Cognitive dysfunction in chronic Chagas disease cardiomyopathy

Dias, Jesângeli Sousa; Lacerda, Amanda M.; Vieira-de-Melo, Rodrigo M.; Viana, Leila C.; Jesus, Pedro A.P.; Reis, Francisco J.F.B.; Nitrini, Ricardo; Charchat-Fichman, Helenice; Lopes, Antônio A.; Oliveira-Filho, Jamary

doi:10.1590/S1980-57642009DN30100006

Abstract

Chagas disease (CD) remains a major cause of stroke in developing countries, but cognitive repercussion of CD has not been well studied.

Objective:

To compare the frequency and pattern of cognitive dysfunction in patients with CD cardiomyopathy (CDC) and other cardiomyopathies (OC).

Methods:

We studied 37 patients with CDC and 42 patients with OC with similar age, educational level and cardiac systolic function. Cognitive tests were applied to both groups by a single examiner blinded to CD status. Logistic regression multivariable models were constructed to ascertain predictors of cognitive dysfunction for each test.

Results:

Cognitive dysfunction was detected in 9 (24%) CDC patients and 6 (14%) OC patients by Mini Mental State Exam (MMSE) corrected for educational level. Independent predictors of abnormal MMSE (p <0.05) included stroke history (OR=5.51; 95% CI=1.27-24.01) and digoxin use (OR=0.23, 95% CI=0.06-0.89), while CD showed a trend toward statistical significance (OR=4.63; 95% CI=0.87-24.73, p =0.07). Delayed recall of Rey's Complex Figure Test was significantly worse in CD patients, where this remained a significant predictor in the multivariable analysis (OR=4.67; 95% CI=1.23-17.68).

Conclusions:

Cognitive dysfunction is frequent in Chagas disease and should be considered as an outcome measure in Chagas disease studies.

Key words:
Chagas disease; American trypanosomiasis; cognition; cerebrovascular disorders.

Resumo

A doença de Chagas (DC) permanence uma causa importante de acidente vascular cerebral em países em desenvolvimento, mas a repercussão cognitiva dessa doença não tem sido bem estudada.

Objetivo:

Comparar a frequência e padrão de disfunção cognitiva em pacientes com cardiomiopatia associada à DC (CDC) em comparação com outras cardiomiopatias (OC).

Métodos:

Foram estudados 37 pacientes com CDC e 42 portadores de OC com idade, nível de instrução e função sistólica cardíaca semelhantes. Testes cognitivos foram realizados em ambos os grupos por um único investigador cegado quanto ao diagnóstico de DC. Modelos de regressão logística multi-variável foram construídos para detectar preditores de disfunção cognitiva para cada teste.

Resultados:

Disfunção cognitiva foi detectada em 9 (24%) pacientes com CDC e 6 (14%) com OC pelo Mini Exame do Estado Mental (MEEM) corrigido pelo nível de instrução. Preditores independentes de MEEM anormal (p <0,05) foram: história de AVC (OR=5,51; IC 95%=1,27-24,01) e uso de digoxina (OR=0,23, IC 95%=0,06-0,89); DC mostrou tendência a significância estatística (OR=4,63; IC 95%=0,87-24,73, p =0,07). Pacientes com CDC apresentaram pior desempenho na evocação tardia da figura complexa de Rey. Neste teste, a DC se manteve um preditor significante de disfunção cognitiva na análise multivariável (OR=4,67; IC 95%=1,23-17,68).

Conclusões:

Disfunção cognitiva é frequente na doença de Chagas e deve ser considerada como desfecho quantificado nos estudos da doença de Chagas.

Palavras-chave:
doença de Chagas; Tripanossomíase americana; cognição; transtornos cerebrovasculares.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

References

¹
Carod-Artal FJ, Vargas AP, Melo M, Horan TA. American trypanosomiasis (Chagas' disease): an unrecognised cause of stroke. J Neurol Neurosurg Psychiatry 2003;74:516-518.
²
Control of Chagas disease. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 1991;811:1-95.
³
Frank M, Hegenscheid B, Janitschke K, Weinke T. Prevalence and epidemiological significance of Trypanosoma cruzi infection among Latin American immigrants in Berlin, Germany. Infection 1997;25:355-358.
⁴
Reesink HW. European strategies against the parasite transfusion risk. Transfus Clin Biol 2005;12:1-4.
⁵
Chagas C. Nova entidade mórbida do homem. Rezumo geral de estudos etiologicos e clinicos. Mem Inst Oswaldo Cruz 1911;3:219-275.
⁶
Pittella JE. Central nervous system involvement in Chagas' disease. An updating. Rev Inst Med Trop Sao Paulo 1993;35:111-116.
⁷
Pitella JE. Ischemic cerebral changes in the chronic chagasic cardiopathy. Arq Neuropsiquiatr 1984;42:105-115.
⁸
de Queiroz AC, Ramos EA. Anatomo-pathological study of the brain in idiopathic cardiomegaly. Arq Neuropsiquiatr 1979;37:405-411.
⁹
Mangone CA, Sica RE, Pereyra S, et al. Cognitive impairment in human chronic Chagas' disease. Arq Neuropsiquiatr 1994;52:200-203.
¹⁰
Zuccala G, Cattel C, Manes-Gravina E, Di Niro MG, Cocchi A, Bernabei R. Left ventricular dysfunction: a clue to cognitive impairment in older patients with heart failure. J Neurol Neurosurg Psychiatry 1997;63:509-512.
¹¹
Zuccala G, Onder G, Pedone C, et al. Hypotension and cognitive impairment: Selective association in patients with heart failure. Neurology 2001;57:1986-1992.
¹²
Cacciatore F, Abete P, Ferrara N, et al. Congestive heart failure and cognitive impairment in an older population. Osservatorio Geriatrico Campano Study Group. J Am Geriatr Soc 1998;46:1343-1348.
¹³
Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Suggestions for utilization of the mini-mental state examination in Brazil. Arq Neuropsiquiatr 2003;61:777-781.
¹⁴
Nitrini R, Lefevre BH, Mathias SC, et al. Neuropsychological tests of simple application for diagnosing dementia. Arq Neuropsiquiatr 1994;52:457-465.
¹⁵
Nitrini R, Caramelli P, Herrera Junior E, et al. Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory. J Int Neuropsychol Soc 2004;10:634-638.
¹⁶
Wechsler D. Wechsler Adult Intelligence Scale-Revised (WAIS-R). San Antônio: in Corporation TP;1981.
¹⁷
Diniz LFMC, Torres MF, Macedo V, Cosenza RC. The Rey auditory-verbal learning test: norms for a Brazilian sample. Rev Bras Neurol 2000;36:79-83.
¹⁸
Rey A. Manuel du test de copie d'une figure complexe de A. Rey. Paris: Les Editions du Centre de Psychologie Appliquée;1959.
¹⁹
Snaith RP, Zigmond AS: The hospital anxiety and depression scale. Br Med J (Clin Res Ed) 1986;292:344.
²⁰
Herrera Jr E, Caramelli P, Silveira AS, Nitrini R. Epidemiologic survey of dementia in a community-dwelling Brazilian population. Alzheimer Dis Assoc Disord 2002;16:103-108.
²¹
Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. The Mini-Mental State Examination in a general population: impact of educational status. Arq Neuropsiquiatr 1994;52:1-7.
²²
Zuccala G, Marzetti E, Cesari M, et al. Correlates of cognitive impairment among patients with heart failure: results of a multicenter survey. Am J Med 2005;118:496-502.
²³
Zuccala G, Onder G, Pedone C, et al. Cognitive dysfunction as a major determinant of disability in patients with heart failure: results from a multicentre survey. On behalf of the GIFA (SIGG-ONLUS) Investigators. J Neurol Neurosurg Psychiatry 2001;70:109-112.
²⁴
Zuccala G, Pedone C, Cesari M, et al. The effects of cognitive impairment on mortality among hospitalized patients with heart failure. Am J Med 2003;115:97-103.
²⁵
Tucker AR, Ng KT. Digoxin-related impairment of learning and memory in cardiac patients. Psychopharmacology (Berl) 1983;81:86-88.
²⁶
Kurup RK, Kurup PA. Hypothalamic digoxin, hemispheric chemical dominance, and creativity. Int J Neurosci 2003; 113:565-577.
²⁷
Kurup RK, Kurup PA. A hypothalamic digoxin-mediated model for conscious and subliminal perception. Int J Neurosci 2003;113:815-820.
²⁸
Nunes MC, Barbosa MM, Rocha MO. Peculiar aspects of cardiogenic embolism in patients with Chagas' cardiomyopathy: a transthoracic and transesophageal echocardiographic study. J Am Soc Echocardiogr 2005;18:761-767.
²⁹
Oliveira-Filho J, Viana LC, Vieira-de-Melo RM, et al. Chagas disease is an independent risk factor for stroke: baseline characteristics of a Chagas disease cohort. Stroke 2005;36:2015-2017.
³⁰
Foerch C, Misselwitz B, Sitzer M, et al. Difference in recognition of right and left hemispheric stroke. Lancet 2005;366:292-293.
³¹
Ostrosky-Solis F, Ardila A, Rosselli M, Lopez-Arango G, Uriel-Mendoza V. Neuropsychological test performance in illiterate subjects. Arch Clin Neuropsychol 1998;13:645-660.
³²
Castro-Caldas A, Petersson KM, Reis A, Stone-Elander S, Ingvar M. The illiterate brain. Learning to read and write during childhood influences the functional organization of the adult brain. Brain 1998;121(Pt 6):1053-1063.

Publication Dates

Publication in this collection
Jan-Mar 2009

History

Received
31 Dec 2008
Accepted
11 Feb 2009

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Carod-Artal FJ, Vargas AP, Melo M, Horan TA. American trypanosomiasis (Chagas' disease): an unrecognised cause of stroke. J Neurol Neurosurg Psychiatry 2003;74:516-518.

[2] ²
Control of Chagas disease. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 1991;811:1-95.

[3] ³
Frank M, Hegenscheid B, Janitschke K, Weinke T. Prevalence and epidemiological significance of Trypanosoma cruzi infection among Latin American immigrants in Berlin, Germany. Infection 1997;25:355-358.

[4] ⁴
Reesink HW. European strategies against the parasite transfusion risk. Transfus Clin Biol 2005;12:1-4.

[5] ⁵
Chagas C. Nova entidade mórbida do homem. Rezumo geral de estudos etiologicos e clinicos. Mem Inst Oswaldo Cruz 1911;3:219-275.

[6] ⁶
Pittella JE. Central nervous system involvement in Chagas' disease. An updating. Rev Inst Med Trop Sao Paulo 1993;35:111-116.

[7] ⁷
Pitella JE. Ischemic cerebral changes in the chronic chagasic cardiopathy. Arq Neuropsiquiatr 1984;42:105-115.

[8] ⁸
de Queiroz AC, Ramos EA. Anatomo-pathological study of the brain in idiopathic cardiomegaly. Arq Neuropsiquiatr 1979;37:405-411.

[9] ⁹
Mangone CA, Sica RE, Pereyra S, et al. Cognitive impairment in human chronic Chagas' disease. Arq Neuropsiquiatr 1994;52:200-203.

[10] ¹⁰
Zuccala G, Cattel C, Manes-Gravina E, Di Niro MG, Cocchi A, Bernabei R. Left ventricular dysfunction: a clue to cognitive impairment in older patients with heart failure. J Neurol Neurosurg Psychiatry 1997;63:509-512.

[11] ¹¹
Zuccala G, Onder G, Pedone C, et al. Hypotension and cognitive impairment: Selective association in patients with heart failure. Neurology 2001;57:1986-1992.

[12] ¹²
Cacciatore F, Abete P, Ferrara N, et al. Congestive heart failure and cognitive impairment in an older population. Osservatorio Geriatrico Campano Study Group. J Am Geriatr Soc 1998;46:1343-1348.

[13] ¹³
Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Suggestions for utilization of the mini-mental state examination in Brazil. Arq Neuropsiquiatr 2003;61:777-781.

[14] ¹⁴
Nitrini R, Lefevre BH, Mathias SC, et al. Neuropsychological tests of simple application for diagnosing dementia. Arq Neuropsiquiatr 1994;52:457-465.

[15] ¹⁵
Nitrini R, Caramelli P, Herrera Junior E, et al. Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory. J Int Neuropsychol Soc 2004;10:634-638.

[16] ¹⁶
Wechsler D. Wechsler Adult Intelligence Scale-Revised (WAIS-R). San Antônio: in Corporation TP;1981.

[17] ¹⁷
Diniz LFMC, Torres MF, Macedo V, Cosenza RC. The Rey auditory-verbal learning test: norms for a Brazilian sample. Rev Bras Neurol 2000;36:79-83.

[18] ¹⁸
Rey A. Manuel du test de copie d'une figure complexe de A. Rey. Paris: Les Editions du Centre de Psychologie Appliquée;1959.

[19] ¹⁹
Snaith RP, Zigmond AS: The hospital anxiety and depression scale. Br Med J (Clin Res Ed) 1986;292:344.

[20] ²⁰
Herrera Jr E, Caramelli P, Silveira AS, Nitrini R. Epidemiologic survey of dementia in a community-dwelling Brazilian population. Alzheimer Dis Assoc Disord 2002;16:103-108.

[21] ²¹
Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. The Mini-Mental State Examination in a general population: impact of educational status. Arq Neuropsiquiatr 1994;52:1-7.

[22] ²²
Zuccala G, Marzetti E, Cesari M, et al. Correlates of cognitive impairment among patients with heart failure: results of a multicenter survey. Am J Med 2005;118:496-502.

[23] ²³
Zuccala G, Onder G, Pedone C, et al. Cognitive dysfunction as a major determinant of disability in patients with heart failure: results from a multicentre survey. On behalf of the GIFA (SIGG-ONLUS) Investigators. J Neurol Neurosurg Psychiatry 2001;70:109-112.

[24] ²⁴
Zuccala G, Pedone C, Cesari M, et al. The effects of cognitive impairment on mortality among hospitalized patients with heart failure. Am J Med 2003;115:97-103.

[25] ²⁵
Tucker AR, Ng KT. Digoxin-related impairment of learning and memory in cardiac patients. Psychopharmacology (Berl) 1983;81:86-88.

[26] ²⁶
Kurup RK, Kurup PA. Hypothalamic digoxin, hemispheric chemical dominance, and creativity. Int J Neurosci 2003; 113:565-577.

[27] ²⁷
Kurup RK, Kurup PA. A hypothalamic digoxin-mediated model for conscious and subliminal perception. Int J Neurosci 2003;113:815-820.

[28] ²⁸
Nunes MC, Barbosa MM, Rocha MO. Peculiar aspects of cardiogenic embolism in patients with Chagas' cardiomyopathy: a transthoracic and transesophageal echocardiographic study. J Am Soc Echocardiogr 2005;18:761-767.

[29] ²⁹
Oliveira-Filho J, Viana LC, Vieira-de-Melo RM, et al. Chagas disease is an independent risk factor for stroke: baseline characteristics of a Chagas disease cohort. Stroke 2005;36:2015-2017.

[30] ³⁰
Foerch C, Misselwitz B, Sitzer M, et al. Difference in recognition of right and left hemispheric stroke. Lancet 2005;366:292-293.

[31] ³¹
Ostrosky-Solis F, Ardila A, Rosselli M, Lopez-Arango G, Uriel-Mendoza V. Neuropsychological test performance in illiterate subjects. Arch Clin Neuropsychol 1998;13:645-660.

[32] ³²
Castro-Caldas A, Petersson KM, Reis A, Stone-Elander S, Ingvar M. The illiterate brain. Learning to read and write during childhood influences the functional organization of the adult brain. Brain 1998;121(Pt 6):1053-1063.

Brasil