular block, isolated or in association, were more frequently found in seropositive cases (p<0.0001). Both QRS and QTc duration were associated with LVEF values (correlation coefficients −0.159,p<0.0003, and −0.142,p = 0.002) and showed a moderate accuracy in the detection of reduced LVEF (area under the ROC curve: 0.778 and 0.790, both p<0.0001). Several ECG abnormalities were more commonly found in seropositive donors with depressed LVEF, including rhythm disorders (frequent supraventricular ectopic beats, atrial fibrillation or flutter and pacemaker), intraventricular blocks (right bundle branch block and left anterior fascicular block) and ischemic abnormalities (possible old myocardial infarction and major and minor ST abnormalities). ECG was sensitive (92%) for recognition of seropositive donors with depressed LVEF and had a high negative predictive value (99%) for ruling out LV dysfunction. Conclusions ECG abnormalities are more frequent in seropositive than in seronegative blood donors. Several ECG abnormalities may help the recognition of seropositive cases with reduced LVEF who warrant careful follow-up and treatment.

Implementation of a telecardiology system in the state of Minas Gerais: the Minas Telecardio Project

FUNDAMENTO: Embora as doencas cardiovasculares sejam a maior causa de morbimortalidade em todo Brasil, o acesso das populacoes de cidades pequenas a eletrocardiografia e a avaliacao cardiologica e limitado. O uso da telecardiologia para facilitar o acesso da populacao de municipios remotos a eletrocardiografia e a segunda opiniao em cardiologia e promissora, entretanto nao foi formalmente testada. OBJETIVO: Avaliar a viabilidade de se implantar o sistema publico de telecardiologia de baixo custo em pequenas cidades brasileiras. METODOS: Foram selecionadas 82 cidades do Estado de Minas Gerais, com populacao 70% de cobertura pelo Programa Saude da Familia (PSF), com interesse do gestor e acesso pela internet. Em cada municipio foi instalado um aparelho de eletrocardiografo (ECG) digital, com subsequente treinamento da equipe. A implantacao foi coordenada pelo HC/UFMG, em conjunto com outros quatro hospitais universitarios mineiros (UFU, UFTM, UFJF e UNIMONTES). Os ECGs foram realizados nos municipios e enviados pela internet para analise imediata em plantao de telecardiologia. Realizaram-se discussoes de casos medicos on-line e off-line e cursos de atualizacao via web. RESULTADOS: No periodo de implantacao, foram treinados 253 profissionais de saude. De julho de 2006 a novembro de 2008, o projeto atendeu 42.664 pacientes, realizando 62.865 ECGs. Foram efetuados 2.148 atendimentos de urgencia e 420 teleconsultorias. A avaliacao intermediaria apontou boa aceitacao da tecnologia implantada e uma diminuicao de 70% de encaminhamentos de pacientes para outros centros de referencia. CONCLUSAO: E factivel a utilizacao de recursos habituais de informatica para facilitar o acesso de populacoes de cidades pequenas a eletrocardiografia e avaliacao cardiologica especializada.BACKGROUND Although cardiovascular diseases are the main cause of morbimortality in Brazil, the access of small-town populations to electrocardiography and cardiology assessment is limited. The use of telecardiology to assist the access of distant towns to electrocardiography and a second opinion in cardiology is promising; however, it has not been formally assessed. OBJECTIVE To assess the feasibility of implementing a low-cost public telecardiology system in small Brazilian towns. METHODS A total of 82 towns in the state of Minas Gerais, with a population < 10,500 inhabitants, presenting > 70% coverage by the Family Health Program (Programa Saude da Familia-PSF), local government compliance and internet access, were selected. Each town was supplied with digital electrocardiography (ECG) device and a team was trained. The implementation was coordinated by HC/UFMG, together with four university hospitals in the state of Minas Gerais (UFU, UFTM, UFJF and UNIMONTES). The ECG assessments were carried out in the towns and sent through the Internet for prompt analysis by an on-duty telecardiology team. Online and offline discussions on the medical cases were carried out through the Internet, as well as refreshment courses. RESULTS During the implementation period, a total of 253 health professionals were trained. From July 2006 to November 2008, the project assisted 42,664 patients, with a total of 62,865 ECG assessments being performed. A total of 2,148 emergency cases were treated, as well as 420 teleconsultations. The intermediate evaluation showed good acceptance of the implemented technology and a 70% decrease in patient referrals to other reference centers. CONCLUSION The use of the customary resources in informatics to assist the access of small-town populations to electrocardiography and specialized cardiology assessment is feasible.

Detection of Trypanosoma cruzi DNA in blood by PCR is associated with Chagas cardiomyopathy and disease severity

The significance of detection of Trypanosoma cruzi DNA in blood of antibody‐positive patients for risk of development of Chagas heart disease is not well established. The objective of this study was to compare detection of T. cruzi DNA with known clinical and laboratory markers of Chagas cardiomyopathy (CC) severity.

Implantação de um sistema de telecardiologia em Minas Gerais: projeto Minas Telecardio

FUNDAMENTO: Embora as doencas cardiovasculares sejam a maior causa de morbimortalidade em todo Brasil, o acesso das populacoes de cidades pequenas a eletrocardiografia e a avaliacao cardiologica e limitado. O uso da telecardiologia para facilitar o acesso da populacao de municipios remotos a eletrocardiografia e a segunda opiniao em cardiologia e promissora, entretanto nao foi formalmente testada. OBJETIVO: Avaliar a viabilidade de se implantar o sistema publico de telecardiologia de baixo custo em pequenas cidades brasileiras. METODOS: Foram selecionadas 82 cidades do Estado de Minas Gerais, com populacao 70% de cobertura pelo Programa Saude da Familia (PSF), com interesse do gestor e acesso pela internet. Em cada municipio foi instalado um aparelho de eletrocardiografo (ECG) digital, com subsequente treinamento da equipe. A implantacao foi coordenada pelo HC/UFMG, em conjunto com outros quatro hospitais universitarios mineiros (UFU, UFTM, UFJF e UNIMONTES). Os ECGs foram realizados nos municipios e enviados pela internet para analise imediata em plantao de telecardiologia. Realizaram-se discussoes de casos medicos on-line e off-line e cursos de atualizacao via web. RESULTADOS: No periodo de implantacao, foram treinados 253 profissionais de saude. De julho de 2006 a novembro de 2008, o projeto atendeu 42.664 pacientes, realizando 62.865 ECGs. Foram efetuados 2.148 atendimentos de urgencia e 420 teleconsultorias. A avaliacao intermediaria apontou boa aceitacao da tecnologia implantada e uma diminuicao de 70% de encaminhamentos de pacientes para outros centros de referencia. CONCLUSAO: E factivel a utilizacao de recursos habituais de informatica para facilitar o acesso de populacoes de cidades pequenas a eletrocardiografia e avaliacao cardiologica especializada.BACKGROUND Although cardiovascular diseases are the main cause of morbimortality in Brazil, the access of small-town populations to electrocardiography and cardiology assessment is limited. The use of telecardiology to assist the access of distant towns to electrocardiography and a second opinion in cardiology is promising; however, it has not been formally assessed. OBJECTIVE To assess the feasibility of implementing a low-cost public telecardiology system in small Brazilian towns. METHODS A total of 82 towns in the state of Minas Gerais, with a population < 10,500 inhabitants, presenting > 70% coverage by the Family Health Program (Programa Saude da Familia-PSF), local government compliance and internet access, were selected. Each town was supplied with digital electrocardiography (ECG) device and a team was trained. The implementation was coordinated by HC/UFMG, together with four university hospitals in the state of Minas Gerais (UFU, UFTM, UFJF and UNIMONTES). The ECG assessments were carried out in the towns and sent through the Internet for prompt analysis by an on-duty telecardiology team. Online and offline discussions on the medical cases were carried out through the Internet, as well as refreshment courses. RESULTS During the implementation period, a total of 253 health professionals were trained. From July 2006 to November 2008, the project assisted 42,664 patients, with a total of 62,865 ECG assessments being performed. A total of 2,148 emergency cases were treated, as well as 420 teleconsultations. The intermediate evaluation showed good acceptance of the implemented technology and a 70% decrease in patient referrals to other reference centers. CONCLUSION The use of the customary resources in informatics to assist the access of small-town populations to electrocardiography and specialized cardiology assessment is feasible.

Benznidazole therapy for Chagas disease in asymptomatic Trypanosoma cruzi -seropositive former blood donors: evaluation of the efficacy of different treatment regimens

INTRODUCTION: Chagas disease currently affects 5.7 million people in Latin America and is emerging in non-endemic countries. There is no consensus concerning the efficacy of trypanocidal therapy for patients with the chronic form of the disease. We evaluated cardiac function and sociodemographic, clinical, and serologic characteristics of a group of asymptomatic Trypanosoma cruzi-seropositive former blood donors, and compared the effects of benznidazole treatment applied for different lengths of time. METHODS: Blood donors who screened positive for T. cruzi between 1998 and 2002 were recruited 10 years later for follow-up (n = 244); 46 individuals had received treatment. Three subjects had terminated treatment prematurely. The remaining 43 individuals were divided into two groups: individuals who had received benznidazole therapy for 50-60 days (n = 28; BT ≤60 group) or more than 60 days (n = 15; BT >60). Serologic assays, biochemical tests, electrocardiographic, echocardiographic, and clinical examinations were performed on all participants. Parasite loads were determined by qualitative and quantitative polymerase chain reaction. RESULTS: Parasitemia was significantly reduced in the BT ≤60 and BT >60 groups compared with the untreated group. There were no differences in epidemiologic profiles or clinical, biochemical, electrocardiographic, or echocardiographic data between any of the groups. CONCLUSIONS: Despite elimination or significant reduction in parasitemia in patients with chronic Chagas disease who received benznidazole, there was no clinical difference between those who were treated for >60 days and those treated for a shorter duration. Furthermore, the adverse effects of benznidazole appear to be less severe than previous reports would suggest.

Coordinated regional care of myocardial infarction in a rural area in Brazil: Minas Telecardio Project 2

Aims In Brazil, there are considerable disparities in access to healthcare. The aim of this study was to assess how implementation of a coordinated regional management protocol for patients with ST-elevation myocardial infarction (STEMI) affected quality of care and outcomes in a rural and deprived Brazilian region with considerable social inequalities. Methods and results The quality of care and outcomes of STEMI was evaluated in two cohorts before (n = 214) and after (n = 143) implementation of the coordinated regional management protocol. Central to this protocol was a tablet-based digital electrocardiogram (ECG) recording in the emergency ambulance that was transmitted for analysis by trained professionals. If the pre-hospital ECG was diagnostic, it triggered a management cascade involving a direct transfer to the regional intervention centre with reperfusion by primary percutaneous coronary intervention (PPCI) or pre-hospital fibrinolysis for anticipated journey times of less than or greater than 2 h, respectively. Following implementation of the protocol, the adjusted medical delay (system delay - transport time) decreased by 40% (95% confidence intervals: -66%, -13%). The proportion of patients who received reperfusion therapy increased from 70.6 to 80.8% (P = 0.045), with increases in treatment with aspirin [94.2-100% (P = 0.003)] and P2Y12 inhibitors [87.5-100% (P < 0.001)]. The odds of in-hospital death showed a non-significant decrease [odds ratio 0.73 (95% confidence intervals: 0.34-1.60)]. Conclusion The implementation of a coordinated regional management protocol for patients with STEMI led to marked improvements in the quality of care in a remote Brazilian region with limited resources.

Satisfaction of Emergency Physicians with the Care Provided to Patients with Cardiovascular Diseases in the Northern Region of Minas Gerais

Background The dissatisfaction of health professionals in emergency services has a negative influence on both the quality of care provided for acute myocardial infarction (AMI) patients and the retention of those professionals. Objective To assess physicians’ satisfaction with the structure of care and diagnosis at the emergency services in the Northern Region of Minas Gerais before the implementation of the AMI system of care. Methods This cross-sectional study included physicians from the emergency units of the ambulance service (SAMU) and level II, III and IV regional hospitals. Satisfaction was assessed by using the CARDIOSATIS-Team scale. The median score for each item, the overall scale and the domains were calculated and then compared by groups using the non-parametric Mann-Whitney test. Correlation between time since graduation and satisfaction level was assessed using Spearman correlation. A p value < 0.05 was considered significant. Results Of the 137 physicians included in the study, 46% worked at SAMU. Most of the interviewees showed overall dissatisfaction with the structure of care, and the median score for the overall scale was 2.0 [interquartile range (IQR) 2.0-4.0]. Most SAMU physicians expressed their dissatisfaction with the care provided (54%), the structure for managing cardiovascular diseases (52%), and the technology available for diagnosis (54%). The evaluation of the overall satisfaction evidenced that the dissatisfaction of SAMU physicians was lower when compared to that of hospital emergency physicians. Level III/IV hospital physicians expressed greater overall satisfaction when compared to level II hospital physicians. Conclusion This study showed the overall dissatisfaction of the emergency physicians in the region assessed with the structure of care for cardiovascular emergencies.

Epidemiological Profile and Quality Indicators in Patients with Acute Coronary Syndrome in Northern Minas Gerais - Minas Telecardio 2 Project

Background: Coronary artery disease is the main cause of death in Brazil. In the Brazilian public health system, the in-hospital mortality associated with acute myocardial infarction is high. The Minas Telecardio 2 Project (Projeto Minas Telecardio 2) aims at implementing a myocardial infarction system of care in the Northern Region of Minas Gerais (MG) to decrease hospital morbidity and mortality. The aim of this study was to describe the profile of the patients with acute coronary syndrome (ACS) cared for in the period that preceded the implementation of the system of care. Methods: Observational, prospective study of patients with ACS admitted between June 2013 and March 2014 to six emergency departments in Montes Claros, MG, and followed up until hospital discharge. Results: During the study period, 593 patients were admitted with a diagnosis of ACS (mean age 63 ± 12 years, 67.6% men), including 306 (51.6%) cases of unstable angina, 214 (36.0%) of ST-elevation myocardial infarction (STEMI), and 73 (12.3%) of non-ST-elevation myocardial infarction (NSTEMI). The total STEMI mortality was 21%, and the in-hospital mortality was 17.2%. In the STEMI patients, 46,0% underwent reperfusion therapy, including primary angioplasty in 88 and thrombolysis in six. Overall, aspirin was administered to 95.1% of the patients within 24 hours and to 93.5% at discharge, a P2Y12 inhibitor was administered to 88.7% participants within 24 hours and to 75.1% at discharge. A total of 73.1% patients received heparin within 24 hours. Conclusion: We observed a low reperfusion rate in patients with STEMI and limited adherence to the recommended ACS treatment in the Northern Region of MG. These observations enable opportunities to improve health care.

Response to Letters Regarding Article, “Ten-Year Incidence of Chagas Cardiomyopathy Among Asymptomatic, Trypanosoma cruzi–Seropositive Former Blood Donors”

We are grateful that our article has stimulated interest in and discussion of the incidence of clinical cardiomyopathy among asymptomatic persons infected with Trypanosoma cruzi .1 Rassi and Rassi comment that without more frequent interval examinations, we are unable to determine whether the incidence density of cardiomyopathy was constant over the 10 years of follow-up. This is true. However, their comment that “T cruzi–infected individuals who develop cardiomyopathy usually do so within 20 years after being infected” is not referenced in their letter; in a recent review article, the same authors postulated a 10- to 30-year incubation period.2 We are therefore unsure that the question of a constant versus declining incidence density has been settled. We also caution that the 18-year estimate for duration of exposure to T cruzi in our article was derived from an analysis of subject-reported risk factors and residence in endemic areas and should not be overinterpreted. However, we agree that the question of whether incidence density is constant or declines with time is important, and …