Chagas cardiomyopathy

Chagas cardiomyopathy, caused by chronic infection with Trypanosoma cruzi , is a leading cause of non-ischaemic heart failure in Latin America and is increasingly recognised worldwide due to migration. Its pathogenesis is multifactorial, involving persistent parasitism, immune-mediated myocardial injury, microvascular dysfunction and progressive fibrosis, leading to a heterogeneous clinical spectrum. Four main phenotypes are recognised, including subclinical, arrhythmic, heart failure and thromboembolic, which often overlap and evolve throughout the disease course. Diagnosis relies on serological confirmation of T. cruzi infection, with electrocardiography and echocardiography forming the cornerstone of cardiac evaluation and risk stratification. Management includes antiparasitic therapy for acute, congenital and early chronic infection, and guideline-directed heart failure and arrhythmia management in established cardiomyopathy, including device therapy and heart transplantation in advanced cases. Despite advances in understanding disease mechanisms and clinical management, early detection remains a major challenge, particularly in non-endemic settings where under-recognition and limited access to specialised care persist. Strengthening screening strategies, expanding access to diagnostic tools and implementing multidisciplinary care models are critical to improving outcomes. This state-of-the-art review summarises current evidence on the pathophysiology, clinical spectrum, diagnosis and management of Chagas cardiomyopathy and highlights key controversies, knowledge gaps and research priorities to guide future advances in care.