International Journal of Cardiology xxx (2014) xxx–xxx

IJCA-18043; No of Pages 2

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International Journal of Cardiology

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Letter to the Editor

Mode of death in chronic systolic heart failure: Chagas cardiomyopathyversus systemic arterial hypertension

Reinaldo B. Bestetti ⁎, Ana Paula Otaviano, João Paulo Fantini, Augusto Cardinalli-Neto,Marcelo A. Nakazone, Paulo R. NogueiraDepartment of Cardiology and Cardiovascular Surgery, Hospital de Base, São José do Rio Preto City, Brazil

⁎ Corresponding author at: Rua Jerônimo Panazollo, 43Preto City, Brazil. Tel.: +55 36037013; fax: +55 1636037

E-mail address: rbestetti44@gmail.com (R.B. Bestetti).

http://dx.doi.org/10.1016/j.ijcard.2014.04.1420167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved

Please cite this article as: Bestetti RB, et al,hypertension, Int J Cardiol (2014), http://dx

a r t i c l e i n f o

Article history:

Received 7 April 2014Accepted 12 April 2014Available online xxxx

Keywords:Chagas disease: heart failureSudden cardiac deathMode of deathSystemic arterial hypertensionBetablockers

major role played by sudden cardiac death (SCD) in driving total mor-tality. It has long been recognized, however, that Betablocker therapydecreases not only SCD, but also pump failure death [4]. Therefore, westill believe that lack of Betablocker therapy not necessarily increasedthe risk of just SCD in our patients.

Veloso [1] stated that SCD is the principal mechanism of death inpatients with chronic Chagas disease, quoting older studies that didnot include patients with overt CHF or patients with CHF not treatedwith angiotensin converting enzyme-inhibitor or Betablockers.Studies performed in the current era have demonstrated that SCDis not the most important mode of death in chronic Chagas disease.

With regard to the letter by Veloso [1], we would like to empha-size that our study [2] was comprised of patients with chronic systol-ic heart failure (CHF) secondary to systemic arterial hypertension(SAH) with mild to moderate symptoms; by contrast, Freitas et al.[3] studied patients with more severe forms of the syndrome. Weruled out concomitant coronary disease (CAD) in patients with SAHby coronary angiography and/or myocardium scintigraphy; Freitaset al. [3] did not perform such exams routinely. We gave Betablockertherapy routinely for patients with CHF due to SAH; Freitas et al [3]did not provide routine Betablocker therapy for their patients withCHF secondary to SAH. We compared prognosis of patients withCHF secondary to Chagas cardiomyopathy directly with that of pa-tients with CHF due to SAH; Freitas et al. [3] compared the prognosisof CHF secondary to Chagas cardiomyopathy with those of severaltypes of cardiomyopathies concomitantly. Therefore, the statementthat “the concept of a poorer prognosis of patients with CHF due toChagas disease in comparison to those with hypertensive cardiomy-opathy (not necessarily patients with CHF due to SAH) was alreadydemonstrated” is not correct.

Veloso [1] stressed that our explanation for the worst prognosis ofChagas cardiomyopathy patients with CHF regarding the less frequentuse of Betablocker therapy, as well as a lower dose of Betablockers in

4, Zip code: 14096-430 Ribeirão005.

.

Mode of death in chronic sy.doi.org/10.1016/j.ijcard.2014

those partially able to take the drug, could be an indication of the

For example, Gonçalves et al. [5] clearly demonstrated that SCD af-fected only 17% of patients, whereas death due to CHF was found in50% of patients of a population-based longitudinal cohort comprisedof patients with chronic Chagas disease. Furthermore, Ayub-Ferreiraet al. [6] studying patients with CHF due to Chagas cardiomyopathywith mild to moderate CHF showed that SCD and CHF death victim31% and 38% of patients, respectively. In Patients in the New YorkHeart Association Class III or IV, SCD and CHF death affected 15%and 57% of patients, respectively, in the study by Ayub-Ferreiraet al. [6].

Veloso [1] believes that the presence of ventricular prematurecontractions (VPC) on the resting ECG as well as the higher use ofamiodarone in the Chagas disease group in comparison to SAH pa-tients would indicate a higher risk for malignant ventricular arrhyth-mias, what could explain the higher mortality observed in Chagasdisease group. However, it is well known that the presence of VPCon the resting ECG has not independently been associated with SCDin patients with chronic Chagas disease. Furthermore, in patientswith CHF secondary to Chagas cardiomyopathy, amiodarone usehas been associated with increased mortality due to pump failuredeath, but not with SCD [6].

On the basis of the facts outlined earlier, it becomes difficult tobelieve that SCD was the principal cause of the higher mortalityobserved in Chagas disease patients in our study, as suggestedby Veloso [1]. Irrespective of the mode of death, what is impor-tant is that lack of appropriate Betablocker therapy could havedeprived Chagas disease patients of the benefits of these drugs incounteracting the deleterious effect of catecholamine on the myo-cardium [7,8], and the consequent potential beneficial effects onmortality [9,10].

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References

[1] Veloso HH. Incidence of sudden cardiac death in congestive heart failure: Chagas dis-ease versus systemic arterial hypertension. Int J Cardiol 2014 [in press].

[2] Bestetti RB, Otaviano AP, Fantini JP, Cardinalli-Neto A, Nakazone MA, Nogueira PR.Prognosis of patients with chronic systolic heart failure: Chagas disease versus sys-temic arterial hypertension. Int J Cardiol 2013;168:2990–1.

[3] Freitas HFG, Chizzola PR, Paes AT, Lima ACP, Mansur AJ. Risk stratification in aBrazilian hospital-based cohort of 1220 outpatients with heart failure: role of Chagasheart disease. Int J Cardiol 2005;102:239–47.

[4] Merit investigators. Effect of metoprolol XR/CL in chronic heart failure: metoprololXR/CL randomized intervention trial in congestive heart failure (MERIT-HF). Lancet1999;353:2001–7.

[5] Gonçalves JGF, Silva VJD, Borges MCC, Prata A, Correia D. Mortality indicators amongchronic Chagas patients living in an endemic area. Int J Cardiol 2010;143:235–42.

Please cite this article as: Bestetti RB, et al, Mode of death in chronic syhypertension, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014

[6] Ayub-Ferreira SM, Mangini S, Issa VS, et al. Mode of death on Chagas heart disease:comparison with other etiologies. A subanalysis of the REMADHE prospective trial.PLoS Negl Trop Dis 2013;7:e2176.

[7] Bestetti RB, Ramos CP, Figuerêdo-Silva J, Sales-Neto VN, Oliveira JSM. Ability of theelectrocardiogram to detect myocardial lesions in isoproterenol induced rat cardio-myopathy. Cardiovasc Res 1987;21:916–21.

[8] Bestetti RB, Sales-Neto VN, Pinto LZ, Soares EG, Muccillo G, Oliveira JSM. Effects oflong term metoprolol administration on the electrocardiogram of rats infectedwith T cruzi. Cardiovasc Res 1990;24:521–7.

[9] Issa VS, Amaral AF, Cruz FD, et al. Beta-blocker therapy and mortality of patientswith Chagas cardiomyopathy: a subanalysis of the REMADHE prospective trial.Circ Heart Fail 2010;3:82–8.

[10] Bestetti RB, Otaviano AP, Cardinalli-Neto A, da Rocha BF, Theodoropoulos TA,Cordeiro JA. Effects of B-Blockers on outcome of patients with Chagas' cardiomyop-athy with chronic heart failure. Int J Cardiol 2011;151:205–8.

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