By Alvaro Sosa Liprandi*
Chagas Heart Disease (CHHD) is a preventable chronic non-communicable condition that mainly affects the poorest and most vulnerable population of Latin America. Driven by poverty, poor access to health services and other health system weaknesses, the majority of people with this condition live in low- and middle- income countries.
After the acute phase of infection mediated by Trypanosoma cruzi, most patients pass into a chronic form, defined by positive serology and slow progression or even absence, during non-specific period of time, of physical signs or symptoms of cardiac abnormalities. Chagas cardiomyopathy is the most important clinical manifestation, being responsible for most of the morbidity and mortality associated with this disease.1
After two or three decades of initial contact with the parasite, about 30% of infected individuals exhibit evidence of a chronic cardiomyopathy, and a proportion of them develop heart failure with a reduced ejection fraction (HFrEF).
The treatment of heart failure should be similar in chagasic and non-chagasic populations, since the hemodynamia and pathophysiology are similar. However, the medical treatment has been derived from evidence of other forms of heart failure and most of the clinical trials confirming a survival advantage did not include Chagas disease. So, information about treatment in patients with Chagas and heart failure derives from non-randomized studies or clinical trials of heart failure that included only small proportion of Chagas cardiomyopathy.2
In recent years, the need for concerted global action to control non-communicable diseases has become a high priority on the global health agenda. This fact is evident in the UN political declarations on the Prevention and Control of Non-Communicable Diseases (‘25 by 25’ target), the WHO Global NCD Action Plan, and the UN Sustainable Development Goals.3,4
With CVD as the leading cause of premature mortality worldwide, and more than 80% of deaths occurring in low- and middle-income countries, the World Heart Federation (WHF), as the world’s leading global CVD organization, launched its Roadmap Initiative in 2014 to guide and support those seeking to improve CVD control.
The WHF Roadmaps are global implementation strategies designed to help governments, employers, non-governmental organizations (NGOs), health activists, academic and research institutions, health care providers and people who have been affected by CVD, take action to better prevent and control CVD.5 The Roadmaps synthesize existing evidence on the efficacy, feasibility and cost-effectiveness of various strategies. They also identify potential barriers (roadblocks) to their implementation, and propose potential solutions to bypass them.
Under this premise, the WHF and the Inter American Society of Cardiology (IASC) launched the development of the roadmap on CHHD.
The WHF/IASC Roadmap for reducing morbidity and mortality through improved prevention and control of CHHD complements existing roadmaps on tobacco control, raised blood pressure, secondary prevention for CVD, rheumatic heart disease, cholesterol, atrial fibrillation and the on-going on diabetes and heart failure.
The CHHD Roadmap will contribute to reaching the target of 25×25 by acting as a resource to raise the profile of CHHD nationally and globally, and by providing a framework to guide and support the strengthening of national, regional and global CHHD control efforts.
The Roadmap’s content will be derived from searches for relevant systematic and narrative reviews of existing evidence, a synthesis of relevant peer-reviewed and an interactive process of expert consultation.
Developing and effectively implementing country specific roadmaps will require a coalition of the different stakeholders: health professionals; government departments and agencies; in-country and regional health organizations; NGOs; and industry, patient and community groups to advocate for the inclusion of CHHD in national NCD action plans and various other national planning instruments.
The process also requires a range of local expertise that includes knowledge of medicine, cardiology, cultural and social contexts, prevention, health promotion, health systems, economics, and government priorities.
The kick-off meeting of the Chagas roadmap took place in Buenos Aires in October 2018 and involved 20 experts representing 7 countries of America, including researchers, academics and representatives of different organizations. Their conclusions are expected for September 2019.
Alvaro Sosa Liprandi
Head of Cardiology – Sanatorio Güemes, Buenos Aires, Argentina
Director – Lezica Cardiovascular Institutte, San Isidro, Argentina
Director – Idea Médica, Research & Education
Director – Post Graduate Medical School in Cardiology, Universidad de Buenos Aires
Secretary – Inter American Society of Cardiology
REFERENCES
- Tanowitz HB, Machado FS, Spray DC, Friedman JM, Weiss OS, Lora JN, Nagajyothi J, Moraes DN, Garg NJ, Nunes MC, Ribeiro AL. Developments in the management of Chagas cardiomyopathy. Expert Rev Cardiovasc Ther 2015; 13: 1393-409.
- Bocchi EA, Bestetti RB, Scanavacca MI, Cunha Neto E, Issa VS. Chronic Chagas heart disease management: from etiology to cardiomyopathy treatment. J Am Coll Cardiol. 2017;70:1510–24.
- United Nations. Transforming our world: the 2030 agenda for sus-tainable development. New York, NY: United Nations; 2015.
- World Health Organization. Global action plan for the prevention and control of noncommunicable diseases. Geneva, Switzerland: WHO.
- Perel P, Bianco E, Poulter N, et al. Reducing Premature Cardiovascular Mortality By 2025: The World Heart Federation Roadmap. Glob Heart 2015;10:97–8.
- Yusuf S, Perel P, Wood D, Narula J. Reducing Cardiovascular Disease Globally: The World Heart Federation’s Roadmaps. Glob Heart 2015; 10:93–5.