恰加斯心肌病诊疗进展

doi:10.3877/cma.j.issn.1674-1358.2025.03.001

恰加斯心肌病是由克氏锥虫感染引发的感染性心脏病，其病理进程分为自限性急性期与不可逆性慢性期，后者以进行性心肌纤维化及神经源性障碍为特征。诊断需结合流行病学史、血清学检测与多模态影像技术，治疗策略包括病原控制与并发症管理同时进行。2024年报道了国内首例非输入性恰加斯病例。当前恰加斯心肌病临床面临的挑战集中于非流行区域的高漏诊率及慢性期病理逆转手段的缺乏，建立基于血清学筛查的多学科诊疗路径和完善分级防控体系是改善全球恰加斯心肌病负担的关键。随着研究技术的进步，恰加斯心肌病的诊治策略不断更新。本文系统性阐述恰加斯心肌病患者的临床表现、诊疗策略及最新研究进展，旨在提高国内医务人员对该病的认识，为其早期发现、筛查及规范化诊疗提供参考。

关键词: 恰加斯心肌病, 感染, 诊疗

Chagas cardiomyopathy is an infectious heart disease caused by infection of Trypanosoma cruzi. The pathological process of Chagas cardiomyopathy is divided into a self-limiting acute phase and an irreversible chronic phase, which is characterized by progressive myocardial fibrosis and neurogenic disorders. The diagnosis should be combined with epidemiological history, serological detection and multimodal imaging technology, and the treatment strategy includes pathogen control and complication management at the same time. At present, the clinical challenges of Chagas cardiomyopathy are focused on the high rate of missed diagnosis in non-epidemic areas and the lack of means to reverse chronic pathological reversal. Establishing a multidisciplinary diagnosis and treatment pathway based on serological screening and improving the hierarchical prevention and control system are the key to improve the global burden of Chagas cardiomyopathy. With the progress of research technology, the diagnosis and treatment strategies of Chagas cardiomyopathy are updated. In 2024, the first non-imported case of Chagas disease in China was reported. This article systematically discusses the clinical manifestations, diagnostic and treatment strategies, and the latest research progress of patients with Chagas cardiomyopathy, aiming to enhance the understanding of this disease among medical professionals in China and provide a reference for early detection, screening and standardized treatment.

Key words: Chagas cardiomyopathy, Infection, Diagnosis and treatment

表1 恰加斯心肌病慢性期分阶段标准

分期	诊断标准	年病死率（%）	治疗重点
A期	血清学阳性+心电图正常	0.5	定期监测
B期	心电图异常（传导障碍/心律失常）	2.3	抗心律失常
C期	HF症状（NYHA^a Ⅱ～Ⅲ）	12.5	指南导向药物治疗
D期	终末期HF（NYHA Ⅳ）	40.0～60.0	高级生命支持

表1 恰加斯心肌病慢性期分阶段标准

分期	诊断标准	年病死率（%）	治疗重点
A期	血清学阳性+心电图正常	0.5	定期监测
B期	心电图异常（传导障碍/心律失常）	2.3	抗心律失常
C期	HF症状（NYHA^a Ⅱ～Ⅲ）	12.5	指南导向药物治疗
D期	终末期HF（NYHA Ⅳ）	40.0～60.0	高级生命支持

表2 2018年美国心脏协会恰加斯心肌病分阶段标准

分期	诊断标准
急性期	由克氏锥虫感染且符合急性恰加斯病的表现
不确定期
A期	血清学检查阳性+心电图正常，无心脏相关症状
慢性期
B1期	心电图或超声心动图改变，心室整体功能正常
B2期	心电图或超声心动图改变，心室整体功能障碍
C期	出现HF症状（NYHA Ⅰ～Ⅳ ）
D期	治疗后，仍有顽固症状的HF

表2 2018年美国心脏协会恰加斯心肌病分阶段标准

分期	诊断标准
急性期	由克氏锥虫感染且符合急性恰加斯病的表现
不确定期
A期	血清学检查阳性+心电图正常，无心脏相关症状
慢性期
B1期	心电图或超声心动图改变，心室整体功能正常
B2期	心电图或超声心动图改变，心室整体功能障碍
C期	出现HF症状（NYHA Ⅰ～Ⅳ ）
D期	治疗后，仍有顽固症状的HF

表3 恰加斯心肌病抗锥虫治疗剂量与疗程

药物名称	剂量（mg·kg^-1·d^-1）		疗程（d）	关键研究证据
药物名称	成人	儿童	疗程（d）	关键研究证据
苄硝唑	5～10^a	5～10^a	60	CHAGASAZ研究（Ⅲ期）^[46]
硝呋莫司	8～10^b	15^b	60	CHICO试验（缩短疗程致疗效下降）^[47]

表3 恰加斯心肌病抗锥虫治疗剂量与疗程

药物名称	剂量（mg·kg^-1·d^-1）		疗程（d）	关键研究证据
药物名称	成人	儿童	疗程（d）	关键研究证据
苄硝唑	5～10^a	5～10^a	60	CHAGASAZ研究（Ⅲ期）^[46]
硝呋莫司	8～10^b	15^b	60	CHICO试验（缩短疗程致疗效下降）^[47]

[1]	Hochberg NS, Montgomery SP. Chagas disease[J]. Ann Intern Med,2023,176(2):ITC17-ITC32.
[2]	Xu N, Zhang X, Liu H, et al. Clinical and epidemiological investigation of human infection with zoonotic parasite Trypanosoma dionisii in China[J]. J Infect,2024,89(5):106290.
[3]	de Sousa A, Vermeij D, Ramos A, et al. Chagas disease[J]. Lancet,2024,403(10422):203-218.
[4]	No authors listed. Chagas disease in Latin America: an epidemiological update based on 2010 estimates[J]. Wkly Epidemiol Rec,2015,90(6):33-43.
[5]	Bern C, Messenger LA, Whitman JD, et al. Chagas disease in the United States: a public health approach[J]. Clin Microbiol Rev,2019,33(1):e00023-19.
[6]	Sun Y, Huang WH, Niu ZG, et al. Pathogen identification for an imported case with African Trypanosomiasis[J]. Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi,2016,34(4):350-354.
[7]	Wang X, Ruan Q, Xu B, et al. Human African Trypanosomiasis in emigrant returning to China from Gabon, 2017[J]. Emerg Infect Dis,2018,24(2):400-404.
[8]	Wang LJ, Han HJ, Zhao M, et al. Trypanosoma dionisii in insectivorous bats from northern China[J]. Acta Trop,2019,193:124-128.
[9]	Swett MC, Rayes DL, Campos SV, et al. Chagas disease: epidemiology, diagnosis, and treatment[J]. Curr Cardiol Rep,2024,26(10):1105-1112.
[10]	Nunes MC, Dones W, Morillo CA, et al. Chagas disease: an overview of clinical and epidemiological aspects[J]. J Am Coll Cardiol,2013,62(9):767-776.
[11]	Burgos JM, Diez M, Vigliano C, et al. Molecular identification of Trypanosoma cruzi discrete typing units in end-stage chronic Chagas heart disease and reactivation after heart transplantation[J]. Clin Infect Dis,2010,51(5):485-495.
[12]	Bocchi EA, Bestetti RB, Scanavacca MI, et al. Chronic Chagas heart disease management: from etiology to cardiomyopathy treatment[J]. J Am Coll Cardiol,2017,70(12):1510-1524.
[13]	Passos L, Koh CC, Magalhaes L, et al. Distinct CD4(-)CD8(-) (double-negative) memory T-cell subpopulations are associated with indeterminate and cardiac clinical forms of chagas disease[J]. Front Immunol,2021,12:761795.
[14]	Yeung C, Mendoza I, Echeverria LE, et al. Chagas’ cardiomyopathy and Lyme carditis: Lessons learned from two infectious diseases affecting the heart[J]. Trends Cardiovasc Med,2021,31(4):233-239.
[15]	Bern C. Chagas’ disease[J]. N Engl J Med,2015,373(5):456-466.
[16]	Nunes M, Beaton A, Acquatella H, et al. Chagas cardiomyopathy: An update of current clinical knowledge and management: A scientific statement from the American Heart Association[J]. Circulation,2018,138(12):e169-e209.
[17]	Rassi AJ, Rassi A. Rassi score: Another external validation with high performance in patients with chagas cardiomyopathy[J]. J Am Coll Cardiol,2019,73(13):1734-1735.
[18]	Bern C, Montgomery SP, Herwaldt BL, et al. Evaluation and treatment of chagas disease in the United States: a systematic review[J]. JAMA,2007,298(18):2171-2181.
[19]	Umezawa ES, Nascimento MS, Stolf AM. Enzyme-linked immunosorbent assay with Trypanosoma cruzi excreted-secreted antigens (TESA-ELISA) for serodiagnosis of acute and chronic Chagas’ disease[J]. Diagn Microbiol Infect Dis,2001,39(3):169-176.
[20]	Mcclean M, Bhattacharyya T, Mertens P, et al. A lineage-specific rapid diagnostic test (Chagas Sero K-SeT) identifies Brazilian Trypanosoma cruzi Ⅱ/Ⅴ/Ⅵ reservoir hosts among diverse mammalian orders[J]. PLoS One,2020,15(1):e0227828.
[21]	Elisei R, Matos CS, Carvalho A, et al. Immunogenomic screening approach to identify new antigens for the serological diagnosis of chronic Chagas’ disease[J]. Appl Microbiol Biotechnol,2018,102(14):6069-6080.
[22]	Marin-Neto JA, Andrade ZA. Why is there predominance of right heart failure in Chagas’ disease?[J]. Arq Bras Cardiol,1991,57(3):181-183.
[23]	Rassi AJ, Rassi A, Little WC, et al. Development and validation of a risk score for predicting death in Chagas’ heart disease[J]. N Engl J Med,2006,355(8):799-808.
[24]	Ramos M, Moreira HT, Volpe GJ, et al. Correlation between cardiomegaly on chest X-ray and left ventricular diameter on echocardiography in patients with chagas disease[J]. Arq Bras Cardiol,2021,116(1):68-74.
[25]	Nunes MC, Rocha MO, Ribeiro AL, et al. Right ventricular dysfunction is an independent predictor of survival in patients with dilated chronic Chagas’ cardiomyopathy[J]. Int J Cardiol,2008,127(3):372-379.
[26]	Carmo RD, Hotta VT, Gomes FR, et al. Incidence and variables associated with arrhythmias during dobutamine-atropine stress echocardiography among patients with Chagas disease[J]. Echocardiography, 2019,36(7):1338-1345.
[27]	Marcolino MS, Palhares DM, Ferreira LR, et al. Electrocardiogram and chagas disease: a large population database of primary care patients[J]. Glob Heart,2015,10(3):167-172.
[28]	Kann S, Mendoza G, Hartmann M, et al. Chagas disease: medical and ECG related findings in an indigenous population in colombia[J]. Trop Med Infect Dis,2023,8(6):297.
[29]	Rassi AJ, Rassi A, Marin-Neto JA. Chagas heart disease: pathophysiologic mechanisms, prognostic factors and risk stratification[J]. Mem Inst Oswaldo Cruz,2009,104(Suppl 1):152-158.
[30]	Senra T, Ianni BM, Costa A, et al. Long-term prognostic value of myocardial fibrosis in patients with chagas cardiomyopathy[J]. J Am Coll Cardiol,2018,72(21):2577-2587.
[31]	Weinsaft JW, Kim HW, Shah DJ, et al. Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with systolic dysfunction[J]. J Am Coll Cardiol,2008,52(2):148-157.
[32]	Volpe GJ, Moreira HT, Trad HS, et al. Left ventricular scar and prognosis in chronic Chagas cardiomyopathy[J]. J Am Coll Cardiol,2018,72(21):2567-2576.
[33]	Borges JP, Mendes F, Rangel M, et al. Exercise training improves microvascular function in patients with Chagas heart disease: Data from the PEACH study[J]. Microvasc Res,2021,134:104106.
[34]	Viotti R, Vigliano C, Lococo B, et al. Exercise stress testing as a predictor of progression of early chronic Chagas heart disease[J]. Heart,2006,92(3):403-404.
[35]	Figueiredo CS, de Melo R, Viana TT, et al. Clinical and echocardiographic characteristics after six months of sacubitril/valsartan in Chagas heart disease-A case series[J]. Br J Clin Pharmacol,2022,88(2):429-436.
[36]	Mastrocola LE, Amorim BJ, Vitola JV, et al. Update of the Brazilian Guideline on nuclear cardiology-2020[J]. Arq Bras Cardiol,2020,114(2):325-429.
[37]	Gadioli LP, Miranda CH, Pintya AO, et al. The severity of ventricular arrhythmia correlates with the extent of myocardial sympathetic denervation, but not with myocardial fibrosis extent in chronic Chagas cardiomyopathy: Chagas disease, denervation and arrhythmia[J]. J Nucl Cardiol,2018,25(1):75-83.
[38]	Sara L, Szarf G, Tachibana A, et al. Ⅱ guidelines on cardiovascular magnetic resonance and computed tomography of the Brazilian Society of Cardiology and the Brazilian College of Radiology[J]. Arq Bras Cardiol,2014,103(6 Suppl 3):1-86.
[39]	Abbott A, Montgomery SP, Chancey RJ. Characteristics and adverse events of patients for whom nifurtimox was released through CDC-sponsored investigational new drug program for treatment of Chagas disease-United States, 2001-2021[J]. MMWR Morb Mortal Wkly Rep,2022,71(10):371-374.
[40]	Chadalawada S, Rassi AJ, Samara O, et al. Mortality risk in chronic Chagas cardiomyopathy: a systematic review and meta-analysis[J]. ESC Heart Fail,2021,8(6):5466-5481.
[41]	Marti-Carvajal AJ, Kwong JS. Pharmacological interventions for treating heart failure in patients with Chagas cardiomyopathy[J]. Cochrane Database Syst Rev,2016,7(7):CD009077.
[42]	Liu Z, Ulrich VR, Kendricks AL, et al. Localized cardiac small molecule trajectories and persistent chemical sequelae in experimental Chagas disease[J]. Nat Commun,2023,14(1):6769.
[43]	Pedrosa RC. Does galectin-3 (myocardial fibrosis biomarker) predict progression in Chagas disease?[J]. Arq Bras Cardiol,2021,116(2):257-258.
[44]	Brochet P, Ianni B, Nunes J, et al. Blood DNA methylation marks discriminate Chagas cardiomyopathy disease clinical forms[J]. Front Immunol,2022,13:1020572.
[45]	Sperandio DSG, Mediano M, Hasslocher-Moreno AM, et al. Benznidazole treatment safety: the Medecins Sans Frontieres experience in a large cohort of Bolivian patients with Chagas’ disease[J]. J Antimicrob Chemother,2017,72(9):2596-2601.
[46]	Dias JC, Ramos AJ, Gontijo ED, et al. Brazilian consensus on Chagas disease, 2015[J].Epidemiol Serv Saude,2016,25(spe):7-86.
[47]	Altcheh J, Corral R, Biancardi MA, et al. Anti-F2/3 antibodies as cure marker in children with congenital Trypanosoma cruzi infection[J]. Medicina (B Aires),2003,63(1):37-40.
[48]	Vamos M, Erath JW, Benz AP, et al. Meta-analysis of effects of digoxin on survival in patients with atrial fibrillation or heart failure: An update[J]. Am J Cardiol,2019,123(1):69-74.
[49]	Quiros FR, Morillo CA, Casas JP, et al. CHARITY: Chagas cardiomyopathy bisoprolol intervention study: a randomized double-blind placebo force-titration controlled study with Bisoprolol in patients with chronic heart failure secondary to Chagas cardiomyopathy [NCT00323973][J]. Trials,2006,7:21.
[50]	Yeh RW, Valsdottir LR, Yeh MW, et al. Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial[J]. BMJ,2018,363:k5094.
[51]	Nasrallah D, Abdelhamid A, Tluli O, et al. Angiotensin receptor blocker-neprilysin inhibitor for heart failure with reduced ejection fraction[J]. Pharmacol Res,2024,204:107210.
[52]	Heran BS, Musini VM, Bassett K, et al. Angiotensin receptor blockers for heart failure[J]. Cochrane Database Syst Rev,2012,2012(4):CD003040.
[53]	Botoni FA, Poole-Wilson PA, Ribeiro AL, et al. A randomized trial of carvedilol after renin-angiotensin system inhibition in chronic Chagas cardiomyopathy[J]. Am Heart J,2007,153(4):541-544.
[54]	Kotecha D, Holmes J, Krum H, et al. Efficacy of beta blockers in patients with heart failure plus atrial fibrillation: an individual-patient data Meta-analysis[J]. Lancet,2014,384(9961):2235-2243.
[55]	Issa VS, Amaral AF, Cruz FD, et al. Beta-blocker therapy and mortality of patients with Chagas cardiomyopathy: a subanalysis of the REMADHE prospective trial[J]. Circ Heart Fail,2010,3(1):82-88.
[56]	Bestetti RB, Theodoropoulos TA, Cardinalli-Neto A, et al. Treatment of chronic systolic heart failure secondary to Chagas heart disease in the current era of heart failure therapy[J]. Am Heart J,2008,156(3):422-430.
[57]	Pfeffer MA, Claggett B, Lewis EF, et al. Angiotensin receptor-neprilysin inhibition in acute myocardial infarction[J]. N Engl J Med,2021,385(20):1845-1855.
[58]	Ramires F, Martinez F, Gomez EA, et al. Post hoc analyses of SHIFT and PARADIGM-HF highlight the importance of chronic Chagas’ cardiomyopathy Comment on: “Safety profile and efficacy of ivabradine in heart failure due to Chagas heart disease: a post hoc analysis of the SHIFT trial” by Bocchi et al[J]. ESC Heart Fail,2018,5(6):1069-1071.
[59]	Packer M, Anker SD, Butler J, et al. Cardiovascular and renal outcomes with empagliflozin in heart failure[J]. N Engl J Med,2020,383(15):1413-1424.
[60]	Anker SD, Butler J, Filippatos G, et al. Empagliflozin in heart failure with a preserved ejection fraction[J]. N Engl J Med,2021,385(16):1451-1461.
[61]	Mendes F, Mediano M, Silva RS, et al. Discussing the score of cardioembolic ischemic stroke in Chagas disease[J]. Trop Med Infect Dis,2020,5(2):82.
[62]	Martinelli-Filho M, Marin-Neto JA, Scanavacca MI, et al. Amiodarone or implantable cardioverter-defibrillator in Chagas cardiomyopathy: The CHAGASICS randomized clinical trial[J]. JAMA Cardiol,2024,9(12):1073-1081.
[63]	Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial[J]. N Engl J Med,1991,324(12):781-788.
[64]	Rassi AJ, Rassi A, Rassi SG. Predictors of mortality in chronic Chagas disease: a systematic review of observational studies[J]. Circulation, 2007,115(9):1101-1108.
[65]	Marin-Neto JA, Rassi AJ, Oliveira G, et al. SBC guideline on the diagnosis and treatment of patients with cardiomyopathy of Chagas disease-2023[J]. Arq Bras Cardiol,2023,120(6):e20230269.
[66]	Romero J, Velasco A, Pisani CF, et al. Advanced therapies for ventricular arrhythmias in patients with chagasic cardiomyopathy: JACC state-of-the-art review[J]. J Am Coll Cardiol,2021,77(9):1225-1242.
[67]	Da S JO, Borges MC, de Melo CS, et al. Alternative sites for right ventricular pacing in Chagas disease: a comparative study of the mid-septum and inflow tract[J]. Pacing Clin Electrophysiol, 2014,37(9):1166-1173.
[68]	Moreira LF, Galantier J, Benicio A, et al. Left ventricular circulatory support as bridge to heart transplantation in Chagas’ disease cardiomyopathy[J]. Artif Organs,2007,31(4):253-258.
[69]	Echeverria LE, Figueredo A, Rodriguez MJ, et al. Survival after heart transplantation for Chagas cardiomyopathy using a conventional protocol: A 10-year experience in a single center[J]. Transpl Infect Dis,2021,23(4):e13549.

[1]	王昭珏, 朱庆莉, 李文波, 杨红, 钱家鸣, 李建初. 超声医学科在中国炎症性肠病多学科诊疗中实施的现况调查[J/OL]. 中华医学超声杂志（电子版）, 2025, 22(02): 131-138.
[2]	刘湘奇, 陈莺, 吴家顺, 罗雪婷, 杨辛, 匡世军. 硝基咪唑类抗生素在预防骨性埋伏下颌第三磨牙拔除术后感染的前瞻性随机对照研究[J/OL]. 中华口腔医学研究杂志(电子版), 2025, 19(02): 112-118.
[3]	曾弘. 膀胱癌病理报告中常用免疫组化标记物的解读[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2025, 19(03): 296-302.
[4]	董振阳, 瞿旻, 王燕, 张韻, 高旭. 序贯多学科会诊模式在前列腺癌全程管理中的应用[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2025, 19(02): 152-158.
[5]	王可依, 吴冲, 刘寒松, 高磊. 腹股沟疝术后补片感染的诊疗进展[J/OL]. 中华疝和腹壁外科杂志(电子版), 2025, 19(03): 331-334.
[6]	张亚伟, 刘琪, 姜建武, 邓瑞, 符洋. 肠造口还纳联合巨大切口疝一期修补六例分析[J/OL]. 中华疝和腹壁外科杂志(电子版), 2025, 19(03): 276-280.
[7]	苟学静, 李真真, 董建, 刘紫霄, 徐锋, 李雯. 肺部感染患者支气管镜检查恐惧潜在剖面分析[J/OL]. 中华肺部疾病杂志(电子版), 2025, 18(03): 475-478.
[8]	朱丹丹, 杨云, 胡忠, 韩明丽, 彭广艳, 郝钊. 类鼻疽菌感染重症肺炎临床特征及预后分析[J/OL]. 中华肺部疾病杂志(电子版), 2025, 18(02): 289-294.
[9]	韩莉, 王启源, 蒙洁, 杨新亮, 刘侠, 贺晨艳. 糖尿病并发肺结核患者继发肺部真菌感染危险因素分析[J/OL]. 中华肺部疾病杂志(电子版), 2025, 18(02): 304-309.
[10]	童生莲, 张茜. 异基因造血干细胞移植后感染新冠病毒发生可逆性后部脑病变综合征1 例并文献复习[J/OL]. 中华细胞与干细胞杂志(电子版), 2025, 15(03): 190-192.
[11]	中国医师协会结直肠肿瘤专业委员会, 中华医学会外科学分会结直肠外科学组, 中国医师协会肛肠医师分会, 中国医师协会结直肠肿瘤专业委员会低位直肠癌保肛学组. 低位直肠癌术前多学科整合临床决策专家共识（2025版）[J/OL]. 中华结直肠疾病电子杂志, 2025, 14(03): 221-233.
[12]	洪敏, 许建峰, 丰陈. 内脏型肥胖对结直肠癌根治术患者术后感染并发症的预测价值[J/OL]. 中华消化病与影像杂志(电子版), 2025, 15(03): 199-204.
[13]	谷肖明, 沈敏, 王瑀, 边燕. 肝癌术后感染患者肠道菌群特征与机体炎症、免疫功能及肠道功能的相关性研究[J/OL]. 中华消化病与影像杂志(电子版), 2025, 15(03): 224-228.
[14]	张庭秀, 胡绳, 马李杰, 肖贞良. 链格孢菌致侵袭性肺部真菌感染一例并文献复习[J/OL]. 中华诊断学电子杂志, 2025, 13(02): 122-125.
[15]	朱其菲, 张莎莎. 187例肺炎支原体感染的哮喘患儿骨膜素、肌腱蛋白-C、sST2水平特征及对哮喘急性发作的影响[J/OL]. 中华卫生应急电子杂志, 2025, 11(02): 73-80.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Progress on diagnosis and treatment of Chagas cardiomyopathy

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Progress on diagnosis and treatment of Chagas cardiomyopathy