ABC | Volume 111, Nº3, September 2018

Original Article Obstructive Sleep Apnea is Common and Associated with Heart Remodeling in Patients with Chagas Disease Carolina de Araújo Medeiros, 1,2 Isaac Vieira Secundo, 1 Carlos Antônio da Mota Silveira, 1 José Maria del Castilho, 1 Afonso Luiz Tavares de Albuquerque, 1 Sílvia Marinho Martins, 2 Wilson de Oliveira Júnior, 2 Geraldo Lorenzi-Filho, 3 Luciano F. Drager, 3 Rodrigo Pinto Pedrosa 1 Laboratório do Sono e Coração do Pronto Socorro Cardiológico de Pernambuco (PROCAPE) da Universidade de Pernambuco, 1 Recife, PE - Brazil Ambulatório de Doença de Chagas e insuficiência Cardíaca - PROCAPE da Universidade de Pernambuco, 2 Recife, PE - Brazil Instituto do Coração (InCor) - Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), 3 São Paulo, SP - Brazil Mailing Address: Rodrigo Pinto Pedrosa • Rua dos Palmares, SN. Postal Code 50100-060, Santo Amaro, Recife, PE - Brasil E-mail: rppedrosa@terra.com.br Manuscript received March 11,2018, revised manuscript May 09, 2018, accepted May 09, 2018 DOI: 10.5935/abc.20180131 Abstract Background: Chagas Disease (CD) is an important cause of morbimortality due to heart failure andmalignant arrhythmias worldwide, especially in Latin America. Objective: To investigate the association of obstructive sleep apnea (OSA) with heart remodeling and cardiac arrhythmias in patients CD. Methods: Consecutive patients with CD, aged between 30 to 65 years old were enrolled. Participants underwent clinical evaluation, sleep study, 24-hour Holter monitoring, echocardiogram and ambulatory blood pressure monitoring. Results: We evaluated 135 patients [age: 56 (45-62) years; 30% men; BMI: 26 ± 4 kg/m 2 , Chagas cardiomyopathy: 70%]. Moderate to severe OSA (apnea-hypopnea index, AHI, ≥ 15 events/h) was present in 21% of the patients. OSA was not associated with arrhythmias in this population. As compared to patients with mild or no OSA, patients with moderate to severe OSA had higher frequency of hypertension (79% vs. 72% vs. 44%, p < 0.01) higher nocturnal systolic blood pressure: 119 ± 17 vs. 113 ± 13 vs. 110 ± 11 mmHg, p = 0.01; larger left atrial diameter [37 (33-42) vs. 35 (33-39) vs. 33 (30-36) mm, p < 0.01]; and a greater proportion of left ventricular dysfunction [LVEF < 50% (39% vs. 28% vs. 11%), p < 0.01], respectively. Predictor of left atrial dimension was Log 10 (AHI) ( β = 3.86, 95% CI: 1.91 to 5.81; p < 0.01). Predictors of ventricular dysfunction were AHI > 15 events/h (OR = 3.61, 95% CI: 1.31 - 9.98; p = 0.01), systolic blood pressure (OR = 1.06, 95% CI: 1.02 - 1.10; p < 0.01) and male gender (OR = 3.24, 95% CI: 1.31 - 8.01; p = 0.01). Conclusions: OSA is independently associated with atrial and ventricular remodeling in patients with CD. (Arq Bras Cardiol. 2018; 111(3):364-372) Keywords: Chagas Disease; Sleep Apnea, Obstructive; Ventricular Remodeling; Arrhythmias, Cardiac. Introduction Chagas disease (CD) is the third most common parasitic infection, after malaria and schistosomiasis, affecting about 7 to 8 million people worldwide. 1  CD is caused by the protozoan Trypanosoma cruzi, transmitted to humans by insects ( Triatominae ), blood transfusion, organ and tissue transplantation, oral contamination or congenital transmission. 2 The epidemiological profile of the disease has been modified in recent decades, due to migratory flows, 2 thus also generating attention in non-endemic countries such as the United States, Canada, Spain, Italy and Japan. 3,4 Chagas cardiomyopathy is the most common form of nonischemic cardiomyopathy and one of the leading causes of complications and death in Latin America. 5 Approximately one third of patients with CD develop Chagas cardiomyopathy 3 characterized by ventricular arrhythmias, cardiac blockages, alterations in cardiac proteins with heart remodeling, heart failure and sudden death. Heart failure due to CD worsens patient prognosis, when compared with other cardiomyopathies. 6 In addition to the myriad of characteristics involved in CD, it is important to consider potential comorbidities that may have a negative impact on patients’ health. Obstructive sleep apnea (OSA) is themost frequent respiratory disturbance in the overall population and is associated with heart remodeling and arrhythmias in patients without 7,8 and with comorbidities, including heart failure. 6 However, whether this association exists in patients with CD is unknown. We hypothesized that OSA is independently associated with cardiac arrhythmias and heart remodeling in patients with CD. Methods Subjects Consecutive patients with CD (with two positive blood tests‑immunofluorescence and ELISA), aged between 30 and 65 years oldwere recruited froma specialized outpatient service 364