Abstracts

Chagas disease or American trypanosomiasis is a neglected tropical disease with expressive morbidity and mortality and high prevalence, especially among adults and older adults ¹1. Pan American Health Organization. Chagas disease. https://www.paho.org/en/topics/chagas-disease (accessed on 10/Dec/2020).
https://www.paho.org/en/topics/chagas-di... . Previous estimates show that there are 6 to 7 million people infected with Trypanosoma cruzi worldwide and about 70 million people in vulnerable conditions to new infections in endemic areas. About 10,000 to 12,000 deaths per year are attributable to the disease. Latin America, in which the wild cycle of this anthropozoonosis occurs, concentrates 90% of the infected world population ¹1. Pan American Health Organization. Chagas disease. https://www.paho.org/en/topics/chagas-disease (accessed on 10/Dec/2020).
https://www.paho.org/en/topics/chagas-di... ^,22. World Health Organization. Chagas disease (also known as American trypanosomiasis). https://www.who.int/news-room/fact-sheets/detail/chagas-disease-(american-trypanosomiasis) (accessed on 11/Dec/2020).
https://www.who.int/news-room/fact-sheet... ^,33. Secretaria de Vigilância em Saúde, Ministerio da Saúde. Boletim Epidemiológico Doenças de Chagas 2021; (número especial). https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/boletins/boletins-epidemiologicos/especiais/2021/boletim_especial_chagas_14abr21_b.pdf.
https://www.gov.br/saude/pt-br/centrais-... .

With a biphasic course, the acute phase of Chagas disease shows an oligosymptomatic clinical picture (usually fever) related to the large number of circulating parasites. It is possible that serious situations of acute Chagas disease lead to cardiac or neurological impairment, though observed in less than 1% of affected individuals ⁴4. Acquatella H. Echocardiography in Chagas heart disease. Circulation 2007; 115:1124-31.^,55. Bern C. Chagas' disease. N Engl J Med 2015; 373:456-66.^,66. Dias JCP, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saúde 2016; 25:7-86.. Remarkably, acute myocarditis is a common complication in cases of oral transmission, occurring in Brazil as a result of the consumption of contaminated foods, such as açaí juice. In these cases, acute manifestations are more frequent, probably due to the greater number of parasites in the initial inoculum ⁷7. Pinto AYN, Valente SA, Valente VC, Ferreira Junior AG, Coura JR. Fase aguda da doença de Chagas na Amazônia brasileira: estudo de 233 casos do Pará, Amapá e Maranhão observados entre 1988 e 2005. Rev Soc Bras Med Trop 2008; 41:602-14..

Patients in the chronic phase can develop different clinical forms. Initially, there is the indeterminate form, which is asymptomatic and do not compromise the patients’ health. Posteriorly, after 10 to 30 years, about 10% to 30% of patients evolve to cardiac, digestive, or cardiodigestive forms of the disease, which greatly affect patients’ quality of life ⁴4. Acquatella H. Echocardiography in Chagas heart disease. Circulation 2007; 115:1124-31.^,55. Bern C. Chagas' disease. N Engl J Med 2015; 373:456-66..

Patients’ low quality of life, medical expenses, and the impact on social security generated by work incapacities in an economically active population cause great social and economic burden ⁶6. Dias JCP, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saúde 2016; 25:7-86.. In Latin America, estimates suggest that Chagas disease generates approximately USD 1.2 billion a year in expenses ⁸8. Lee BY, Bacon KM, Connor DL, Willig AM, Bailey RR. The potential economic value of a Trypanosoma cruzi (Chagas disease) vaccine in Latin America. PLoS Negl Trop Dis 2010; 14:e916.. Chronic Chagas cardiomyopathy (CCC), more severe and prevalent, is the major responsible for the greatest individual, social, and economic repercussions ⁶6. Dias JCP, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saúde 2016; 25:7-86..

In Brazil, approximately 1 million people are estimated to be infected ³3. Secretaria de Vigilância em Saúde, Ministerio da Saúde. Boletim Epidemiológico Doenças de Chagas 2021; (número especial). https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/boletins/boletins-epidemiologicos/especiais/2021/boletim_especial_chagas_14abr21_b.pdf.
https://www.gov.br/saude/pt-br/centrais-... . Nevertheless, a systematic review and meta-analysis published in 2014 showed that these numbers may be underestimated and that there are approximately 4.6 million Brazilians infected ⁹9. Martins-Melo FR, Ramos AN, Alencar CH, Heukelbach J. Prevalence of Chagas disease in Brazil: a systematic review and meta-analysis. Acta Trop 2014; 130:167-74.. According to the Brazilian Health Informatics Department (DATASUS), from 2000 to 2019, 94,788 deaths from Chagas disease were registered in the country ¹⁰10. Departamento de Informática do SUS. Mortalidade. Doença de Chagas. http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/obt10br.def (accessed on 08/Jun/2021).
http://tabnet.datasus.gov.br/cgi/deftoht... .

Recently, the role of primary healthcare (PHC) has been highlighted as imperative to care and monitor chronic Chagas disease patients in Brazil ⁶6. Dias JCP, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saúde 2016; 25:7-86.^,1111. Melo HNS, Oliveira AC, Lima IGM, Fonsêca DV, Silva AL. Análise da importância da atenção primária á saúde na prevenção e controle da doença de Chagas. In: Sousa IC, editor. Ciências da saúde no Brasil: impasses e desafios 2. Ponta Grossa: Atena; 2020. p. 160-71.^,1212. Ministério da Saúde. Portaria nº 57, de 30 de outubro de 2018. Torna pública a decisão de aprovar o Protocolo Clínico e Diretrizes Terapêuticas da doença de Chagas no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2018; 31 oct.^,1313. Carvalho NB, Atala MM, Leite RM, Yasuda MAS. Manual de atendimento a pacientes com doença de Chagas: atenção básica 2014/2015. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2015.^,1414. Rodrigues FCS, Souza ICA, Araujo AP, Souza JMB, Diotaiuti LG, Ferreira RA. Agentes comunitários de saúde: percepção sobre os serviços de saúde relacionados à doença de Chagas. Cad Saúde Colet (Rio J.) 2020; 28:130-9.. PHC is closer to the community and thus individuals’ first access to care networks. Notably, it assumes a pivotal role in health education, along with functions and attributes such as communication, accountability, and resolvability.

Chagas disease is within the scope of essential actions which PHC must perform, with the role of diagnosing, screening, controlling, preventing, educating, treating, referring, and monitoring clinical cases, hence reducing expenses arising from the disease and improving affected individuals’ biopsychosocial conditions ¹¹11. Melo HNS, Oliveira AC, Lima IGM, Fonsêca DV, Silva AL. Análise da importância da atenção primária á saúde na prevenção e controle da doença de Chagas. In: Sousa IC, editor. Ciências da saúde no Brasil: impasses e desafios 2. Ponta Grossa: Atena; 2020. p. 160-71.^,1212. Ministério da Saúde. Portaria nº 57, de 30 de outubro de 2018. Torna pública a decisão de aprovar o Protocolo Clínico e Diretrizes Terapêuticas da doença de Chagas no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2018; 31 oct.. For this purpose, articulated actions for the proper management of Chagas disease must be conducted by principles guiding PHC, including territorialization, multi-professional interventions, humanized care, person-centered care, and resoluteness ⁶6. Dias JCP, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saúde 2016; 25:7-86..

Thus, this study aimed to characterize Chagas disease cases regarding CCC staging and death prognosis and, based on that, to propose the longitudinal follow-up of cases by PHC.

Materials and methods

This is a cross-sectional study based on secondary data from the medical records of the Hospital of Clinics of the Federal University of Uberlândia (HC-UFU), a reference service in the region for medium- and high-complexity health care. This study included medical records of patients with CCC in the cardiac or cardiodigestive clinical forms of the disease who showed information about the clinical, epidemiological, and laboratory diagnosis of Chagas disease, resided in the municipality of Uberlândia, Minas Gerais State, Brazil, and sought care related to the disease from March 2018 to February 2020. Patients’ medical records with incomplete information which made it impossible to identify the disease or those who died were excluded from this study.

Gender, age, presence of comorbidities, number of hospitalizations, length of hospitalization, number of visits to outpatient clinics, number of visits to the emergency department, cardiac staging, and death prognosis were the evaluated variables.

For CCC staging, the classification proposed by Dias et al. ⁶6. Dias JCP, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saúde 2016; 25:7-86. was used. In this classification, five stages are distinguished (A, B1, B2, C, and D), considering electrocardiogram, echocardiogram, and degree of heart failure analysis, according to the New York Heart Association (NYHA; United States) (Box 1).

Death prognosis followed the score created by Rassi Jr. et al. ¹⁵15. Rassi Jr. A, Rassi A, Little WC, Xavier SS, Rassi SG, Rassi A G, et al. Development and validation of a risk score for predicting death in Chagas' heart disease. N Engl J Med 2006; 355:799-808., in which heart failure III or IV (according to the NYHA), cardiomegaly (according to chest radiography or echocardiogram exams), segmental or global abnormality (on echocardiograms), non-sustained ventricular tachycardia (according to Holter), low voltage of the QRS complex (on electrocardiograms), and male patients are considered. In this score, each risk factor is assigned a score and individuals are classified as at low, intermediate, and high risk of death. The expected mortality rates in these groups, in periods of 5 and 10 years, are as follows: low risk (2% and 10%), intermediate risk (18% and 44%), and high risk (63% and 84%), respectively ¹⁵15. Rassi Jr. A, Rassi A, Little WC, Xavier SS, Rassi SG, Rassi A G, et al. Development and validation of a risk score for predicting death in Chagas' heart disease. N Engl J Med 2006; 355:799-808..

The clinical evolution of patients over time was also investigated by the analysis of their medical records. Therefore, the initial cardiac staging was established based on the first clinical information about Chagas disease registered in the medical records of patients, regardless of the date (clinical condition I). Clinical condition II refers to recent observations in the medical records up to this study deadline. For statistical analysis of demographic factors and health service use, information from the most recent clinical condition was used.

A specific database in the Epi Info 7.2.2 computer software (https://www.cdc.gov/epiinfo/index.html) was constructed for data entry and analysis. The distribution of frequencies of all studied variables and data consistency were performed. A logistic regression was applied to estimate variable association. For each dependent variable, four models were created: first, simple logistic regression models were used to study the relations between the independent variables and cardiac staging (dependent variable 1) or prognosis of death (dependent variable 2). Models 2, 3, and 4 were adjusted for the variables age, presence of comorbidity, and age + presence of comorbidity, respectively. The dependent variable cardiac staging was defined as 1 = cardiac stage C/D; 0 = cardiac stage A/B1/B2. The dependent variable prognosis of death was defined as 1 = intermediate/high risk, 0 = low risk. The independent variables were gender, number of hospitalizations, days in the hospital, number of visits to outpatient clinics, and number of visits to the emergency unit. For the models related to prognosis of death, the variable gender was not used as it is one of the variables included in Rassi Jr. et al.’s risk score ¹⁵15. Rassi Jr. A, Rassi A, Little WC, Xavier SS, Rassi SG, Rassi A G, et al. Development and validation of a risk score for predicting death in Chagas' heart disease. N Engl J Med 2006; 355:799-808.. Logistic regression results were shown with odds ratios (OR) and 95% confidence intervals (95%CI).

This study was approved by the Human Research Ethics Committee of the UFU (registration n. 3,655,664/2019). Informed consent forms were not signed because this is a study with secondary data. Data confidentiality and volunteers’ anonymity were guaranteed.

Results

A total of 433 medical records of patients with CCC were evaluated, 334 (77.1%) with the cardiac form and 99 (22.9%) with the cardiodigestive ones. These individuals received treatment at the institution outpatient clinic, ward, and emergency department. We found a greater predominance of female patients (236; 54.5%), aged from 24 to 99 years, with a mean age of 68.47 ± 11.02. Most patients came from the state of Minas Gerais (363; 83.8%), mainly from the Triângulo Mineiro and Alto Paranaíba mesoregion (277; 64%), followed by the state of Goiás (39; 9%). Overall, 283 (65.4%) and 144 (33.3%) medical records registered the use of outpatient and emergency services, respectively. We also found hospitalizations, in the ward or intensive care unit of the hospital, in 323 (74.6%) medical records.

We could classify CCC staging in 252 medical records. Patients in the C/D stages of CCC were associated with a higher number of hospitalizations and a greater number of days in the hospital. Patients in these stages were 3.41 more likely to be hospitalized for more than three times and 3.15 times more likely to remain hospitalized for more than 10 days (Table 1).

By assessing the most recent medical records, we could classify 44.4% of the patients as showing mild to moderate forms of CCC (A, B1, and B2) and 55.6%, more advanced forms (C and D).

Regarding death prognosis, patients classified at intermediate and high risk of death were more associated with a greater number of hospitalizations (OR = 1.92; 95%CI: 1.09-3.37), days in the hospital (OR = 2.04; 95%CI: 1.30-3.18), and visits to the emergency department (OR = 3.12; 95%CI: 1.27-7.66) and the outpatient clinic (OR = 2.18; 95%CI: 1.39-3.41) (Table 2).

Overall, out of 410 records which enabled us to estimate death scores, we classified 68.3% of patients as low risk for it.

Regarding the evolution of their clinical condition, among the nine patients initially classified as stage A, 66.7% remained in this classification over time; 11.1% and 22.2% progressed, with worsened cardiac function, to stages B1 and C, respectively. In total, 83 patients who were classified as B1 in the initial stage (89.2%) remained in this classification; 1.2%, 8.4%, and 1.2% progressed to stages B2, C, and D, respectively. The nine patients initially classified as stage B2 (22.2%) improved to stage B1, whereas 22.2% remained at stage B2 and 55.6% progressed to stage C. Initially, 63 patients were in stage C, 93.7% remained in this classification and 6.3% progressed to stage D. Finally, among 35 patients classified in stage D, only 11.4% remained in this classification, whereas 88.6% regressed to stage C (Table 3). Overall, 72.9% of the cases remained in the stages in which they were initially evaluated, 16.6% showed improvement, and 10.5%, worsening.

Discussion

This study shows that cases of CCC in advanced stages of Chagas disease and at high or intermediate risk of death cause a major impact on more complex health services, with patients in stages C and D showing high hospital dependence. There is a direct relation of these individuals with the need for a greater number of hospitalizations throughout their lives and for longer periods. In this scenario, a justification for this finding is that patients classified in these stages have heart failure and, therefore, high rates of hospitalization and rehospitalization ¹⁶16. Mesquita ET, Jorge AJL, Rabelo LM, Souza-Jr CV. Entendendo a hospitalização em pacientes com insuficiência cardíaca. Int J Cardiovasc Sci 2017; 30:81-90.. Furthermore, hospitalized individuals with this condition require complex management to restore hemodynamic stability, especially in decompensated patients, and treatment requires several medications which can impair renal function ¹⁷17. Vilas-Boas F, Follath F. Tratamento atual da insuficiência cardíaca descompensada. Arq Bras Cardiol 2006; 87:369-77.. This complexity of heart failure management explains the more numerous and longer hospitalizations, when compared to groups A/B1/B2.

Patients with high and intermediate risk of death were associated with the highest number of hospitalizations, number of days in the hospital, and number of visits to the outpatient clinic and to the emergency department. Affected individuals’ low quality of life is also noteworthy, especially those with the most advanced forms of CCC, as is the important influence of the biopsychosocial context of these individuals ¹⁸18. Mendes EV. A construção social da atenção primária à saúde. Brasília: Conselho Nacional de Secretários de Saúde; 2015.. A previous literature review examined studies on health-related quality of life (HRQoL) and Chagas cardiomyopathy. It identified three main findings: (1) cardiac complications are associated with a poor HRQoL; (2) HRQoL is associated with the functional capacity of patients; and (3) simple and inexpensive therapeutic interventions are effective to improve HRQoL ¹⁹19. Sousa GR, Costa HS, Souza AC, Nunes MCP, Lima MMO, Rocha MOC. Health-related quality of life in patients with Chagas disease: a review of the evidence. Rev Soc Bras Med Trop 2015; 48:121-8..

Thus, PHC plays a fundamental role in managing and monitoring patients to avoid the worsening of cases and to monitor the disease evolution. The provision of adequate assistance to its most serious forms, together with specialized services, should also be recommended ¹¹11. Melo HNS, Oliveira AC, Lima IGM, Fonsêca DV, Silva AL. Análise da importância da atenção primária á saúde na prevenção e controle da doença de Chagas. In: Sousa IC, editor. Ciências da saúde no Brasil: impasses e desafios 2. Ponta Grossa: Atena; 2020. p. 160-71..

Referrals to specialized care should be carried out by PHC teams, following referral flows and encouraging counter-referral in cases of severe acute Chagas disease, severe CCC, patients with advanced digestive forms which would indicate invasive procedures, pregnant women with severe acute Chagas disease or CCC, individuals with decompensated immunosuppressive conditions, and chronic Chagas disease patients with nifurtimox indications ¹²12. Ministério da Saúde. Portaria nº 57, de 30 de outubro de 2018. Torna pública a decisão de aprovar o Protocolo Clínico e Diretrizes Terapêuticas da doença de Chagas no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2018; 31 oct..

Thus, the National Commission for Technology Incorporation (CONITEC) at the Brazilian Unified National Health System (SUS) of the Brazilian Ministry of Health created the Clinical Protocol and Therapeutic Guidelines for Chagas Disease in 2018. It targets healthcare providers involved in the care of people with Chagas disease, especially family and community physicians, internists, cardiologists, obstetricians, infectious diseases specialists, gastroenterologists, and nurses working in PHC ¹²12. Ministério da Saúde. Portaria nº 57, de 30 de outubro de 2018. Torna pública a decisão de aprovar o Protocolo Clínico e Diretrizes Terapêuticas da doença de Chagas no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2018; 31 oct.. The protocol mentions that most cases in Brazil show a non-serious clinical condition and should be mostly followed up within PHC, with the possibility of treating patients with benznidazole. A recent retrospective cohort observational study showed that benznidazole treatment was associated with a decreased risk of Chagas disease progression from the indeterminate to the cardiac form and a decreased risk of cardiovascular events, recommending its implementation into clinical practice ²⁰20. Hasslocher-Moreno AM, Saraiva RM, Sangenis LHC, Xavier SS, Sousa AS, Costa AR, et al. Benznidazole decreases the risk of chronic Chagas disease progression and cardiovascular events: a long-term follow up study. EClinicalMedicine 2021; 31:100694.. Patients with non-severe acute diseases, indeterminate chronic phases, chronic cardiac, digestive, or cardiodigestive phases, with stable and non-severe diseases, and pregnant women with Chagas disease in the chronic phase without comorbidities are likely to be monitored by PHC ¹²12. Ministério da Saúde. Portaria nº 57, de 30 de outubro de 2018. Torna pública a decisão de aprovar o Protocolo Clínico e Diretrizes Terapêuticas da doença de Chagas no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2018; 31 oct..

Of the 410 medical records in which we could evaluate death prognosis, 68.3% were classified as low risk. Of the 252 medical records of patients in which we could analyze Chagas disease staging, 44.4% were classified as mild to moderate forms of CCC (A, B1, and B2). Individuals in these classifications would find technical and infrastructure conditions to be adequately assisted in basic health units after teams were trained in the management of this disease ¹³13. Carvalho NB, Atala MM, Leite RM, Yasuda MAS. Manual de atendimento a pacientes com doença de Chagas: atenção básica 2014/2015. São Paulo: Faculdade de Medicina, Universidade de São Paulo; 2015.^,1414. Rodrigues FCS, Souza ICA, Araujo AP, Souza JMB, Diotaiuti LG, Ferreira RA. Agentes comunitários de saúde: percepção sobre os serviços de saúde relacionados à doença de Chagas. Cad Saúde Colet (Rio J.) 2020; 28:130-9.^,2121. Ferreira AM, Sabino EC, Moreira HF, Cardoso CS, Oliveira CDIL, Riberiro ALP, et al. Avaliação do conhecimento acerca do manejo clínico de portadores da doença de Chagas em região endêmica no Brasil. Rev APS 2018; 21:345-54..

Importantly, PHC teams must keep patients and families informed about the actions to be taken so CCC patients receive suitable treatment and monitoring, reducing the overload of highly complex services and the economic and biopsychosocial impacts of individuals and their families ¹²12. Ministério da Saúde. Portaria nº 57, de 30 de outubro de 2018. Torna pública a decisão de aprovar o Protocolo Clínico e Diretrizes Terapêuticas da doença de Chagas no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2018; 31 oct.^,1818. Mendes EV. A construção social da atenção primária à saúde. Brasília: Conselho Nacional de Secretários de Saúde; 2015.. For indeterminate Chagas disease, the most prevalent clinical form, medical evaluation, and conventional ECG are recommended once a year. In case of disease evolution, patients should be referred to specialized services but with integrated management to PHC (referral and counter-referral) ⁶6. Dias JCP, Ramos Jr. AN, Gontijo ED, Luquetti A, Shikanai-Yasuda MA, Coura JR, et al. II Consenso Brasileiro em Doença de Chagas, 2015. Epidemiol Serv Saúde 2016; 25:7-86.^,2222. Dias JCP, Siqueira IOC, Dias RB. Doença de Chagas: diagnóstico e manejo na atenção primária à saúde. In: Gusso G, Lopes JMC, editors. Tratado de medicina de família e comunidade. v. 2: princípios, formação e prática. Porto Alegre: Artmed; 2012. p. 2067-80..

The role of PHC in intervention projects is imperative to receive and monitor men with CCC in their territories, improving adherence to monitoring programs, as this population tends to develop more severe forms of the disease ²³23. Elias BK, Gervásio VL, Dell'Acqua MAQ, Lima MAJ, Silva NMMG. Avaliação do acesso e acolhimento de homens na atenção básica: revisão de literatura. Brazilian Journal of Development 2021; 7:22582-90..

In total, 65.4% of the records reported the use of an outpatient service. These are sectors responsible for the therapeutic plan and monitoring of patients with CCC. They monitor these individuals, establish complication prevention practices, and educate patients about their diagnosis and the care inherent to their disease, hence improving the quality of life of these people. However, many of these actions could be conducted within the scope of PHC without the need to overload the infrastructure, human resources, and inputs of highly complex services, which could be directed to other groups with more urgent, highly complex needs ¹²12. Ministério da Saúde. Portaria nº 57, de 30 de outubro de 2018. Torna pública a decisão de aprovar o Protocolo Clínico e Diretrizes Terapêuticas da doença de Chagas no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União 2018; 31 oct.^,1818. Mendes EV. A construção social da atenção primária à saúde. Brasília: Conselho Nacional de Secretários de Saúde; 2015..

The greater participation of PHC provides easier access for monitoring people affected by CCC, benefiting them with reduced costs related to transport, as well as reduced waiting time for assistance. In this study, the cases classified as having a low risk of death proved to be prevalent and are distributed throughout Brazil. Likewise, the PHC network in the municipality of Uberlândia is well divided and needs to ensure access and longitudinality in the care of these patients.

This study evinced that 72.9% of patients diagnosed with CCC tended to show a stabilized disease. These findings show the slow and gradual evolution of the disease over time and, thus, the possibility of continued PHC practice involvement ²⁴24. Lidani KCF, Sandri TL, Castilho-Neira R, Andrade FA, Guimarães CM, Marques EN, et al. Clinical and epidemiological aspects of chronic Chagas disease from Southern Brazil. Rev Soc Bras Med Trop 2020; 53:e20200225.. Furthermore, 16.6% of the cases improved, showing stage regression, and 10.5% progressed to more severe stages. There was a high percentage of regression from stage D to stage C. Stage D is a condition of severe clinical instability (i.e., refractory heart failure) a situation in which medical teams must take striking interventions to stabilize the condition, evolving the patient to a compensable heart failure (stage C). It is very common for patients in severe stage D to be unsuccessful and progress to death. Costa et al. ²⁵25. Costa AA, Rassi S, Freitas EMM, Gutierrez NS, Boaventura FM, Sampaio LPC, et al. Prognostic factors in severe chagasic heart failure. Arq Bras Cardiol 2017; 108:246-54. investigated 60 patients with severe heart failure of originated from Chagas disease for 90 months. Most (88.3%) died during the follow-up period. Indeed, Chagas disease is a predictor of poor prognosis in patients with chronic heart failure ²⁶26. Silva CP, Del Carlo CH, Oliveira Junior MT, Scipioni A, Strunz-Cassaro C, Ramirez JAF, et al. Why do patients with chagasic cardiomyopathy have worse outcomes than those with non-chagasic cardiomyopathy? Arq Bras Cardiol 2008; 91:389-94.. This study only considered active medical records (of patients still alive), and this may have influenced the percentage of stage regression.

Despite the relevant information about the classification of Chagas disease cases and their associated factors, we should mention data reliability uncertainty, inherent to any cross-sectional study using secondary data as a limitation of this work. Additionally, the absence of complete data in the medical records made it impossible to classify some patients’ cardiac staging and death prognosis.

In conclusion, cases of CCC classified in the most severe stages and with high or intermediate risk of death were associated with greater hospital dependence. Nevertheless, most cases were classified as milder forms of the disease, with low risk of death and clinical stability. These findings aim to promote the role of PHC as a protagonist in the longitudinal follow-up of CCC cases in Brazil.

References

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History