Roque Aras

Acute Chagas disease outbreak associated with oral transmission

Seven individuals living in a town in the Southwest of Bahia developed sudden signs of cardiac and systemic impairment, with lethality of 28.6%. Serological tests were positive at least in one test in the five patients examined. Forty percent of the Triatoma sordida mynphs found inside or around Trypanosoma cruzi were found by blood culturig in there out five cases the homes of these cases were positive for Trypanosoma cruzi. Transmission probably occurred through consumption of water contaminated with triatomine feces. These findings emphasize the necessity to evaluation the importance of vectors like Triatoma sordida in maintaining the endemicity of this disease.

Clinical Outcomes of Thirteen Patients with Acute Chagas Disease Acquired through Oral Transmission from Two Urban Outbreaks in Northeastern Brazil

Background Outbreaks of orally transmitted Trypanosoma cruzi continue to be reported in Brazil and are associated with a high mortality rate, mainly due to myocarditis. Methods This study is a detailed report on the disease progression of acute Chagas disease in 13 patients who were infected during two micro-outbreaks in two northeastern Brazilian towns. Clinical outcomes as well as EKG and ECHO results are described, both before and after benznidazole treatment. Results Fever and dyspnea were the most frequent symptoms observed. Other clinical findings included myalgia, periorbital edema, headache and systolic murmur. Two patients died of cardiac failure before receiving benznidazole treatment. EKG and ECHO findings frequently showed a disturbance in ventricular repolarization and pericardial effusion. Ventricular dysfunction (ejection fraction <55%) was present in 27.3% of patients. After treatment, EKG readings normalized in 91.7% of patients. Ventricular repolarization abnormalities persisted in 50% of the patients, while sinus bradycardia was observed in 18%. The systolic ejection fraction normalized in two out of three patients with initially depressed ventricular function, while pericardial effusion disappeared. Conclusions Myocarditis is frequently found and potentially severe in patients with acute Chagas disease. Benznidazole treatment may improve clinical symptoms, as well as EKG and ECHO findings.

Aspectos clínicos e terapêuticos da insuficiência cardíaca por doença de Chagas

OBJECTIVE Describe the clinical and therapeutic characteristics of patients with heart failure (HF) secondary to chronic chagasic cardiomyopathy and evaluate if these characteristics are different from those found in other etiologies. METHODS A prospective analysis of the patients treated between August 2003 and June 2004 at a HF referral outpatient clinic was conducted. RESULTS Three hundred and fifty six patients diagnosed with HF were included in the study. Chagasic cardiomyopathy was the most common etiology (48% of the cases). Other etiologies included hypertensive cardiomyopathy in 19% of the patients, idiopathic dilated in 11% and ischemic in 9%. Patients with HF secondary to chagasic cardiomyopathy were more frequently from non-white ethnic groups (88 vs. 75%; p = 0.002), had a family history of Chagas disease (57 vs. 21%; p = 0.001), had the disease for a longer length of time (71 vs. 56 months; p = 0.034), had lower levels of education (4.4 +/- 4.1 vs. 5.7 +/- 4.2 years of study; p = 0.004), had a lower heart rate (69 +/- 12 vs. 73 +/- 13; p = 0.03) and a lower systolic blood pressure (121 +/- 25 vs. 129 +/- 28 mmHg; p = 0.006). There was also a higher incidence of the use of amiodarone (22 vs. 13%; p = 0.036) and artificial pacemakers (15 vs. 1%; p = 0.001). There was a lower usage of beta-blockers (39 vs. 59%; p = 0.001). CONCLUSION In this sample of HF outpatients, in a state with a high prevalence of Chagas disease, chagasic cardiomyopathy was the most common etiology and they presented some unique clinical and therapeutic characteristics in comparison to other heart failure patients.

Suporte ventilatório na capacidade funcional de pacientes com insuficiência cardíaca: estudo piloto

BACKGROUND Heart failure (HF) is an important public health problem, of which main clinical symptoms are dyspnea and fatigue. Noninvasive ventilatory support has been used as adjuvant therapy in cardiac rehabilitation in order to improve the functional capacity of patients. OBJECTIVE To evaluate the functional capacity of patients with HF submitted to ventilatory support. METHODS We evaluated the sociodemographic information, as well as data on quality of life, blood pressure (BP), peripheral oxygen saturation (SpO2), dyspnea, lactate concentration before and after the 6-minute walk test (6MWT) and the distance walked by patients of both sexes with chronic heart failure (CHF), with left ventricular ejection fraction (LVEF) < 45.0% , randomized in two groups: control and CPAP (the group used CPAP - 10 cmH2O for 30 minutes). RESULTS A total of 12 patients, of which 8 were males, with CHF functional class II and III (NYHA) participated in the study. The patients had mean LVEF of 35.3 ± 8.7 and mean age was 46.3 ± 10.3 years. When comparing the control group with the CPAP group at the end of the 6th minute, there was a significant difference between the groups regarding SpO2 values ( CONTROL 93.6 ± 1.5 % vs CPAP: 96.1±1.8%; p = 0.027), index of dyspnea ( CONTROL 13.1 ± 1.16 vs CPAP: 11 ± 0.8; p = 0.009), lactate concentration ( CONTROL 3.3 ± 0.7 mmol/l vs CPAP: 2.3 ± 0.5 mmol/l; p = 0.025) and distance walked at the 6MWT (CONTROL: 420.6 ± 73.8 m vs CPAP: 534 ± 89.91 m; p = 0.038). CONCLUSION The previous use of the CPAP had beneficial effects on SpO2, index of dyspnea, lactate concentration, double product and the distance walked at the 6MWT in patients with CHF when performing the 6MWT.FUNDAMENTO: A insuficiencia cardiaca e um importante problema de saude publica, apresentando a dispneia e a fadiga como principais sintomas clinicos. A utilizacao do suporte ventilatorio nao invasivo vem atuando como coadjuvante da reabilitacao cardiaca na tentativa de melhorar a capacidade funcional dos pacientes. OBJETIVO: Avaliar a capacidade funcional de pacientes com insuficiencia cardiaca submetidos ao suporte ventilatorio. METODOS: Foram avaliados dados sociodemograficos, qualidade de vida, FC, pressao arterial (PA), saturacao periferica de oxigenio (SpO2), dispneia, concentracao de lactato, antes e depois do teste de caminhada de 6 minutos, e a distância percorrida de pacientes com insuficiencia cardiaca cronica (ICC), de ambos os sexos, com fracao FEVE < 45,0%, randomizados em dois grupos: controle e CPAP (utilizou CPAP 10 cmH2O por 30 minutos). RESULTADOS: Participaram 12 pacientes com ICC classe funcional II e III (NYHA), com media de fracao de ejecao do ventriculo esquerdo (FEVE, %) de 35,3 ± 8,7, sendo que 8 eram do sexo masculino. A media de idade foi de 46,3 ± 10,3 anos. Na comparacao entre os grupos Controle e CPAP, no final do 6o min, foi encontrada diferenca significativa nos valores de SpO2% entre os grupos (Controle: 93,6 ± 1,5 % vs CPAP: 96,1 ± 1,8%; p = 0,027), dispneia (Controle: 13,1 ± 1,16 vs CPAP: 11 ± 0,8; p = 0,009), concentracao de lactato (Controle: 3,3 ± 0,7 mmol/l vs CPAP: 2,3 ± 0,5 mmol/l; p = 0,025), e distância percorrida no TC6 (Controle: 420,6 ± 73,8 m vs CPAP: 534 ± 89,91 m; p = 0,038). CONCLUSAO: A realizacao previa do CPAP apresentou efeitos beneficos na SpO2, na dispneia, na concentracao de lactato, no duplo produto e na distância percorrida no TC6 de pacientes com ICC na realizacao do TC6.

Troponin in Chagas disease

Chagas disease is still a major tropical diseasein Latin America, affecting 16 to 18 million people.About 6 million people are infected with thecausative organism, Trypanosoma cruzi , in Brazil[1]. However, it often remains for decades in itsindeterminate form, symptomless, with tissue injuryin about 30% of the cases, which eventually willevolve to serious arrhythmia and sudden death [1].There is no effective clinical or laboratorytechnique to monitor chronic Chagas myocarditis.Several researchers have found that Troponin I andT are important biochemical markers of heartmuscle damage. Increased levels of myocardialtroponins have been found associated with acutemyocardial ischemia, infarction, myocarditis andheart failure [2-4].Recently, we tested sera from 60 Chagasdisease patients (24 with the indeterminate formand 36 with chronic chagasic cardiomyopathy. Serafrom 24 healthy volunteers (Control Group) weretested for Troponin I (Immulite 1000 Turbo DPC-Medlab). The Troponin I value was considerednormal when it was below 0.15ng/dl, and high whenit was above 0.30ng/dl. The upper limit was set tobe at least two standard deviations above thenormal value.The mean value for Troponin I was 0.46ng/dl inthe Chagas disease patients, and 0.027ng/dl in thecontrol group. The mean age was 44.1±9.9 yearsof the Chagas patients, and 34 were male. Whenwe tested We found 13 (54%) and 26 (74%)patients with high Troponin I, respectively, forchronic Chagas cardiomyopathy and theindeterminate form of Chagas disease. Twenty-onepatients from the Chagas disease group wereexcluded due to other cardiovascular diseases,myopathy or kidney disease.Troponin I levels were significantly higher amongthe Chagas disease patients with cardiomyopathywhen compared to the indeterminate form andcontrols, mean 0.60ng/dl vs 0.25ng/dl, respectively,and controls 0.027ng/dl (P < 0.001).All the patients with the indeterminate form ofChagas disease had normal EKGs, chest X-raysand echocardiograms. Possibly, the increased levelsof Troponin I, found in our sample, are related tochronic foci of myocardial inflammation, provokedby Chagas disease.Moreover, the utilization of a sensitive and easilymeasured biochemical marker should allow us toadopt different clinical cut-offs, facilitating theidentification of the different degrees of myocardialdamage, which now requires various diagnostic andtherapeutic approaches [5].The serum level of Troponin I is elevated indifferent clinical presentations of Chagas’ diseaseand may become an important element for earlydetection of myocardial inflammation, to preventfurther myocardial damage.References

Serum levels of cytokines and chemokines associated with cardiovascular disease in Brazilian patients treated with statins for dyslipidemia

The anti-inflammatory effect of 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors (statins) has been investigated in dyslipidemic patients treated with these pharmacologic agents. The aim of this study was to investigate the serum levels of cytokines and chemokines that have been associated with atherosclerosis and cardiovascular disease in Brazilian patients treated for hypercholesterolemia with statin. The serum levels of the cytokines IL-1β, IL-6, IL-10, TNF-α and TGF-β, and the levels of the chemokines IL-8 (CXCL8) and MCP-1 were determined by enzyme-linked immunosorbent assay and tested for their association with cardiovascular disease. The suppression of circulating levels of TNF-α, MCP-1 and IL-8 and their enhancing effect on IL-10 and TGF-β production were more pronounced in male patients. Female patients treated with statins who had a previous myocardial infarction presented higher median levels of both TNF-α and IL-8 (P<0.05) and a lower median level of IL-10 than female patients without MI (P<0.05). Except in women with a previous myocardial infarction, the treatment of dyslipidemic Brazilian patients with statins down-modulates the production of atherogenic cytokines and chemokines and increases the circulating levels of anti-atherogenic cytokines.

Stroke Correlates in Chagasic and Non-Chagasic Cardiomyopathies

Background Aging and migration have brought changes to the epidemiology and stroke has been shown to be independently associated with Chagas disease. We studied stroke correlates in cardiomyopathy patients with focus on the chagasic etiology. Methodology/Principal Findings We performed a cross-sectional review of medical records of 790 patients with a cardiomyopathy. Patients with chagasic (329) and non-chagasic (461) cardiomyopathies were compared. There were 108 stroke cases, significantly more frequent in the Chagas group (17.3% versus 11.1%; p<0.01). Chagasic etiology (odds ratio [OR], 1.79), pacemaker (OR, 2.49), atrial fibrillation (OR, 3.03) and coronary artery disease (OR, 1.92) were stroke predictors in a multivariable analysis of the entire cohort. In a second step, the population was split into those with or without a Chagas-related cardiomyopathy. Univariable post-stratification stroke predictors in the Chagas cohort were pacemaker (OR, 2.73), and coronary artery disease (CAD) (OR, 2.58); while atrial fibrillation (OR, 2.98), age over 55 (OR, 2.92), hypertension (OR, 2.62) and coronary artery disease (OR, 1.94) did so in the non-Chagas cohort. Chagasic stroke patients presented a very high frequency of individuals without any vascular risk factors (40.4%; OR, 4.8). In a post-stratification logistic regression model, stroke remained associated with pacemaker (OR, 2.72) and coronary artery disease (OR, 2.60) in 322 chagasic patients, and with age over 55 (OR, 2.38), atrial fibrillation (OR 3.25) and hypertension (OR 2.12; p = 0.052) in 444 non-chagasic patients. Conclusions/Significance Chagas cardiomyopathy presented both a higher frequency of stroke and an independent association with it. There was a high frequency of strokes without any vascular risk factors in the Chagas as opposed to the non-Chagas cohort. Pacemaker rhythm and CAD were independently associated with stroke in the Chagas group while age over 55 years, hypertension and atrial fibrillation did so in the non-Chagas cardiomyopathies.

Risk factors for dementia in a rural area of Northeastern Brazil

OBJECTIVE To identify risk factors for dementia among the elderly in a rural area of Northeastern Brazil. METHOD The subjects assessed were all 60 years old or older, and lived in a rural region of Bahia, a Northeastern State of Brazil. CAMDEX, a structured clinical evaluation protocol, was used for diagnosis, and applied at the home of the subjects. RESULTS The risk factors identified were divided in accordance with socio-demographic characteristics, the presence of co-morbid conditions, and the use of medications. The variables with strong association with dementia were age, history of stroke, arterial hypertension, and sight impairment. CONCLUSION Advanced age, arterial hypertension, and vascular brain injury were the main risk factors associated with dementia, which suggests that public health measures adopted to prevent and control modifiable risk factors can mitigate the prevalence of high rates of dementia.

Estimation of lung vital capacity before and after coronary artery bypass grafting surgery: a comparison of incentive spirometer and ventilometry

BackgroundMeasurement of vital capacity (VC) by spirometry is the most widely used technique for lung function evaluation, however, this form of assessment is costly and further investigation of other reliable methods at lower cost is necessary. Objective: To analyze the correlation between direct vital capacity measured with ventilometer and with incentive inspirometer in patients in pre and post cardiac surgery.MethodologyCross-sectional comparative study with patients undergoing cardiac surgery. Respiratory parameters were evaluated through the measurement of VC performed by ventilometer and inspirometer. To analyze data normality the Kolmogorov-Smirnov test was applied, for correlation the Pearson correlation coefficient was used and for comparison of variables in pre and post operative period Students t test was adopted. We established a level of ignificance of 5%. Data was presented as an average, standard deviation and relative frequency when needed. The significance level was set at 5%.ResultsWe studied 52 patients undergoing cardiac surgery, 20 patients in preoperative with VC-ventilometer: 32.95 ± 11.4 ml/kg and VC-inspirometer: 28.9 ± 11 ml/Kg, r = 0.7 p < 0.001. In the post operatory, 32 patients were evaluated with VC-ventilometer: 28.27 ± 12.48 ml/kg and VC-inspirometer: 26.98 ± 11 ml/Kg, r = 0.95 p < 0.001. Presenting a very high correlation between the evaluation forms studied.ConclusionThere was a high correlation between DVC measures with ventilometer and incentive spirometer in pre and post CABG surgery. Despite this, arises the necessity of further studies to evaluate the repercussion of this method in lowering costs at hospitals.

Effect of ventilatory support on functional capacity in patients with heart failure: a pilot study

BACKGROUND Heart failure (HF) is an important public health problem, of which main clinical symptoms are dyspnea and fatigue. Noninvasive ventilatory support has been used as adjuvant therapy in cardiac rehabilitation in order to improve the functional capacity of patients. OBJECTIVE To evaluate the functional capacity of patients with HF submitted to ventilatory support. METHODS We evaluated the sociodemographic information, as well as data on quality of life, blood pressure (BP), peripheral oxygen saturation (SpO2), dyspnea, lactate concentration before and after the 6-minute walk test (6MWT) and the distance walked by patients of both sexes with chronic heart failure (CHF), with left ventricular ejection fraction (LVEF) < 45.0% , randomized in two groups: control and CPAP (the group used CPAP - 10 cmH2O for 30 minutes). RESULTS A total of 12 patients, of which 8 were males, with CHF functional class II and III (NYHA) participated in the study. The patients had mean LVEF of 35.3 ± 8.7 and mean age was 46.3 ± 10.3 years. When comparing the control group with the CPAP group at the end of the 6th minute, there was a significant difference between the groups regarding SpO2 values ( CONTROL 93.6 ± 1.5 % vs CPAP: 96.1±1.8%; p = 0.027), index of dyspnea ( CONTROL 13.1 ± 1.16 vs CPAP: 11 ± 0.8; p = 0.009), lactate concentration ( CONTROL 3.3 ± 0.7 mmol/l vs CPAP: 2.3 ± 0.5 mmol/l; p = 0.025) and distance walked at the 6MWT (CONTROL: 420.6 ± 73.8 m vs CPAP: 534 ± 89.91 m; p = 0.038). CONCLUSION The previous use of the CPAP had beneficial effects on SpO2, index of dyspnea, lactate concentration, double product and the distance walked at the 6MWT in patients with CHF when performing the 6MWT.FUNDAMENTO: A insuficiencia cardiaca e um importante problema de saude publica, apresentando a dispneia e a fadiga como principais sintomas clinicos. A utilizacao do suporte ventilatorio nao invasivo vem atuando como coadjuvante da reabilitacao cardiaca na tentativa de melhorar a capacidade funcional dos pacientes. OBJETIVO: Avaliar a capacidade funcional de pacientes com insuficiencia cardiaca submetidos ao suporte ventilatorio. METODOS: Foram avaliados dados sociodemograficos, qualidade de vida, FC, pressao arterial (PA), saturacao periferica de oxigenio (SpO2), dispneia, concentracao de lactato, antes e depois do teste de caminhada de 6 minutos, e a distância percorrida de pacientes com insuficiencia cardiaca cronica (ICC), de ambos os sexos, com fracao FEVE < 45,0%, randomizados em dois grupos: controle e CPAP (utilizou CPAP 10 cmH2O por 30 minutos). RESULTADOS: Participaram 12 pacientes com ICC classe funcional II e III (NYHA), com media de fracao de ejecao do ventriculo esquerdo (FEVE, %) de 35,3 ± 8,7, sendo que 8 eram do sexo masculino. A media de idade foi de 46,3 ± 10,3 anos. Na comparacao entre os grupos Controle e CPAP, no final do 6o min, foi encontrada diferenca significativa nos valores de SpO2% entre os grupos (Controle: 93,6 ± 1,5 % vs CPAP: 96,1 ± 1,8%; p = 0,027), dispneia (Controle: 13,1 ± 1,16 vs CPAP: 11 ± 0,8; p = 0,009), concentracao de lactato (Controle: 3,3 ± 0,7 mmol/l vs CPAP: 2,3 ± 0,5 mmol/l; p = 0,025), e distância percorrida no TC6 (Controle: 420,6 ± 73,8 m vs CPAP: 534 ± 89,91 m; p = 0,038). CONCLUSAO: A realizacao previa do CPAP apresentou efeitos beneficos na SpO2, na dispneia, na concentracao de lactato, no duplo produto e na distância percorrida no TC6 de pacientes com ICC na realizacao do TC6.