Guideline sources The following summarized guidelines for the evaluation and management of chagas cardiomyopathy are prepared by our editorial team based on guidelines from the Pathway (Pathway 2023), the European Society of Cardiology (ESC 2022), the Brazilian Society of Cardiology (BSC/ASE 2018), the American Heart Association (AHA/HRS/ACC 2013), and the Brazilian Society of Cardiology (BSC 2011). 1 2 3 4 5 Calculator NYHA functional classification f Guidelines 1. Diagnostic investigations Electrocardiogram: As per ASE 2018 guidelines: https://web.pathway.md/diseases/recE6JGcehvIDxhC4 1/4 6/29/23, 3:50 AM Chagas cardiomyopathy Pathway Obtain an ECG in the initial evaluation to exclude conduction abnormalities (right bundle branch, left anterior fascicular, and AV block) and arrhythmias in all patients with newly diagnosed Chagas disease. E Consider obtaining follow-up ECGs at least every 2-5 years in patients with Chagas disease with the indeterminate form. E As per BSC 2011 guidelines: Obtain a 12-lead ECG for periodic assessment of patients with Chagas disease. B Obtain dynamic ECG (Holter) for evaluation of arrhythmias and prognostic stratification of patients with chronic Chagas cardiomyopathy. B Echocardiography: As per ASE 2018 guidelines, obtain echocardiography in patients with suspected acute Chagas disease. E Show 6 more As per BSC 2011 guidelines: Obtain Doppler echocardiography for additional diagnostic and prognostic assessment of patients with chronic Chagas cardiomyopathy. B Obtain Doppler echocardiography to evaluate patients with the indeterminate form. B Advanced cardiac imaging: As per ASE 2018 guidelines: Do not obtain advanced imaging modalities (such as strain imaging or cardiac MRI) to detect silent myocardial damage in the indeterminate stage. D Consider obtaining cardiac MRI as an alternative modality to achieve imaging identification goals. Consider obtaining nuclear angiography for the evaluation of LV and RV function, and nuclear scintigraphy to detect myocardial perfusion defects, fibrosis, or denervation. E As per BSC 2011 guidelines, obtain cardiopulmonary stress testing for functional assessment, risk stratification, and support in the indication of cardiac transplantation in patients with advanced HF. B Chest radiography: obtain chest radiography for periodic diagnostic assessment of patients with Chagas disease. B 2. Medical management Management of heart failure: manage HF in patients with Chagas-related heart disease according to current published guidelines on HF. E Management of ventricular arrhythmia: Manage ventricular arrhythmias in patients with Chagas-related heart disease according to current published guidelines on ventricular arrhythmias. E As per ESC 2022 guidelines, consider initiating amiodarone to reduce the arrhythmia burden in patients with Chagas cardiomyopathy presenting with symptomatic premature ventricular https://web.pathway.md/diseases/recE6JGcehvIDxhC4 2/4 6/29/23, 3:50 AM Chagas cardiomyopathy Pathway complexes or VT. C Anticoagulation therapy: initiate anticoagulation therapy for AF in patients with Chagas-related heart disease according to current published guidelines on thromboprophylaxis in AF. E 3. Therapeutic procedures Implantable cardioverter-defibrillator: As per ACC 2022 guidelines, consider placing an ICD in patients with Chagas cardiomyopathy and symptomatic VT, if antiarrhythmic drugs (amiodarone and -blockers) are ineffective or not tolerated. C As per ESC 2013 guidelines, consider placing an ICD in patients with Chagas cardiomyopathy. C Catheter ablation: consider performing catheter ablation in specialized centers in patients with Chagas cardiomyopathy and recurrent, symptomatic sustained monomorphic VT or ICD shocks for sustained monomorphic VT, if antiarrhythmic drugs are ineffective, contraindicated, or not tolerated. C Clinical findings Symptoms Past medical history Chest pain Dilated cardiomyopathy HF Vital signs Stroke Bradycardia Cardiac exam Respiratory exam Split S2 heart sound Rales ECG findings Imaging findings Ventricular arrhythmia MR Tricuspid regurgitation References 1. Katja Zeppenfeld, Jacob Tfelt-Hansen, Marta de Riva et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2022 Aug 26;ehac262. Open 2. Karapetyan H, Grigoryan A, Mullie L. Recommendations & Algorithms. Pathway Editors. Open https://web.pathway.md/diseases/recE6JGcehvIDxhC4 3/4 6/29/23, 3:50 AM Chagas cardiomyopathy Pathway 3. Jadelson Pinheiro de Andrade, Jose Antonio Marin Neto, Angelo Amato Vincenzo de Paola et al. I Latin American Guidelines for the diagnosis and treatment of Chagas' heart disease: executive summary. Arq Bras Cardiol. 2011 Jun;96 6 434 42. Open 4. Harry Acquatella, Federico M Asch, Marcia M Barbosa et al. Recommendations for Multimodality Cardiac Imaging in Patients with Chagas Disease: A Report from the American Society of Echocardiography in Collaboration With the InterAmerican Association of Echocardiography ECOSIAC and the Cardiovascular Imaging Department of the Brazilian Society of Cardiology DIC SBC . J Am Soc Echocardiogr. 2018 Jan;31 1 3 25. Open 5. Epstein AE, DiMarco JP, Ellenbogen KA et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2013 Jan 22;61 3):e6 75. Open https://web.pathway.md/diseases/recE6JGcehvIDxhC4 4/4