Doença de Chagas : implante de marcapasso, manejo por médicos da Atenção Primária à Saúde e produções de um coorte

Abstract

Chagas disease (CD) is a tropical disease of neglected populations, endemic in Latin America, including Brazil. This dissertation aims to discuss issues related to CD, with three different studies. 1) The first study aimed to: 1. Identify contextual factors associated with pacemaker (PM) implantation (case vs. control group) among patients with chronic chagasic heart disease. 2. Evaluate the prognosis (death) of these groups, after 4 years of follow-up. A case control study nested within a cohort study was conducted, and Logistic Regression and subsequently, survival analysis (Cox Regression) were conducted between the two groups. The cases were those that implemented MP and the controls were those that did not (1:3 pairing). In survival, death was the outcome. Results: 46 cases and 138 controls participated in the study. The chance of MP implementation was greater among individuals who lived in municipalities with a larger population (OR = 3.6; 95% CI = 1.3 – 9.6), among those who lived in municipalities with greater ESF coverage ( OR = 5.3; 95% CI = 1.8-15.8), with this variable being more strongly associated with the outcome, among those who lived in municipalities with a lower number of electrocardiographs in the SUS / 1000 inhabitants (OR = 2.6; 95% CI = 1.0 -6.6). Considering 4 years of follow-up, 15 (32.6%) cases and 24 (21.2%) controls died. Survival analysis demonstrated that only ejection fraction (RR= 7.2 - 95% CI: 3.6-14.2) significantly affected survival. MP did not remain associated with the outcome. 2) The second study aimed to investigate the feeling of insecurity of Primary Health Care (PHC) doctors in the management of chronic CD and identify associated factors. This is an analytical cross-sectional study, carried out with PHC doctors from 23 municipalities endemic for CD in Minas Gerais. Binary Logistic Regression was conducted. 136 doctors participated in the study. Among them, 53.7% were female, 56% felt insecure and 34.6% did not know the Clinical Protocol and Therapeutic Guidelines for CD (PCDT). There was greater insecurity among female professionals (OR = 2.245) and among those who did not know the PCDT (OR = 3.070). 3) The third study was a narrative review that aimed to bring together the productions and knowledge generated about CD from a Brazilian cohort (SaMi-Trop). 18 studies were identified, 17 of which were published in English, in journals with impact factors ranging from 1.3 to 4.7. In the designs, three studies presenting the cohort profile were identified, six conventional epidemiological studies, one epidemiological study with a multilevel approach, five molecular epidemiology studies, one qualitative study and two studies using artificial intelligence. Among the themes, there are factors associated with antiparasitic treatment, quality of life, prognosis and survival, creation of risk scores and artificial intelligence models to predict mortality, identification of new biomarkers, association between cardiac changes and biomarkers, in addition to challenges for CD care in PHC. Conclusion: The context of individuals with CD influences the implementation of MP, and having or not having MP did not affect their survival. The clinical management of people with CD is permeated by the feeling of insecurity among medical professionals in regions endemic for CD. Finally, the SaMi-Trop cohort has contributed to the production of relevant scientific knowledge regarding the diagnosis, treatment and progression of CD.