Evolução clínica da insuficiência cardíaca sistólica crônica secundária à doença de chagas comparada às demais cardiomiopatias de etiologias não-chagásicas

Abstract

Chronic heart failure (CHF) is a leading cause of morbidity and mortality worldwide, representing a major public health issue, with an increasing incidence and prevalence. The likelihood of survival may vary significantly among different etiologies and subsets of patients with CHF. In this context, CHF secondary to Chagas cardiomyopathy (CC) shows a poorer prognosis compared to other etiologies, mainly in Latin American where the disease is endemic. Objectives: [Article 1] to determine whether the presence of Left Ventricular Reverse Remodeling (LVRR) could predict long-term mortality in patients with CC; [Article 2] to evaluate the risk prediction performance of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and anemia in patients with CHF secondary to CC; [Article 3] to develop and to validate a simple method for predicting long-term mortality in ambulatory CHF patients in an area where Chagas disease is endemic. Material and Methods: From January 2000 to December 2010, [Article 1] the medical charts of 159 patients were reviewed. LVRR was defined as an increase of left ventricular ejection fraction and a decrease of left ventricular end-diastolic diameter by 2D-echocardiography. A Cox proportional hazards model was used to evaluate the ability of LVRR to predict all-cause mortality; [Article 2] a total of 232 patients were studied. The creatinine clearance was estimated according to CKD-EPI equation and CKD was defined as CrCl<60 mL/min/1.73m2. Anemia was defined as hemoglobin <12 g/dL for women and <13 g/dL for men. Cox proportional hazards models were used to establish independent predictors for long-term mortality; [Article 3] The development cohort included 450 patients receiving evidence-based treatment for CHF, prospectively followed. Independent prognostic factors were identified using logistic regression analysis and thresholds defined to stratify low-, intermediate-, and -high-risk groups. The CALLM Risk Score was validated in an independent retrospective cohort with 228 individuals. Results: [All Articles] LVRR, chronic kidney disease (CKD) and anemia were not associated with late-mortality, hospitalizations, cardiogenic shock, or heart transplantation indication. The CALLM risk score showed good discrimination and consistent calibration to predict mortality in our series. Conclusions: [All Articles] LVRR, CKD and anemia have no impact on outcomes of patients with CC. The CALLM risk score represents a simple method that allows prediction of survival in a real-world in ambulatory CHF patients in an area where Chagas disease is endemic. The model provides an accurate identification of a subgroup of high-risk patients who should be closely managed.