ABC | Volume 112, Nº3, March 2019

Original Article Cardiac Evaluation in the Acute Phase of Chagas’ Disease with Post- Treatment Evolution in Patients Attended in the State of Amazonas, Brazil Jessica Vanina Ortiz, 1, 2 Bruna Valessa Moutinho Pereira, 1 Katia do Nascimento Couceiro, 1,2 Monica Regina Hosannah da Silva e Silva, 3 Susan Smith Doria, 1,2 Paula Rita Leite da Silva, 2 Edson da Fonseca de Lira, 3 Maria das Graças Vale Barbosa Guerra, 1,2 Jorge Augusto de Oliveira Guerra, 1,2 João Marcos Bemfica Barbosa Ferreira 1,2,4 Universidade do Estado do Amazonas, 1 Manaus, AM – Brazil Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, 2 Manaus, AM – Brazil Fundação de Hematologia e Hemoterapia do Amazonas, 3 Manaus, AM – Brazil Hospital Universitário Francisca Mendes, 4 Manaus, AM – Brazil Mailing Address: Jessica Vanina Ortiz • Av. Pedro Teixeira, 25. Postal Code 69040-000, Manaus, AM – Brazil E-mail: ortiz.jvm@gmail.com Manuscript received April 14, 2018, revised manuscript August 21, 2018, accepted September 05, 2018 DOI: 10.5935/abc.20190007 Abstract Background: In the past two decades, a newepidemiological profile of Chagas’ disease (CD) has been registered in the Brazilian Amazon where oral transmission has been indicated as responsible for the increase of acute cases. In the Amazonas state, five outbreaks of acute CD have been registered since 2004. The cardiac manifestations in these cases may be characterized by diffuse myocarditis, with alteration in the electrocardiogram (ECG) and transthoracic echocardiogram (TTE). Objective: To perform a cardiac evaluation in autochthonous patients in the acute phase and at least one year after submitted to treatment for acute CD and evaluate the demographic variables associated with the presence of cardiac alterations. Methods: We evaluated patients diagnosed with acute CD through direct parasitological or serological (IgM) methods from 2007 to 2015. These patients were treated with benznidazole and underwent ECG and TTE before and after treatment. We assumed a confidence interval of 95% (CI 95%, p < 0.05) for all variables analyzed. Results: We observed 63 cases of an acute CD in which oral transmission corresponded to 75%. Cardiac alterations were found in 33% of the cases, with a greater frequency of ventricular repolarization alteration (13%), followed by pericardial effusion (10%) and right bundle branch block and left anterior fascicular block (2%). The follow-up occurred in 48 patients with ECG and 25 with TTE for a mean period of 15.5 ± 4.1 months after treatment. Of these, 8% presented normalization of the cardiac alterations in ECG, 62.5% remained with the normal exams. All of the patients presented normal results in TTE in the post-treatment period. As for the demographic variables, isolated cases presented more cardiac alterations than outbreaks (p = 0.044) as well as cases from Central Amazonas mesoregion (p = 0.020). Conclusions: Although cardiac alterations have not been frequent in most of the studied population, a continuous evaluation of the clinical-epidemiological dynamics of the disease in the region is necessary in order to establish preventive measures. (Arq Bras Cardiol. 2019; 112(3):240-246) Keywords: ChagasDisease/epidemiology;AmazonianyEcosystem;Trypanosomacruzi;ChagasCardiomiopathy/physiopathology. Introduction Chagas disease (CD) is an emerging infection caused by Trypanosoma cruzi, discovered by the physician Carlos Chagas, in 1909. He described the clinical manifestations, as well as the morphological features of the parasite. 1 It is estimated that approximately 75millionpeople are at risk of acquiring the disease and 8 million are indeed infected by the parasite worldwide. 2 CD presents two clinical phases: an acute and a chronic phase. In acute CD, nonspecific clinical symptoms may delay early diagnosis and treatment representing a public health concern. In some cases, the absence of symptoms may lead to a chronic indeterminate form or later evolving to a digestive, cardiac or mixed form. 3,4 Oral infection is more likely to cause a symptomatic response and increase the susceptibility to higher mortality rate and may result in unique cardiac characteristics with the most concerning symptom of this phase being diffuse myocarditis with alterations in the ECG and TTE results. 5,6 Due to the parasite’s genetic characteristics that are thought to be associated with the clinical manifestations of CD, in 1998 Tibayrenc 7 proposed a new classification for the parasites’ genetic diversity. In a review in 2009, a consensus established the division into six genotypes, named “Discrete Typing Units” (DTUs): TcI-TVI. 8 Multiple acute cases have been reported in the Brazilian Amazon with most cases concentrated in Pará and Amazonas, 9-14 being the first cases registered in 1968 and 1980, respectively. 15,16 Afterwards, micro-epidemics of acute cases have been reported and mostly associated with the ingestion of contaminated food, such as açaí fruits, bacaba 240