Project Summary Chagas disease is responsible for a compelling number of cases of sudden cardiac death and heart failure. Of those infected with the causal protozoan parasite, only 20-30% develop cardiomyopathy and the underlying reason of this selective progression remains unknown. As part of our existing RO1 in Santa Cruz, Bolivia, we have one of if not the largest ongoing longitudinal Chagas-infected cohorts. This study has already enabled us to collect multiple EKGs, Echocardiograms, and serum samples for biomarker analysis, as well as specimens preserved for RNA analysis. This renewal grant proposes to utilize this ongoing survey to detect markers for detecting early progression versus those who do not progress over a ten-year period. This is essential in determining interventions in those infected by defining those who are likely advance to disease. Our group has demonstrated RNA transcriptome changes in progressors vs. non-progressors as well as in the inflammasome genes, particularly in NLRP1, CASP1 and CARD, which may be associated with CCC. We also demonstrated that the most sensitive indicator of progression from Cardiac stage A to B is the adjusted Sylvester QRS score. Finally, we demonstrated early changes using Global Longitudinal Strain pattern. Our overarching aim is to continue to examine subjects who progress and don’t progress to cardiac disease and determine genetic and pathogenetic characteristics that differentiate between the two groups. Specific Aim 1: To compare EKG, QRS score, and echocardiogram global strain as indicators of cardiomyopathy progression in Chagas disease. The current standard for monitoring disease progression is an EKG, and in the first five years of this grant, we found that QRS score may also be a useful indicator. We hypothesize that the QRS score will provide a more sensitive indicator of those who go to cardia global strain will prove to be more sensitive than both of these as an early indicator of eventual disease progression. In addition, we will add Holter monitoring to a randomized subgroup of individuals. Specific Aim 2: To assess changes in the transcriptome associated with the inflammasome and cardiac neural and structural components that are altered with disease progression. We hypothesize that Chagas cardiomyopathy results from an immunological reaction to the parasite and is genetically influenced. Specifically, we will identify differentially expressed immune-related genes through RNAseq, particularly concentrating on Th1 T cell activation, ion channels, myocardial remodeling, intermediate filament expression, and other inflammatory-related markers to evaluate differences over time.