Circulation 2016 Nov 4;134(19):1456-1466. Epub 2016 Oct 4.
From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Ontario, Canada (S.R., P.M., S.I., K.T., S.Y.); Department of Statistical Sciences, University of Cape Town, South Africa (K.M.); Department of Surgery, School of Medicine, College of Health Sciences, University of Nairobi, Kenya (S.O.); Cardiology Unit, Department of Medicine, Kenyatta National Teaching and Referral Hospital, Nairobi, Kenya (B.G.); Cardiology Unit, Department of Medicine, Mulago Hospital, Kampala, Uganda (C.M.); Uganda Heart Institute, Kampala (E.O., P.L.); Faculty of Medicine & Surgery, University of Sana'a, Al-Thawrah Cardiac Center, Yemen (M.M.A.-K.); Paediatric Cardiology Service, Windhoek Central Hospital, Namibia (C.H.-H.); Department of Paediatrics, Division of Paediatric Cardiology, Faculty of Medicine, Cairo University Children's Hospital, Egypt (S.S.S.); Department of Paediatrics and Child Health, Jimma University Hospital, Ethiopia (A.H., W.D.); Department of Internal Medicine, Faculty of Medicine, Addis Ababa, Ethiopia (D.Y.G., S.G.A., A.G.D., B.A.S., D.M.B.); Cardiothoracic Surgery Department, Al Shaab Teaching Hospital and Faculty of Medicine, Alzaiem Alazhari University, Khartoum, Sudan (A.E., A.S.I.); University Teaching Hospital, Department of Paediatrics and Child Health, University of Zambia, Lusaka (J.M.); Departments of Paediatrics and Medicine, Jos University Teaching Hospital, Nigeria (F.B.-T., C.C.Y., G.A.A., O.I., B.O.); Department of Paediatrics and Child Health, University of Limpopo, Polokwane, South Africa (C.S.); Department of Internal Medicine, University of Limpopo, Polokwane, South Africa (R.M.); Faculty of Medicine, Benha University, Cairo, Egypt (A.A.F.); Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre (N.K.); Department of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); Department of Medicine, Bayero University and Aminu Kano Teaching Hospital, Nigeria (M.U.S.); Division of Cardiology, Department of Medicine, University College Hospital, Ibadan, Nigeria (O.S.O., A.M.A.); Nigeria Ministry of Health, Umuahia, Abia State (O.S.O.); Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria (O.S.O., T.O.); Ahmed Gasim Teaching Hospital, Khartoum, Sudan (H.H.M.E.); Instituto Nacional de Saúde and Eduardo Mondlane University, Maputo, Mozambique (A.O.M.); Department of Cardiology, Dr. George Mukhari Hospital and Sefako Makgatho Health Sciences University, Tshwane, South Africa (P.M.); Cardiology Unit, Department of Medicine, University of Abuja Teaching Hospital, Nigeria (D.O.); and Paediatric Cardiology Unit, Department of Paediatrics, King Faisal Hospital, Kigali, Rwanda (J.M.).
Background: There are few contemporary data on the mortality and morbidity associated with rheumatic heart disease or information on their predictors. We report the 2-year follow-up of individuals with rheumatic heart disease from 14 low- and middle-income countries in Africa and Asia.
Methods: Between January 2010 and November 2012, we enrolled 3343 patients from 25 centers in 14 countries and followed them for 2 years to assess mortality, congestive heart failure, stroke or transient ischemic attack, recurrent acute rheumatic fever, and infective endocarditis.
Results: Vital status at 24 months was known for 2960 (88.5%) patients. Two-thirds were female. Although patients were young (median age, 28 years; interquartile range, 18-40), the 2-year case fatality rate was high (500 deaths, 16.9%). Mortality rate was 116.3/1000 patient-years in the first year and 65.4/1000 patient-years in the second year. Median age at death was 28.7 years. Independent predictors of death were severe valve disease (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.80-3.11), congestive heart failure (HR, 2.16; 95% CI, 1.70-2.72), New York Heart Association functional class III/IV (HR, 1.67; 95% CI, 1.32-2.10), atrial fibrillation (HR, 1.40; 95% CI, 1.10-1.78), and older age (HR, 1.02; 95% CI, 1.01-1.02 per year increase) at enrollment. Postprimary education (HR, 0.67; 95% CI, 0.54-0.85) and female sex (HR, 0.65; 95% CI, 0.52-0.80) were associated with lower risk of death. Two hundred and four (6.9%) patients had new congestive heart failure (incidence, 38.42/1000 patient-years), 46 (1.6%) had a stroke or transient ischemic attack (8.45/1000 patient-years), 19 (0.6%) had recurrent acute rheumatic fever (3.49/1000 patient-years), and 20 (0.7%) had infective endocarditis (3.65/1000 patient-years). Previous stroke and older age were independent predictors of stroke/transient ischemic attack or systemic embolism. Patients from low- and lower-middle-income countries had significantly higher age- and sex-adjusted mortality than patients from upper-middle-income countries. Valve surgery was significantly more common in upper-middle-income than in lower-middle- or low-income countries.
Conclusions: Patients with clinical rheumatic heart disease have high mortality and morbidity despite being young; those from low- and lower-middle-income countries had a poorer prognosis associated with advanced disease and low education. Programs focused on early detection and the treatment of clinical rheumatic heart disease are required to improve outcomes.