Mechanisms behind the high mortality rate in chronic Chagas cardiomyopathy: Unmasking a three‐headed monster

Figures

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  Figure 1. Chagas disease (CD) estimated prevalence rates per 100 000 population in 2021 according to the Global Burden of Disease Study. (A) Prevalence rates by country worldwide. (B) Prevalence rates of European countries with its own adapted colour scale. Data source: https://vizhub.healthdata.org/gbd‐compare/ 14

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  Figure 2. Algorithm for the serological diagnosis and clinical staging of patients at risk of Chagas disease (CD) in non‐endemic countries. CCC, chronic Chagas cardiomyopathy; HF, heart failure; LV, left ventricular; SCD, sudden cardiac death; WHO, World Health Organization.

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  Figure 3. Cardiac magnetic resonance imaging and 24‐h Holter findings in patients with Chagas disease. (A) A 55‐year‐old female patient with a diagnosis of indeterminate stage Chagas disease. Long‐axis (left) and short‐axis (right) magnetic resonance images reveal subtle late mid‐wall enhancement located in the inferolateral and basal segments compatible with myocardial fibrosis. (B) A 58‐year‐old female patient with a diagnosis of stage C Chagas cardiomyopathy. Long‐axis (left) and short‐axis (right) magnetic resonance images reveal the presence of contractility disorders and transmural late enhancement in the inferolateral wall. Both patients presented non‐sustained ventricular tachycardia events on 24‐h Holter (right images).

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  Figure 4. Characteristics of myocardial fibrosis by magnetic resonance imaging in patients with chronic Chagas cardiomyopathy. (Left) Pooled proportion and 95% confidence interval (CI) of late gadolinium enhancement (LGE) (detected fibrosis) per left ventricular segment in individuals with CCC. (Right) Prevalence of different patterns of myocardial replacement by fibrosis assessed by LGE. Image generated from data from Gómez‐Ochoa et al. 52

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  Figure 5. Summary of current diagnostic and therapeutic needs and opportunities regarding the major pathophysiological components of chronic Chagas cardiomyopathy (CCC). ACEI, angiotensin‐converting enzyme inhibitor; ARB, angiotensin receptor blocker; DOAC, direct oral anticoagulant; ECG, electrocardiogram; ICD, implantable cardioverter‐defibrillator; MRA, mineralocorticoid receptor antagonist; MRI, magnetic resonance imaging; QoL, quality of life; SGLT2i, sodium–glucose cotransporter 2 inhibitor; TGF‐β, transforming growth factor‐beta; VKA, vitamin K antagonist.