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Rheumatic Heart Disease Clinical Outcomes
Study Questions:
What are the rates and predictors of mortality and morbidity associated with rheumatic heart disease (RHD) in low and middle income countries in Africa and Asia?
Methods:
REMEDY is a prospective, multicenter, international, hospital-based registry of patients with symptomatic RHD; the registry did not include asymptomatic patients in whom RHD was detected solely by clinical or echocardiographic screening. Between January 2010 and November 2012, 3,343 patients from 25 centers in 14 countries (12 African countries, Yemen, and India) were enrolled and followed for 2 years to assess mortality, congestive heart failure (CHF), stroke or transient ischemic attack (TIA), recurrent acute rheumatic fever (ARF), and infective endocarditis (IE).
Results:
Vital status at 24 months was known for 2,960 (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 116.3/1,000 patient-years in the first year and 65.4/1,000 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), CHF (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 (AF; 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. Post-primary 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. New CHF was observed in 204 (6.9%, 38.42/1,000 patient-years), stroke or TIA occurred in 46 (1.6%, 8.45/1,000 patient-years), recurrent ARF occurred in 19 (0.6%, 3.49/1,000 patient-years), and IE in 20 (0.7%, 3.65/1,000 patient-years). Previous stroke and older age were independent predictors of stroke/TIA or systemic embolism. Patients from low and lower-middle income countries had significantly higher age- and sex-adjusted mortality compared with 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 RHD 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. The authors concluded that programs focused on early detection and treatment of clinical RHD are required to improve outcomes.
Perspective:
Despite a median patient age of 28 years, clinical RHD was associated with high rates of mortality and morbidity, with higher mortality rates in low and low-middle income countries compared with upper-middle income countries. Although clinical guidelines recommend the use of percutaneous or surgical valve interventions for patients with RHD and CHF, these interventions are not available to the majority of affected patients, and many patients living in low and middle income countries present with relatively advanced disease. In order to improve outcomes among patients with RHD, strategies should be considered to make more accessible proven percutaneous and surgical valve interventions.
Keywords: Atrial Fibrillation, Cardiac Surgical Procedures, Echocardiography, Embolism, Endocarditis, Heart Failure, Heart Valve Diseases, Ischemic Attack, Transient, Outcome Assessment, Health Care, Rheumatic Heart Disease, Socioeconomic Factors, Stroke
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