Electrocardiogram in Chagas disease

Brito, Bruno Oliveira de Figueiredo; Ribeiro, Antônio Luiz Pinho

doi:10.1590/0037-8682-0184-2018

Bruno Oliveira de Figueiredo Brito

Programa de Pós-Graduação Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.

Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.

Antônio Luiz Pinho Ribeiro

Programa de Pós-Graduação Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.

Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.

Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.

Corresponding author: Dr. Antonio L. Ribeiro, MD, ScD. e-mail:tom@hc.ufmg.br

Conflict of interest: The authors declare that there is no conflict of interest.

Author (year)	Number sample	Mean age	RBBB	RBBB + LAH	LBBB	VR	EI	VES	AF/Flutter	PM	AVB 1^st or 2^nd	AVB 3^rd	LV
Rosenbaum & Alvarez, 1955²⁰20. Rosenbaum MB, Alvarez AJ. The electrocardiogram in chronic chagasic myocarditis. Am Heart J . 1955;50(4):492-527.	130 (H)	47	48.4	-	2.3	37.0	-	47.0	14.6	-	6.1	3.8	13.0
Laranja et al, 1956⁵³53. Dias E, Laranja FS, Miranda A, Nobrega G. Chagas' disease; a clinical, epidemiologic, and pathologic study. Circulation. 1956;14(6):1035-60.	683 (P)	-	48.3	-	2.2	12.9	-	42.6	6.6	-	28.1	8.2	-
Dias & Kloetzel, 1968²⁹29. Dias JC, Kloetzel K. The prognostic value of the electrocardiographic features of chronic Chagas' disease. Rev Instit Med Trop Sao Paulo. 1968;10(3):158-62.	387 (P)	-	11.3	-	0.5	4.9	-	17.0	1.8	-	2.8	2.6	-
Maguire et al, 1983¹⁰10. Maguire JH, Mott KE, Lehman JS, Hoff R, Muniz TM, Guimaraes AC, et al. Relationship of electrocardiographic abnormalities and seropositivity to Trypanosoma cruzi within a rural community in northeast Brazil. Am Heart J. 1983;105(2):287-94.	346 (P)	-	5.8	4.6	-	9.0	0.6	7.5	-	-	1.4	-	-
Arteaga et al, 1985²²22. Arteaga-Fernandez E, Barretto AC, Mady C, Ianni BM, Bellotti G, Pileggi F. The electrocardiogram in patients with positive serological reactions for Chagas' disease. Study of 600 cases. Arq Bras Cardiol . 1985;44(5):333-7.	553 (H)	46	10.6	25.3	2.3	30.9	30.7	18.8	4.4	-	5.5	11.2	-
Pereira & Coura, 1986⁵⁴54. Pereira JB, Coura JR. Morbidade da doenca de Chagas. Estudo seccional em uma area endemica, Virgem da Lapa, Minas Gerais. Rev Soc Bras Med Trop . 1986;19(3):139-48.	255 (P)	-	18.4	-	-	18.0	5.5	14.5	1.2		6.6	-	2.7
Acquatella et al, 1987⁵⁵55. Acquatella H, Catalioti F, Gomez-Mancebo JR, Davalos V, Villalobos L. Long-term control of Chagas disease in Venezuela: effects on serologic findings, electrocardiographic abnormalities, and clinical outcome. Circulation. 1987;76(3):556-62.	775 (P)	47.7	16.7	-	0.7	19.6	5.9	20.1	3.8	-	4.2	0.5	-
Barretto et al, 1989²⁷27. Barretto AC, Bellotti G, Deperon SD, Arteaga-Fernandez E, Mady C, Ianni BM, et al. The value of the electrocardiogram in evaluating myocardial function in patients with Chagas' disease. Arq Bras Cardiol . 1989;52(2):69-73.	1,004 (O)	41.5	40.7	-	2.0	40.4	38.5	29.0	4.2	-	10.4	5.6	-
Prata et al, 1993¹³13. Prata SP, da Cunha DF, da Cunha SF, Prata SC, Nogueira N. Prevalence of electrocardiographic abnormalities in 2,000 aged and non-aged chagasic patients. Arq Bras Cardiol . 1993;60(6):369-72.	2,000 (O)	45.5	32.4	-	1.9	28.2	7.1	42.2	9.0	-	10.8	3.9	1.2
Garzon et al, 1995²⁶26. Garzon SA, Lorga AM, Nicolau JC. Electrocardiography in Chagas' heart disease. Sao Paulo Med J. 1995;113(2):802-13.	1,010 (O)	-	33.3	-	3.1	26.7	25.1	40.3	2.5	-	6.0	5.6	7.0
Salles et al, 2003⁵¹51. Salles G, Xavier S, Sousa A, Hasslocher-Moreno A, Cardoso C. Prognostic value of QT interval parameters for mortality risk stratification in Chagas' disease: results of a long-term follow-up study. Circulation. 2003;108(3):305-12.	738 (O)	46.3	14.1	24.3	3.3	7.7	3.7	14.5	-	-	6.5	-	-
Rassi et al, 2006⁵²52. Rassi Jr A, Rassi A, Little WC, Xavier SS, Rassi SG, Rassi AG, et al. Development and validation of a risk score for predicting death in Chagas' heart disease. N Engl J Med. 2006;355(8):799-808.	424 (H)	47	18.6	24.3	7.1	27.8	6.6	37.3	3.1	-	9.0	-	9.0
Williams-Blangero et al, 2007¹⁵15. Williams-Blangero S, Magalhaes T, Rainwater E, Blangero J, Correa-Oliveira R, Vandeberg JL. Electrocardiographic characteristics in a population with high rates of seropositivity for Trypanosoma cruzi infection. Am J Trop Med Hyg. 2007;77(3):495-9.	722 (P)	41.9	15.2	5.2	-	-	-	-	0.7	-	-	-	-
Gonçalves et al, 2011⁵⁷57. Goncalves JG, Prata A, Dias JC, Macedo V. O inquerito eletrocardiografico. Rev Soc Bras Med Trop . 2011;44(Suppl 2):40-6.	2,120 (P)	-	3.7	2.9	0.5	13.3	9.8	4.3	0.2	-	1.0	-	0.1
Ribeiro et al, 2013¹⁴14. Ribeiro AL, Sabino EC, Marcolino MS, Salemi VM, Ianni BM, Fernandes F, et al. Electrocardiographic abnormalities in Trypanosoma cruzi seropositive and seronegative former blood donors. PLoS Negl Trop Dis. 2013;7(2):e2078.	497 (P)	48	16.1	3.6	0.6	4.6	2.4	2.4	0.4	1.0	3.0	0	3.4
Ribeiro et al, 2014⁸8. Ribeiro AL, Marcolino MS, Prineas RJ, Lima-Costa MF. Electrocardiographic abnormalities in elderly Chagas disease patients: 10-year follow-up of the Bambui Cohort Study of Aging. J Am Heart Assoc. 2014;3(1):e000632.	557 (P)	69	23.2^*	9.2^*	3.2	11.3	5.9	10.1	6.1	1.1	6.8	0.5	2.5
Marcolino et al, 2015⁷7. Marcolino MS, Palhares DM, Ferreira LR, Ribeiro AL. Electrocardiogram and Chagas disease: a large population database of primary care patients. Glob Heart. 2015;10(3):167-72.	7,590 (O)	57	22.7	13.7	3.0	0.2	1.5	5.4	5.3	3.5	5.1	0.2	-

Author (year)	Number	Population	End points	Follow up	Prognostic factors
Cohort studies
Pereira et al, 1985¹⁸18. Pereira JB, Willcox HP, Coura JR. Morbidity in Chagas' disease. III. Longitudinal study of 6 years, in Virgem da Lapa, MG, Brazil. Mem Inst Oswaldo Cruz . 1985;80(1):63-71.	248	ChD vs Seronegatives	Progression to HF	6 years	EI, VR, VES incidence
Acquatella et al, 1987⁵⁵55. Acquatella H, Catalioti F, Gomez-Mancebo JR, Davalos V, Villalobos L. Long-term control of Chagas disease in Venezuela: effects on serologic findings, electrocardiographic abnormalities, and clinical outcome. Circulation. 1987;76(3):556-62.	775	With and without cardiomyopathy	Functional class (NYHA)	5 years	Abnormal ECG
Barretto et al, 1989²⁷27. Barretto AC, Bellotti G, Deperon SD, Arteaga-Fernandez E, Mady C, Ianni BM, et al. The value of the electrocardiogram in evaluating myocardial function in patients with Chagas' disease. Arq Bras Cardiol . 1989;52(2):69-73.	1,004	ChD	Functional class (NYHA), cardiothoracic index	2 years	Higher incidence of abnormal ECG in NYHA III and IV.
Ianni et al, 2001⁵5. Ianni BM, Arteaga E, Frimm CC, Pereira Barretto AC, Mady C. Chagas' heart disease: evolutive evaluation of electrocardiographic and echocardiographic parameters in patients with the indeterminate form. Arq Bras Cardiol. 2001;77(1):59-62.	159	ChD indeterminate form	LVEF	98.6+/- 30.4 months	Incidence of new ECG alterations had no impact on LVEF
Nascimento et al, 2012³³33. Nascimento BR, Araujo CG, Rocha MO, Domingues JD, Rodrigues AB, Barros MV, et al. The prognostic significance of electrocardiographic changes in Chagas disease. J Electrocardiol. 2012;45(1):43-8.	152	With and without cardiomyopathy	Drop of 5% of LVEF, diameter of the left ventricle in diastole	6.8 years	QRS duration and appearance of new ECG alterations.
Cross-sectional studies
Casado et al., 1990³⁴34. Casado J, Davila DF, Donis JH, Torres A, Payares A, Colmenares R, et al. Electrocardiographic abnormalities and left ventricular systolic function in Chagas' heart disease. Int J Cardiol . 1990;27(1):55-62.	44	ChCM without HF	LVEF, left ventricle volume	Cross-sectional	Association of ECG alterations in the same tracing.
Ribeiro et al., 2000³²32. Ribeiro AL, Rocha MO, Barros MV, Rodrigues AR, Machado FS. A narrow QRS does not predict a normal left ventricular function in Chagas' disease. Pacing Clin Electrophysiol. 2000;23(11 Pt 2): 2014-7.	98	With and without cardiomyopathy	LVEF, Diameter of the left ventricle in diastole	Cross-sectional	QRS > 100ms.
Salles et al., 2003⁵⁶56. Salles GF, Cardoso CR, Xavier SS, Sousa AS, Hasslocher-Moreno A. Electrocardiographic ventricular repolarization parameters in chronic Chagas' disease as predictors of asymptomatic left ventricular systolic dysfunction. Pacing Clin Electrophysiol . 2003;26(6):1326-35.	738	With and without cardiomyopathy	LVEF	Cross-sectional	QTd > 60ms, VES > 10%, LBBB
Marques et al., 2006²⁵25. Marques DS, Canesin MF, Barutta Jr F, Fuganti CJ, Barretto AC. Evaluation of asymptomatic patients with chronic Chagas disease through ambulatory electrocardiogram, echocardiogram and B-Type natriuretic peptide analyses. Arq Bras Cardiol . 2006;87(3):336-43.	106	Asymptomatic chronic ChD	Diastolic and systolic dysfunction	Cross-sectional	Presence of typical ECG alterations
Strauss et al., 2011³⁵35. Strauss DG, Cardoso S, Lima JA, Rochitte CE, Wu KC. ECG scar quantification correlates with cardiac magnetic resonance scar size and prognostic factors in Chagas' disease. Heart. 2011;97(5):357-61.	44	With and without cardiomyopathy	Late gadolinium enhancement area, reduced LVEF	Cross-sectional	QRS score
Ribeiro et al., 2013¹⁴14. Ribeiro AL, Sabino EC, Marcolino MS, Salemi VM, Ianni BM, Fernandes F, et al. Electrocardiographic abnormalities in Trypanosoma cruzi seropositive and seronegative former blood donors. PLoS Negl Trop Dis. 2013;7(2):e2078.	1,000	With and without cardiomyopathy	LVEF	Cross-sectional	QTc interval, QRS duration.

Author (year)	Number	Population	Follow up	Prognostic factors
Porto, 1964²⁸28. Porto CC. O eletrocardiograma no prognóstico e evolução da doença de chagas. Arq Bras Cardiol . 1964;17:313-46.	503	With and without	5 years	VES, number of ECG
		cardiomyopathy		alterations
Espinosa et al, 1985⁵⁸58. Espinosa RA, Pericchi LR, Carrasco HA, Escalante A, Martinez O, Gonzalez R. Prognostic indicators of chronic chagasic cardiopathy. Int J Cardiol . 1991;30(2):195-202.	107	With and without	10 years	ECG alterations, HF
		cardiomyopathy		symptoms
Acquatella et al, 1987⁵⁵55. Acquatella H, Catalioti F, Gomez-Mancebo JR, Davalos V, Villalobos L. Long-term control of Chagas disease in Venezuela: effects on serologic findings, electrocardiographic abnormalities, and clinical outcome. Circulation. 1987;76(3):556-62.	775	With and without	5 years	ECG alterations,
		cardiomyopathy		functional class
Maguire et al, 1987⁴4. Maguire JH, Hoff R, Sherlock I, Guimaraes AC, Sleigh AC, Ramos NB, et al. Cardiac morbidity and mortality due to Chagas' disease: prospective electrocardiographic study of a Brazilian community. Circulation. 1987;75(6):1140-5.	1,017	ChD vs	7 years	Incidence of ECG
		Seronegatives		alterations
Barretto et al, 1989²⁷27. Barretto AC, Bellotti G, Deperon SD, Arteaga-Fernandez E, Mady C, Ianni BM, et al. The value of the electrocardiogram in evaluating myocardial function in patients with Chagas' disease. Arq Bras Cardiol . 1989;52(2):69-73.	1,004	ChD	2 years	Higher incidence of VES and IE
Espinosa et al, 1991⁵⁸58. Espinosa RA, Pericchi LR, Carrasco HA, Escalante A, Martinez O, Gonzalez R. Prognostic indicators of chronic chagasic cardiopathy. Int J Cardiol . 1991;30(2):195-202.	66	With and without	12 years	AF
		cardiomyopathy
Bestetti et al, 1993⁴⁶46. Bestetti RB, Freitas OC, Muccillo G, Oliveira JS. Clinical and morphological characteristics associated with sudden cardiac death in patients with Chagas' disease. Eur Heart J. 1993;14(12):1610-4.	24	ChD who had sudden	Case control	ECG alterations
		death		(VES 79%; LAH 58%;
				RBBB 37%; VR
				alterations 41%; EI 25%,
				AVB 1^st 16%; AF 16%)
Salles et al, 2003⁵¹51. Salles G, Xavier S, Sousa A, Hasslocher-Moreno A, Cardoso C. Prognostic value of QT interval parameters for mortality risk stratification in Chagas' disease: results of a long-term follow-up study. Circulation. 2003;108(3):305-12.	738	With and without	58 +/- 39 months	EI, QTd > 65ms
		cardiomyopathy		increments;
				QTc Bazet > 465ms
Salles et al, 2004⁵⁰50. Salles GF, Xavier SS, Sousa AS, Hasslocher-Moreno A, Cardoso CR. T-wave axis deviation as an independent predictor of mortality in chronic Chagas' disease. Am J Cardiol . 2004;93(9):1136-40.	738	With and without	58 +/- 39 months	T-axis deviation
		cardiomyopathy		(> -15° to > -180° or >
				105° to < 180°)
Viotti et al, 2005⁴⁷47. Viotti R, Vigliano C, Lococo B, Petti M, Bertocchi G, Alvarez MG, et al. Clinical predictors of chronic chagasic myocarditis progression. Rev Esp Cardiol. 2005;58(9):1037-44.	856	ChD with cardiomyopathy	8 years	Intraventricular conduction
		without HF and ChD		disturbances; ventricular
		without cardiomyopathy		tachycardia
Rassi et al, 2006⁵²52. Rassi Jr A, Rassi A, Little WC, Xavier SS, Rassi SG, Rassi AG, et al. Development and validation of a risk score for predicting death in Chagas' heart disease. N Engl J Med. 2006;355(8):799-808.	424	ChD with cardiomyopathy	7.9 +/- 3.2 years	LV of QRS
Gonçalves et al, 2010⁴⁸48. Goncalves JGF, Dias Silva VJ, Calzada Borges MC, Prata A, Correia D. Mortality indicators among chronic Chagas patients living in an endemic area. Int J Cardiol . 2010;143(3):235-42.	120	ChD	24 years	RBBB + LAH, LBBB,
				Polymorphic ventricular
				tachycardia, PR interval > 0.16 s.
Ribeiro et al, 2014⁸8. Ribeiro AL, Marcolino MS, Prineas RJ, Lima-Costa MF. Electrocardiographic abnormalities in elderly Chagas disease patients: 10-year follow-up of the Bambui Cohort Study of Aging. J Am Heart Assoc. 2014;3(1):e000632.	1,462	Elderly with and without	10 years	Presence and number of
		cardiomyopathy		major ECG alterations
				(Minnesota code); RBBB
				+ LAH was the most
				important alteration.
Moraes et al, 2018⁴⁹49. Moraes DNM, Nascimento BR, Beaton AZ, Soliman EZ, Lima-Costa MF, dos Reis RCP, et al. Value of the electrocardiographic (P Wave, T Wave, QRS) axis as a predictor of mortality in 14 years in a population with a high prevalence of Chagas disease from the Bambui cohort study of aging. Am J Cardiol . 2018;121(3):364-9.	1,426	General population	12.8 years	Abnormal axis of P, QRS,
		(38% with ChD)		and T waves.

[1] Corresponding author: Dr. Antonio L. Ribeiro, MD, ScD. e-mail:tom@hc.ufmg.br

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Electrocardiogram in Chagas disease

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