An update on the management of Chagas cardiomyopathy

Chagas disease, caused by the protozoan parasite Trypanosoma cruzi, infects nearly 18 million people in Latin America and mainly affects the heart, causing heart failure, arrhythmias, heart block, thromboembolism, stroke and death. In this review, the clinical diagnosis and management of Chagas cardiomyopathy are discussed. Particular emphasis is placed on the clinical staging of patients and the use of various diagnostic tests that may be useful in individualizing treatment of the two most relevant clinical syndromes, that is, heart failure and arrhythmias. The relevance of specific treatments are discussed, stressing the important role of parasite persistence in disease pathogenesis. We also discuss new therapy modalities that may have a role in the treatment of Chagas cardiomyopathy.     

Mortality prediction in Chagas heart disease

Chagas disease continues to be an important cause of cardiac disease in many countries of Latin America. Dilated cardiomyopathy constitutes the more severe manifestation and main cause of death in the disease. Typical clinical presentations include three basic syndromes: heart failure, cardiac arrhythmia and thromboembolism. The identification of markers related to the progression of Chagas heart disease is relevant for appropriate patient management. The most important predictors of death are New York Heart Association functional class, left ventricular systolic dysfunction and nonsustained ventricular tachycardia, which reflect the severity of myocardial damage. Several other potential prognostic factors have recently been reported. Scores for mortality prediction using a combination of prognostic variables have contributed to overall improvement in risk stratification in the setting of Chagas disease.     

Device therapy in Chagas disease heart failure

Chagas disease is the principal cause of chronic heart failure in areas where the disease is endemic. The medical treatment is the same recommended for non-Chagas disease patients. There is no evidence-based medicine support for device therapy in Chagas disease heart failure. Cardiac resynchronization therapy is recommended for Chagas disease heart failure patients with intraventricular conduction disturbances, mainly for those with left bundle branch block, and in advanced congestive heart failure refractory to targeted medical treatment, although this therapy is still polemic in Chagas disease heart failure. Implantable cardioverter–defibrillator (ICD) therapy is indicated to Chagas disease patients with left ventricular ejection fraction <30% for primary prevention of sudden cardiac death. ICD therapy is offered to patients for secondary prevention of sudden cardiac death. Patients with moderate left ventricular dysfunction and inducible arrhythmia at electrophysiological testing should receive ICD therapy.     

Long-term outcomes of autologous skeletal myoblast cell-sheet transplantation for end-stage ischemic cardiomyopathy

1. Download : Download high-res image (248KB)
2. Download : Download full-size image

     

Reoccurrence of takotsubo cardiomyopathy induced by osimertinib: A case report

A patient with lung cancer was administrated osimertinib. She developed symptomatic heart failure due to Takotsubo cardiomyopathy (TC). As her condition improved after discontinuing osimertinib, TC was thought to be caused by osimertinib. Reoccurrence of TC was seen after readministrating half dose of osimertinib.     

脂联素防治糖尿病心肌病的研究进展

糖尿病心肌病(diabetic cardiomyopathy, DCM)是一种基于糖尿病,排除心脏本身疾病导致的独立的缺血性心肌疾病。DCM的发病机制由多因素造成,目前并不十分明确,其主要由心肌细胞的损伤、血糖浓度增高、能量代谢紊乱及微血管病变引起。脂联素(adiponectin, APN)具有降血糖、调血脂、抗凋亡、抗炎症反应、抗氧化作用,也能预防动脉粥样硬化,与DCM的发生发展具有密切关系。本文就APN在DCM中作用的研究进展作一综述。     

Cellular cardiac regenerative therapy in which patients?

Cell-based myocardial regenerative therapy is undergoing experimental and clinical trials in order to limit the consequences of decreased contractile function and compliance of damaged ventricles owing to ischemic and nonischemic myocardial diseases. A variety of myogenic and angiogenic cell types have been proposed, such as skeletal myoblasts, mononuclear and mesenchymal bone marrow cells, circulating blood-derived progenitors, adipose-derived stromal cells, induced pluripotent stem cells, umbilical cord cells, endometrial mesenchymal stem cells, adult testis pluripotent stem cells and embryonic cells. Current indications for stem cell therapy concern patients who have had a left- or right-ventricular infarction or idiopathic dilated cardiomyopathies. Other indications and potential applications include patients with diabetic cardiomyopathy, Chagas heart disease (American trypanosomiasis), ischemic mitral regurgitation, left ventricular noncompacted myocardium and pediatric cardiomyopathy. Suitable sources of cells for cardiac implant will depend on the types of diseases to be treated. For acute myocardial infarction, a cell that reduces myocardial necrosis and augments vascular blood flow will be desirable. For heart failure, cells that replace or promote myogenesis, reverse apoptopic mechanisms and reactivate dormant cell processes will be useful. It is important to note that stem cells are not an alternative to heart transplantation; selected patients should be in an early stage of heart failure as the goal of this regenerative approach is to avoid or delay organ transplantation. Since the cell niche provides crucial support needed for stem cell maintenance, the most interesting and realistic perspectives include the association of intramyocardial cell transplantation with tissue-engineered scaffolds and multisite cardiac pacing in order to transform a passive regenerative approach into a ‘dynamic cellular support’, a promising method for the creation of ‘bioartificial myocardium’.     

Emergency department evaluation and management of peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) affects 1000-1300 women in the United States each year. We present three cases of PPCM seen in our Emergency Department (ED) that cover the entire spectrum of disease from mild heart failure to sudden cardiac death. Without previous heart disease, these women develop cardiomyopathy with impairment of left ventricular function in the last month of pregnancy, or during the first 5 months postpartum. The etiology of PPCM is not clear, although various mechanisms have been proposed, including infection, autoimmune response, prolonged tocolysis during labor, and maladaptive responses to the hemodynamic changes of pregnancy. The initial presentation of these patients is frequently to the ED. The differential diagnosis and key characteristics of PPCM are discussed. ED management should focus on three elements: reduction in pre-load, reduction in afterload, and increase in inotropy. Key differences between the antepartum and postpartum states are highlighted.     

Stem cells for the ischaemic heart

The discovery of adult progenitor cells capable of generating new vascular and myocardial tissue offers the promise of salvage of ischaemically threatened or irreversibly damaged cardiac tissue. Not surprisingly, great interest has focused on the use of a variety of cell types to treat both acute myocardial infarction and chronic ischaemic heart disease. This review focuses on the treatment of these two categories of disease, the cell types being considered, our understanding of timing and methods of cellular administration, and possible mechanisms of myocardial salvage.     

左卡尼汀治疗缺血性心肌病心力衰竭的临床价值

目的探讨左卡尼汀治疗缺血性心肌病心力衰竭的临床价值。方法选取本院诊治的缺血性心肌病心力衰竭患者127例,随机被分为两组,常规治疗患者63例为对照组,常规治疗加用左卡尼汀患者64例为观察组,疗程3个月,比较两组临床病症改善情况、临床指标改变情况、临床疗效及不良反应。结果治疗后,两组左心室射血分数、左心室短轴缩短率、心输出量、每搏输出量、6分钟步行距离均明显增加,两组左心室舒张末期内径、左心室收缩末期内径、血浆B型钠尿肽均明显减小。观察组左心室射血分数、左心室短轴缩短率、心输出量、每搏输出量、6分钟步行距离均明显大于对照组,观察组左心室舒张末期内径、左心室收缩末期内径、血浆B型钠尿肽均明显小于对照组,观察组胸闷病症消失率、气短病症消失率、乏力病症消失率、水肿病症消失率、治疗总有效率均明显高于对照组(均P0.05)。结论左卡尼汀可明显改善缺血性心肌病心力衰竭患者的临床病症,显著改善患者的临床指标,临床疗效显著,引发的不良反应较少,具有较高的安全性。     

扩张型心肌病心力衰竭患者血清韧粘素-C的研究

目的探讨扩张性心肌病伴心力衰竭患者血清韧粘素-C（TN-C）、脑钠肽（BN-P）和Ⅲ型胶原前体氨端肽（PC-Ⅲ）的含量及意义。方法对30例DCM患者和30例健康对照者采用酶联免疫吸附双抗体夹心法（ELISA）测定血清TN-C含量，应用免疫放射法（IRA）测定BNP和PC-Ⅲ含量。结果与正常对照组相比，DCM患者血清TN-C含量显著增高（P〈0．001）。心力衰竭越重，DCM患者血清TN-C、BNP和PC-Ⅲ含量增加越明显，TN-C与左室射血分数负相关（r=-0．8947，P〈0．001）、与BNP（r=0．9522，P〈0．001）正相关结论DCM患者血清TN-C明显升高，血清TN-C可反映DCM患者心力衰竭的严重程度。     

扩张性心肌病心力衰竭病人外周血干细胞内源性动员的观察

目的观察扩张性心肌病（DCM）心力衰竭患者外周血中CD34-阳性的单个核细胞（CD34-positive mononuclear cells,MNCCD34）的动员及其变化规律。方法观察DCM患者外周血中不同时间段MNCCD34的数量,测量粒细胞集落刺激因子（granulocyte colony-stimulating factor,G-CSF）等5项细胞因子在血浆中不同时间段的变化水平。结果 （1）MNCCD34从心力衰竭后便开始增加,第5-7天达到峰值,然后逐渐呈下降趋势,但在第28天MNCCD34的数目仍然较高。（2）DCM心衰组和对照组MNCCD34数目在第10天时差异有非常显著性（P〈0.001）。（3）外周血中的细胞因子G-CSF显著增高,且于第10天达到峰值。（4）单因素回归分析显示,循环中MNCCD34的数目同血浆中G-CSF的水平密切相关（r=0.379,P〈0.01）。结论 DCM心衰患者外周血中MNCCD34的数目和G-CSF水平是增高的,且二者密切相关。证明DCM心衰后机体存在骨髓动员和自我修复现象。G-CSF是外周血干细胞的动员剂。     

Implementation of Cardovascular Cell Therapy Network trials: challenges,innovation and lessons learned from experience in the CCTRN

The cardiovascular cell therapy network was developed by the National Heart, Lung and Blood Institute to design and conduct clinical trials to advance the field of cardiovascular (CV) cell-based therapy. The Cardiovascular Cell Therapy Network successfully completed three clinical trials involving approximately 300 subjects across five centers and six satellites. Although the concept of a network within clinical trials research is not new, the knowledge gained in the implementation of such large-scale trials, particularly in novel therapeutic areas such as cell therapy is not often detailed in the literature. The purpose of this communication is to summarize key factors in achieving network goals and share the knowledge gained to promote success in future cardiovascular disease cell therapy trials and networks.     

曲美他嗪治疗缺血性心肌病心力衰竭的疗效评价

目的评价曲美他嗪治疗缺血性心肌病心力衰竭的临床疗效.方法采用随机、单盲对照及组间对照,将42例缺血性心肌病心力衰竭患者分为曲美他嗪组(21例),服用曲美他嗪20mg,3次/d;常规治疗组(对照组,21例),疗程均为8周,观察两组治疗前后临床疗效、左室射血分数(LVEF)、左室舒张末期容积(EDV)、左室收缩末期容积(ESV)、6min步行距离.结果治疗后曲美他嗪组总有效率76.2%,对照组总有效率52.4%,治疗后与治疗前相比LVEF、EDV、ESV,6min步行距离等相关参数均有显著改善(P＜0.05),曲美他嗪组与对照组比较差异有显著性意义(P＜0.05);未发现与药物相关的不良反应.结论曲美他嗪能改善缺血性心肌病患者心功能,值得临床推广应用.     

基于CT获得的心肌应变参数在肥厚型心肌病和高血压性心脏病中的应用

目的  探讨基于CT获得的心肌应变（MS）参数在评估肥厚型心肌病（HCM）和高血压性心脏病（HHD）早期左室功能的可行性,以及该参数区分这两种疾病的能力。方法  本研究为回顾性研究,纳入2021年12月~2023年1月在空军军医大学西京医院接受心脏冠状动脉血管成像检查,结果呈阴性的205例成年受试者。依据各组纳入及排除标准将受试者分为HCM组（n=70）、HHD组（n=65）和健康对照组（n=70）。采用后处理软件对3组的左室形态学特征、传统心功能参数以及MS参数进行了量化,比较参数的差异,以及对这两种疾病的鉴别能力。结果  相较于健康对照组,HCM与HHD组的左室壁最大厚度、左室质量指数均有不同程度增高（9.25±1.68 vs 15.32±1.67 vs 18.01±2.24;56.64±19.57 vs 86.90±12.31 vs 106.27±19.56,P < 0.001）,而MS绝对值则均有不同程度降低（心肌整体周向应变,-25.80±3.74 vs -23.00±4.49 vs -21.03±4.97;心内膜下整体周向应变,-40.95±8.13 vs -35.86±7.90 vs -31.85±9.16;心肌整体径向应变,81.26±37.76 vs 66.99±18.37 vs 55.31±23.19,P < 0.001）,其中以纵向应变降低最为显著（心肌整体纵向应变,-23.03±3.84 vs -19.86±2.22 vs -15.47±4.28;心内膜下整体纵向应变,-30.35±5.35 vs -25.01±3.62 vs -21.92±8.16,P < 0.001）。多元Logistic回归分析结果显示左室壁最大厚度、左室质量指数和心肌整体纵向应变组合模型的ROC曲线下面积最大,为0.930（敏感度为97%,特异性为83%）。结论  基于CT所获得的MS参数可以用于精确评估HCM和HHD患者的早期左室功能损伤,其中以纵向应变的损伤最为显著。所得参数中左室壁最大厚度、左室质量指数和心肌整体纵向应变的组合模型在区分这两种疾病时效果最佳。     

Trypanosomiasis,cardiomyopathy and the risk of ischemic stroke

American (Chagas disease) and African (sleeping sickness) trypanosomiasis are neglected tropical diseases and are a heavy burden in Latin America and Africa, respectively. Chagas disease is an independent risk factor for stroke. Apical aneurysm, heart failure and cardiac arrhythmias are associated with ischemic stroke in chagasic cardiomyopathy. Not all chagasic patients who suffer an ischemic stroke have a severe cardiomyopathy, and stroke may be the first manifestation of Chagas disease. Cardioembolism affecting the middle cerebral artery is the most common stroke subtype. Risk of recurrence is high and careful evaluation of recurrence risk should be addressed. Repolarization changes, low voltage and prolonged QT interval are common electrocardiography alterations in human African trypanosomiasis, and can be found in more than 70% of patients. Epidemiological studies are needed to asses the risk of stroke in African trypanosomiasis perimyocarditis.     

沙库巴曲缬沙坦钠联合新活素治疗急性左心衰竭的疗效

目的 探讨沙库巴曲缬沙坦钠联合新活素(冻干重组人脑利钠肽)治疗急性左心衰竭(ALHF)的疗效.方法 选择本院2018年6月-2020年10月收诊的ALHF患者112例,随机数字表法分为试验组(56例,沙库巴曲缬沙坦钠联合新活素)与对照组(56例,沙库巴曲缬沙坦钠)2组,观察两组用药2周后的总有效率,分析其心率、血浆N末...     

卡维地洛与美托洛尔治疗扩张型心肌病心力衰竭患者的临床疗效观察

目的观察卡维地洛与关托洛尔对扩张型心肌病（DCM）患者慢性心力衰竭（CHF）的临床疗效。方法选择60例DCM伴中或重度CHF患者随机分为卡维地洛组和美托洛尔组,两组在常规治疗基础上,分别使用卡维地洛和美托洛尔治疗6个月,观察两组治疗前、治疗3个月及6个月后美国纽约心脏病协会（NYHA）心功能分级、N末端原脑利钠肽（NT-pro—BNP）、心率、收缩压及采用超声心动图测定左心室舒张末期内径（LVEDd）、左心室收缩末期内径（LVESd）和左心室射血分数（LVEF）。结果治疗3个月后与治疗前比较,两组心功能均有改善,NT—pro-BNP、心率、收缩压和LVESd降低或减小,NT-pro-BNP（1102．0±176．3）ng／L、（1219．7±213．1）ng／LVS（3107．9±446．1）ng／L、（3077．0±431．6）rig／L（均P〈O．01）,心率（74．5±4．4）次／min、（77．4±3．8）次／min vs（90．5±5．1）次／min、（88．9±5．7）次／min（均P〈0．01）,收缩压（114．5±7．0）mmHg、（120．1±6．6）mmHg vs（122．6±9．3）mmHg、（124．3±9．0）mmHg（P〈0．01或〈0．05）,LVESd（49．2±2．7）mm、（50．6±2．4）mm vs（51．4±2．8）mm、（52．2±2．3）mm（均P〈0．05）,LVEF增加（38．5±4．0）％、（36．5±3．5）％vs（32．8±3．8）％、（34．2±3．5）％（P〈0．01或〈0．05）,LVEDd差异无统计学意义;治疗6个月后,两组上述参数与治疗前及治疗3个月比较差异有统计学意义（均P〈0．01）。两组治疗后上述参数比较差异有统计学意义（均P〈0．01）。两组NT-pro—BNP水平与同期测定的LVEDd、LVESd呈正相关（P〈0．05或〈0．01）,与LVEF呈负相关（P〈0．01）。结论卡维地洛和美托洛尔均能显著改善CHF患者的心功能,但卡维地洛尤为明显;CHF患者NT—pro-BNP与心脏超声指标有很好的相关性,NT-pro—BNP可以作为治疗CHF的一个可靠指标。