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A Four-Year Follow-Upsurvey of Chagasic Cardiopathy in Chile1

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A Four-Year Follow-Upsurvey of Chagasic Cardiopathy in Chile1 A FOUR-YEAR FOLLOW-UPSURVEY OF CHAGASIC CARDIOPATHY IN CHILE1 Arturo Arribada C., 2 Werner Apt B.,3 and J. MantieZ Ugartti I NTRODUCTION of Chagas’ disease in endemic areas and its cardiac implications. This study re- The natural history of Chaga- vealed that all previous assessmentshad sic cardiopathy is still not well-known, underestimated both the incidence of mainly because innumerable clinical pic- the disease and its socioeconomic reper- tures develop without symptoms, and cussions for the country (1-G). Respond- the casesseen at hospitals are merely the ing to these findings, health authorities most overtly serious. This circumstance may tend to create a false impression that took up the problem and adopted a this cardiopathy is relatively benign, be- number of health measures-including periodic disinsection of accessible areas cause of the small demand it generates for hospital beds in comparison with and health education at community cen- other pathologies. Hence, if it were pos- ters and primary schools. (A simple ex- sible to elucidate what happens to the planatory leaflet was produced for these great majority of asymptomatic cases, education campaigns that informed that would constitute an important for- readers about the dangers of the disease ward step in understanding a diseasethat and about ways to prevent household in- afflicts millions of people in the Ameri- festations of triatomid vectors.) We also promoted parallel C&S. In 1977 we launched a long- studies seeking to elucidate epidemio- term project in Chile that was directed at logic relationships between humans, as- investigating the epidemiologic picture sociated animals, and vector insects (7- 8); to detect different types of vectors and examine their interrelationships; %it\ and to define the structures of zymo- 1 ’ This article will also be published in Spanish in the Bo- /ehi de la Ojcina Sanitaria Panamen~ana, Volume demes in various Tgpanosoma crzzi 3 101. 1986. The work reported was financed by a grant strains found in different endemic areas % from the University of Chile and by Grant No. 820599 (9-10). x from the UNDPlWorld Bank/WHO Tropical Diseases Research Program. This article reports our experi- 3 * Associate Professor of Medicine, Paula Jaraquemada ence with long-term field followup of Hospital, Faculty of Medicine, University of Chile, cardiac pathologies observed during the 2 Southern Division, Santiago, Chile. 3 Professor of Parasitology, Department of Experimental first survey, specifically regarding 2 Medicine, Faculty of Medicine, University of Chile, a, Southern Division, Santiago, Chile. ’ Professor of Biostatistics, Faculty of Medicine, Univer- sity of Chile, Northern Division, Santiago, Chile. 245 changes in the subjects’ clinical, sero- All members of these three logic, and electrocardiographic pictures groups were given serologic tests for 1: after a lapse of four years. It also reports crzlzi antibodies at the beginning of the findings concerning the risk that people original study and again after four years exposed to chagasic infection but show- (12-15). On both occasions each serum ing a normal ECG in the original survey sample was tested by two of three sero- would subsequently develop cardiopa- logic methods, the three being indirect thy. hemagglutination (IHA), complement futation (CF), and indirect immuno- fluorescence (IIF). IHA titers above 1: 16, CF titers above 1: 5, and IFF titers above M ATERIALS 1: 20 were considered positive. AND METHODS During the fourth year after the initial survey, the year depending Our original survey begun in upon when the first survey had been car- 1977, whose data were employed in the ried out, a clinical study was conducted work reported here, involved 2,938 sub- of 481 people in the three groups; this jects who were given serologic tests and study was similar to that conducted dur- ECGs. Nearly two-thirds of these sub- ing the original survey. In addition, these jects (1,932) yielded serologic results subjects were given a twelve-lead ECG negative for chagasic infection. Four with an extended II lead for the study of hundred and two (22%) of these 1,932 arrhythmias. These ECGs were analyzed showed significant ECG alterations, and independently of the serologic results ac- these 402 were considered to constitute a cording to the following parameters: spa- control group hereafter referred to as tial P, QRS, and T axes; PR, RR, RS, and “Group A.” The other 1,006 subjects QT intervals; amplitude of R in Vi and yielded serologic results positive for cha- V,; intrinsecoid deflection in Vi and V6; gasic infection. Three hundred and ST-T segment; and T-wave items (Soko- ninety-one (39 % ) of these 1,006 showed low index). The electrocardiographic di- significant ECG alterations, and 298 of agnoses developed in this manner were the latter yielded findings suggesting grouped according to the guidelines pro- chagasic cardiopathy (G,ll). These 298 posed by Maguire and colleagues (IT), constituted a group designated “Group and a statistical analysis was made of the B.” As the foregoing implies, 615 (61%) differences between the groups. In addi- of the 1,006 subjects with positive sero- tion, the diagnoses were analyzed ac- logic findings had normal ECGs; these cording to the age and sex of the persons % 615 were considered to be at risk of con- 2 surveyed in the three groups during the -. tracting chagasic cardiopathy at any initial ECG. When no significant differ- 3 time. For purposes of our study, 67 of ences were found, we used the method z these 615 were selected at random, des- of diagnosis employed in the original .$ ignated “Group C,” and subjected to work (5) to which Student’s t test was u further examination. These three groups B applied. were selected in 1981 when we began the We also studied the trend of 2 followup work reported here. ECG abnormalities in groups A and B by means of time-correlation graphs, and in this manner evaluated the origins of new abnormalities. By definition, there were 246 initially no normal ECGs in groups A and B, and normalization of an abnor- mality that had been recorded on the ini- SULTS tial ECG was regarded as a change for RE purposes of statistical analysis. However, Followup of Groups A and B because we were dealing with multiple abnormalities in many ECGs, normaliza- Table 1 shows the reasons for tion of a specific condition did not neces- reduction in the numbers of subjects in sarily constitute normalization of the groups A and B during the study period. whole tracing. Of the 402 original Group A subjects All of the studies reported (people with negative serology but ab- here-performed in 1981, 1982, 1983, normal ECGs), nine (2.2 % ) died from and 1984-were carried out in the 36 vil- causes indicated below; 168 (41.8%) lages where the original sample survey moved to other areas in search of better was conducted. For reasons to be dis- financial prospects; seven (1.7%) de- cussed, by the end of four years Group A clined to be surveyed; and two (0.5%) had been reduced to 216 subjects and showed a serologic conversion from nega- Group B to 198 subjects, and so it was tive to positive for 1: C~ZLZZ’antibodies. these subjects who provided the basis for Of the 298 original Group B the comparison reported here. subjects (people with positive serology, The members of all three abnormal ECGs, and findings suggesting groups lived in rural, mostly semi-desert Chagas’ disease), 22 (7.4%) died of cha- areas of northern Chile. All were en- gasic cardiopathy; one (0.3 % ) died of gaged in farming arable land found stomach cancer; 48 (16.1% ) moved to along the courses of small rivers flowing other areas; and 29 were eliminated for down from the Andes Mountains, and in the following reasons: Four were hospi- general all had very similar working con- talized in other areas at the time of the ditions. Apart from a few people over 80 survey; one was away in the mountains years of age who were excluded from looking after livestock; four underwent Group B in order to eliminate arterioscle- serologic conversion from positive to rotic pathologies (11), the age distribu- negative; two exhibited symptoms of tion of subjects in Group A and Group B aortic insuffrciency; one showed symp- was similar. The members of Group C toms of obstructive cardiomyopathy; 12 shared essentially the same socioeco- had diastolic pressure readings over 100 nomic conditions as members of the mmHg; and five had been over 80 years other two groups, but they tended to be old when initially surveyed. somewhat younger. The ages of the dif- Causes of death. All deaths in ferent subjects correspond to those re- Chile must be certified by the responsi- corded in the years mentioned above ble physician of the main provincial hos- (1981-1984), so that the recorded ages of pital. Because of this requirement, we all subjects were four years greater than were able to obtain reliable data about those recorded at the time of the original all of the study subjects who died during study. the study period. Four of the nine Group A fatalities (see Table 1) were caused by bronchopneumonial conditions, one by stomach cancer, one by a cerebrovascular accident, and three by refractory cardiac insufficiency. In contrast, nearly all the Group B fatalities appeared attributable 247 TABLE1. Changesin the sizes of groups A and 6 over the four-yearstudy period. GroupA Group 6 No. % No. % Size of original group 402 fW 298 fW Deathsdue to chagasic cardiopathy 0 KY 2; (7.4)a Deathsdue to other causes 9 (2.2)a (0.3) Left the area 168 (41.8) 48 (16.1) other status (2.2) 29 (9.7) Size after four years (53.7) 198 (66.4) a The difference in overall mortali (2.2% in Group A, 7.7% in Group 8) is highly signifint (P<O.COl).
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