Background: Chagas disease, resulting from the protozoan Trypanosoma cruzi , is an important cause of heart failure, stroke, arrhythmia, and sudden death. Traditionally regarded as a tropical disease found only in Central America and South America, Chagas disease now affects at least 300 000 residents of the United States and is growing in prevalence in other traditionally nonendemic areas. Healthcare providers and health systems outside of Latin America need to be equipped to recognize, diagnose, and treat Chagas disease and to prevent further disease transmission. Methods and Results: The American Heart Association and the Inter-American Society of Cardiology commissioned this statement to increase global awareness among providers who may encounter patients with Chagas disease outside of traditionally endemic environments. In this document, we summarize the most updated information on diagnosis, screening, and treatment of T cruzi infection, focusing primarily on its cardiovascular aspects. This document also provides quick reference tables, highlighting salient considerations for a patient with suspected or confirmed Chagas disease. Conclusions: This statement provides a broad summary of current knowledge and practice in the diagnosis and management of Chagas cardiomyopathy. It is our intent that this document will serve to increase the recognition of Chagas cardiomyopathy in low-prevalence areas and to improve care for patients with Chagas heart disease around the world.

Chagas disease, caused by the parasite Trypanosoma cruzi, is a serious health problem in Latin America and is an emerging disease in non-endemic countries. In recent decades, the epidemiological profile of the disease has changed due to new patterns of immigration and successful control in its transmission, leading to the urbanization and globalization of the disease. Dilated cardiomyopathy is the most important and severe manifestation of human chronic Chagas disease and is characterized by heart failure, ventricular arrhythmias, heart blocks, thromboembolic phenomena, and sudden death. This article will present an overview of the clinical and epidemiological aspects of Chagas disease. It will focus on several clinical aspects of the disease, such as chronic Chagas disease without detectable cardiac pathology, as well as dysautonomia, some specific features, and the principles of treatment of chronic cardiomyopathy.

The expression of immune response appears to be associated with morbidity in Chagas disease. However, the studies in this field have usually employed small samples of patients and statistical analyses that do not consider the wide dispersion of cytokine production observed in these patients. The aim of this study was to evaluate the plasma cytokine levels in well-defined clinical polar groups of chagasic patients divided into categories that better reflect the wide cytokine profile and its relationship with morbidity. Patients infected with Trypanosoma cruzi (T. cruzi) were grouped as indeterminate (IND) and cardiac (CARD) forms ranging from 23 to 69 years of age (mean of 45.6±11.25). The IND group included 82 individuals, ranging from 24 to 66 years of age (mean of 39.6±10.3). The CARD group included 94 patients ranging from 23 to 69 years of age (mean of 48±12.52) presenting dilated cardiomyopathy. None of the patients have undergone chemotherapeutic treatment, nor had been previously treated for T. cruzi infection. Healthy non-chagasic individuals, ranging from 29 to 55 years of age (mean of 42.6±8.8) were included as a control group (NI). IND patients have a higher intensity of interleukin 10 (IL-10) expression when compared with individuals in the other groups. By contrast, inflammatory cytokine expression, such as interferon gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), and interleukin 1 beta (IL-1β), proved to be the highest in the CARD group. Correlation analysis showed that higher IL-10 expression was associated with better cardiac function, as determined by left ventricular ejection fraction and left ventricular diastolic diameter values. Altogether, these findings reinforce the concept that a fine balance between regulatory and inflammatory cytokines represents a key element in the establishment of distinct forms of chronic Chagas disease.

AimsThe effects of exercise training in chronic heart failure are well established, however, they have not been evaluated in Chagas cardiomyopathy (ChC). We sought to determine the effects of exercise training on functional capacity, health-related quality of life (HQoL), and brain natriuretic peptide (BNP) levels in patients with ChC. Methods and resultsThis randomized, controlled, single-blind trial included 40 patients with ChC (age 49.5 + 7.8 years, 57.5% male) who did not practice regular exercise. All patients were assessed, at baseline and at the end of the study, by exercise test (VO 2 and exercise time), six-minute walk test (6MWT), Goldman Specific Activity Scale (SAS), HQoL, and BNP levels. Patients were randomized to inactive control group (ICG ¼ 19) or exercise training group (ETG ¼ 21). Exercise training group patients underwent 12 weeks of exercise training: walking for up to 30 min (intensity 50-70% HR reserve + HR at rest) and warm-up and cooling-down exercising, three times a week. The data were analysed for delta values (D¼ end 2 baseline). After intervention, compared with the ICG, the ETG had significant increases in functional parameters including, DVO 2 (6.5 vs. 2.8 mL/kg/min, P ¼ 0.001), D exercise time (2.9 vs.1.1 min, P , 0.001), D6MWT distance (83.5 vs. 2.0 m, P ¼ 0.001) improved DSAS (8 vs. 1 patient, P ¼ 0.008), and HQoL: D domains vitality (7.5 vs. 0 points, P ¼ 0.013), D emotional aspects (16.7 vs. 0 points, P ¼ 0.012), and D mental health (16.1 vs. 0 points, P ¼ 0.031). There was no difference in BNP levels. ConclusionIn patients with ChC, exercise training was associated with a major improvement in functional capacity and HQoL without any adverse effects.--

IE remains a severe disease affecting the young population in Brazil, and rheumatic heart disease continues to be the most common underlying heart condition. Large vegetation size, assessed early in the course of IE by transesophageal echocardiography, along with the clinical and microbiological features, may predict in-hospital death.