Comprehensive care for patients with Chagas cardiomyopathy during the coronavirus disease pandemic

Chagas disease is a neglected tropical disease according to the World Health Organization. The most common clinical complication of Chagas disease is Chagas cardiomyopathy, that represents the main cause of non-ischemic cardiomyopathy in Latin America, affecting 20% to 40% of infected people. The chronic form, with a slow and persistent course, results from the destruction of the myocardial fibers, caused by a chronic inflammatory process. It is associated with intense reparative fibrosis and progressive ventricular remodeling and manifests as heart failure and/or arrhythmic and thromboembolic syndrome.

The elevated morbimortality related to Chagas cardiomyopathy 1 and affected population profiles of low income and poor education directly impact education, interfering with self-care and adherence to treatment programs 4 . In this setting, cardiovascular rehabilitation, which improves the functional capacity in chronic Chagas cardiomyopathy [5][6][7][8] , seems to be a favorable place to institute self-care strategies and adherence to treatment programs 4 .
To improve the care of patients with cardiomyopathy, many types of remote assessments have garnered attention in the past decades 9,10 . The American Association of Cardiovascular and Pulmonary Rehabilitation considers that healthcare professionals should adhere to the practice of cardiopulmonary rehabilitation through remote assessments to assure the highest quality of patient care 11 .
More studies are required to better conclude the effects of remote assessment strategies on the outcome of patients with cardiomyopathy. For example, telemonitoring and structured telephone support seem to reduce hospitalizations and mortality in patients with cardiovascular diseases 10 . Moreover, the improvement in functional capacity does not differ for patients with chronic heart failure subjected to telerehabilitation compared to a centerbased program 12 . To the best of our knowledge, there have been no studies on remote assessments in the management of Chagas cardiomyopathy. However, considering the importance of social isolation during the coronavirus disease (COVID-19) pandemic and need for a close follow-up for most patients with Chagas cardiomyopathy, the remote assessment strategy emerges as a useful alternative during this pandemic period in order to ensure continued comprehensive care delivered to patients while complying with social distancing 13 .
The healthcare team from the Evandro Chagas National Institute of Infectious Disease, a national reference center for the diagnosis and treatment of infectious diseases that regularly follows-up more than 1,000 patients with chronic Chagas disease under a comprehensive care treatment, started a telephone support for all patients with chronic Chagas cardiomyopathy enrolled in the cardiovascular rehabilitation program before the COVID-19 pandemic. To start the telephone support, a questionnaire was established ( Table 1), and a service scale was organized to contact patients to obtain information about their healthcare guidance, answer questions, and provide general guidance on healthcare during the pandemic. During the contact, the health professional confirmed the date of the next medical appointment or need for a new one and filled-out the questionnaire, obtaining information about weight control and blood glucose, regularity of food and drink intake, treatment adherence, personal hygiene measures, presence of physical and mental symptoms, financial difficulty, and maintenance of social isolation. To evaluate treatment adherence, based on our previous experience 14 , questions were asked to know if patients forgot to take medication, if they took it at the correct time, and if they stopped the medication because they felt better or Are you maintaining your body weight? 0/No ( ); 1/Yes ( ); Last weight: ___ 7 Have you been eating well? 0/No ( ); 1/Yes ( ) 8 Have you controlled your fluid intake? 0/No ( ); 1/Yes ( ) 9 Have you checked your glucose daily? 0/No ( ); 1/Yes ( ); Last glucose: ___ 10 Are you managing to take care of your hygiene without help? 0/No ( ); 1/Yes ( ) 11 Have you been active at home? 0/No ( ); 1/Yes ( ) 12 Are you taking care of children or grandchildren at home? 0/No ( ); 1/Yes ( ) 13 Have you experienced breathlessness at bedtime? 0/No ( ); 1/Yes ( ) 14 Have you had chest pain, a racing heart, or a fainting episode? 0/No ( ); 1/Yes ( ) 15 Are you sad from staying at home? 0/No ( ); 1/Yes ( ) 16 Are you feeling anxious? 0/No ( ); 1/Yes ( ) 17 Are you having financial difficulties? worse. In relation to personal hygiene measures, we asked about the ability to perform activities of daily living independently, including the ability to eat, dress, and shower without any help. To evaluate physical and mental symptoms, questions about the presence of breathlessness, pain, heart palpitations, fainting episodes, sadness, and anxiety were asked. Despite being a simple telephone contact, patients demonstrated satisfaction with the team concerned, and it was possible to collect the general information about their clinical status, such as significant weight change and the presence of symptoms. Finally, we believe that this telephone support strategy may help at least in part the maintenance of comprehensive care for our patients and could alert us for early signs and symptoms of decompensation, providing the opportunity for intervention before patients require hospitalization.

AUTHORS' CONTRIBUTION
All authors contributed to the conceptualization, writing, and reviewing of the manuscript. MFFM reviewed the manuscript for English.