IJCA-17913; No of Pages 1 International Journal of Cardiology xxx (2014) xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Incidence of sudden cardiac death in congestive heart failure: Chagas disease versus systemic arterial hypertension Henrique Horta Veloso ⁎ Department of Cardiology (Cardioteam), Hospital do Rio, Rio de Janeiro, Brazil
a r t i c l e
i n f o
Article history: Received 11 March 2014 Accepted 2 April 2014 Available online xxxx Keywords: Chagas disease Heart failure Systemic arterial hypertension Sudden cardiac death
In a recent article, Bestetti et al. [1] compared the outcome of patients with congestive heart failure (CHF) secondary to Chagas cardiomyopathy (n = 244) with those with CHF secondary to systemic arterial hypertension (n = 130). In this interesting research, patients were followed for 33 months and the probability of survival for Chagas disease at 12, 24, 36, 48, and 60 months was 76%, 56%, 45%, 37%, and 29%, respectively; nonetheless, the probability of survival for hypertensive cardiomyopathy at 12, 24, 36, 48, and 60 months was 96%, 92%, 82%, 77%, and 73%, respectively (p b 0.05). Thus, the authors concluded that patients with Chagas heart disease have a poorer outcome in comparison to those with CHF secondary to hypertensive cardiomyopathy. Unfortunately, in this article, the authors did not mention the mechanism of death in the studied population. The concept of a poorer prognosis of patients with CHF due to Chagas disease in comparison to those with hypertensive cardiomyopathy was already demonstrated in a Brazilian cohort of outpatients followed for 26 months [2]. In this study, the mortality rate was of 45% in the chagasic group (110 of 242 patients) versus 26% in the hypertensive group (45 of 170 patients) (p b 0.0001; relative risk 2.73, 95% confidence interval 1.82 to 4.07). Bestetti et al. [1] discussed that the worse prognosis of patients with CHF secondary to Chagas disease in comparison to those secondary to hypertensive cardiomyopathy could be the consequence of a less aggressive ventricular remodeling process observed in the latter, and also to the lower proportion of patients on, and the lower dose of, beta-blocker therapy in the Chagas group. Both of these explanations
can be related to a higher propensity to fatal arrhythmias and sudden cardiac death (SCD) in Chagas cardiomyopathy, but this mechanism of death was not explored. SCD is the main mechanism of death in patients with Chagas disease (62%), followed by progressive heart failure (15%) [3,4]. In chagasic patients with non-sustained ventricular tachycardia, this difference is still more evident (73% of SCD and 9% of heart failure) [5]. In opposition, it is well established that SCD is not a common event in patients with CHF secondary to hypertension. Among patients with SCD and nonischemic dilated cardiomyopathy of several etiologies, the proportion of cases with hypertensive cardiomyopathy is of only 15% [6]. After exploring the clinical characteristics of the patients studied by Bestetti et al. [1], it was found that data related to a higher risk for malignant arrhythmias were more present in the chagasic group than in the hypertensive group, such as the occurrence of ventricular premature complexes (46% versus 18%, p b 0.005), and the necessity for the use of amiodarone (39% versus 19%, p b 0.005) and of an implanted cardioverter-defibrillator (16% versus 0.7%, p b 0.001), despite a similar left ventricular ejection fraction (35% ± 13% versus 36% ± 10%, ns). In conclusion, I do believe that the main reason for the poorer outcome in patients with CHF due to Chagas heart disease, in comparison to those with CHF secondary to hypertensive cardiomyopathy and similar left ventricular ejection fractions, is the occurrence of malignant ventricular arrhythmias leading to SCD in chagasic patients. References [1] Bestetti PR, Otaviano AP, Fantini JP, et al. Prognosis of patients with chronic systolic heart failure: Chagas disease versus systemic arterial hypertension. Int J Cardiol 2013;168:2990–1. [2] Freitas HF, Chizzola PR, Paes AT, Lima AC, Mansur AJ. Risk stratification in a Brazilian hospital-based cohort of 1220 outpatients with heart failure: role of Chagas' heart disease. Int J Cardiol 2005;102:239–47. [3] Rassi Jr A, Rassi A, Little WC, et al. Development and validation of a risk score for predicting death in Chagas heart disease. N Engl J Med 2006;355:799–808. [4] Rassi Jr A, Rassi A, Rassi SG. Predictors of mortality in chronic Chagas disease: a systematic review of observational studies. Circulation 2007;115:1101–8. [5] da Silva RM, Távora MZ, Gondim FA, et al. Predictive value of clinical and electrophysiological variables in patients with chronic chagasic cardiomyopathy and nonsustained ventricular tachycardia. Arq Bras Cardiol 2000;75:33–47. [6] Hookana E, Junttila MJ, Puurunen VP, et al. Causes of nonischemic sudden cardiac death in the current era. Heart Rhythm 2011;8:1570–5.
⁎ Rua Conde de Bonfim 255/505, Tijuca, Rio de Janeiro, RJ, ZIP 20520-051, Brazil.
http://dx.doi.org/10.1016/j.ijcard.2014.04.012 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Veloso HH, Incidence of sudden cardiac death in congestive heart failure: Chagas disease versus systemic arterial hypertension, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.012
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Incidence of sudden cardiac death in congestive heart failure: Chagas disease versus systemic arterial hypertension Henrique Horta Veloso ⁎ Department of Cardiology (Cardioteam), Hospital do Rio, Rio de Janeiro, Brazil
a r t i c l e
i n f o
Article history: Received 11 March 2014 Accepted 2 April 2014 Available online xxxx Keywords: Chagas disease Heart failure Systemic arterial hypertension Sudden cardiac death
In a recent article, Bestetti et al. [1] compared the outcome of patients with congestive heart failure (CHF) secondary to Chagas cardiomyopathy (n = 244) with those with CHF secondary to systemic arterial hypertension (n = 130). In this interesting research, patients were followed for 33 months and the probability of survival for Chagas disease at 12, 24, 36, 48, and 60 months was 76%, 56%, 45%, 37%, and 29%, respectively; nonetheless, the probability of survival for hypertensive cardiomyopathy at 12, 24, 36, 48, and 60 months was 96%, 92%, 82%, 77%, and 73%, respectively (p b 0.05). Thus, the authors concluded that patients with Chagas heart disease have a poorer outcome in comparison to those with CHF secondary to hypertensive cardiomyopathy. Unfortunately, in this article, the authors did not mention the mechanism of death in the studied population. The concept of a poorer prognosis of patients with CHF due to Chagas disease in comparison to those with hypertensive cardiomyopathy was already demonstrated in a Brazilian cohort of outpatients followed for 26 months [2]. In this study, the mortality rate was of 45% in the chagasic group (110 of 242 patients) versus 26% in the hypertensive group (45 of 170 patients) (p b 0.0001; relative risk 2.73, 95% confidence interval 1.82 to 4.07). Bestetti et al. [1] discussed that the worse prognosis of patients with CHF secondary to Chagas disease in comparison to those secondary to hypertensive cardiomyopathy could be the consequence of a less aggressive ventricular remodeling process observed in the latter, and also to the lower proportion of patients on, and the lower dose of, beta-blocker therapy in the Chagas group. Both of these explanations
can be related to a higher propensity to fatal arrhythmias and sudden cardiac death (SCD) in Chagas cardiomyopathy, but this mechanism of death was not explored. SCD is the main mechanism of death in patients with Chagas disease (62%), followed by progressive heart failure (15%) [3,4]. In chagasic patients with non-sustained ventricular tachycardia, this difference is still more evident (73% of SCD and 9% of heart failure) [5]. In opposition, it is well established that SCD is not a common event in patients with CHF secondary to hypertension. Among patients with SCD and nonischemic dilated cardiomyopathy of several etiologies, the proportion of cases with hypertensive cardiomyopathy is of only 15% [6]. After exploring the clinical characteristics of the patients studied by Bestetti et al. [1], it was found that data related to a higher risk for malignant arrhythmias were more present in the chagasic group than in the hypertensive group, such as the occurrence of ventricular premature complexes (46% versus 18%, p b 0.005), and the necessity for the use of amiodarone (39% versus 19%, p b 0.005) and of an implanted cardioverter-defibrillator (16% versus 0.7%, p b 0.001), despite a similar left ventricular ejection fraction (35% ± 13% versus 36% ± 10%, ns). In conclusion, I do believe that the main reason for the poorer outcome in patients with CHF due to Chagas heart disease, in comparison to those with CHF secondary to hypertensive cardiomyopathy and similar left ventricular ejection fractions, is the occurrence of malignant ventricular arrhythmias leading to SCD in chagasic patients. References [1] Bestetti PR, Otaviano AP, Fantini JP, et al. Prognosis of patients with chronic systolic heart failure: Chagas disease versus systemic arterial hypertension. Int J Cardiol 2013;168:2990–1. [2] Freitas HF, Chizzola PR, Paes AT, Lima AC, Mansur AJ. Risk stratification in a Brazilian hospital-based cohort of 1220 outpatients with heart failure: role of Chagas' heart disease. Int J Cardiol 2005;102:239–47. [3] Rassi Jr A, Rassi A, Little WC, et al. Development and validation of a risk score for predicting death in Chagas heart disease. N Engl J Med 2006;355:799–808. [4] Rassi Jr A, Rassi A, Rassi SG. Predictors of mortality in chronic Chagas disease: a systematic review of observational studies. Circulation 2007;115:1101–8. [5] da Silva RM, Távora MZ, Gondim FA, et al. Predictive value of clinical and electrophysiological variables in patients with chronic chagasic cardiomyopathy and nonsustained ventricular tachycardia. Arq Bras Cardiol 2000;75:33–47. [6] Hookana E, Junttila MJ, Puurunen VP, et al. Causes of nonischemic sudden cardiac death in the current era. Heart Rhythm 2011;8:1570–5.
⁎ Rua Conde de Bonfim 255/505, Tijuca, Rio de Janeiro, RJ, ZIP 20520-051, Brazil.
http://dx.doi.org/10.1016/j.ijcard.2014.04.012 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Veloso HH, Incidence of sudden cardiac death in congestive heart failure: Chagas disease versus systemic arterial hypertension, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.012
