Mortality and Morbidity in Adults with Rheumatic Heart Disease

Karthikeyan G. Ntsekhe M. Islam S. Rangarajan S. Avezum A. Benz A. Cabral T.T.J. Changsheng M. Chillo P. Gonzalez-Hermosillo J.A. Gitura B. Damasceno A. Dans A.M.L. Davletov K. Elghamrawy A. Elsayed A. Fana G.T. Gondwe L. Haileamlak A. Kayani A.M. Lwabi P. Maklady F. Molefe-Baikai O.J. Musuku J. Ogah O.S. Paniagua M. Rusingiza E. Sharma S.K. Zuhlke L. Connolly S. Yusuf S.
9 July 2024 American Medical Association

JAMA
2024 #332 Issue 2 133 - 140 pp.

Importance: Rheumatic heart disease (RHD) remains a public health issue in low- and middle-income countries (LMICs). However, there are few large studies enrolling individuals from multiple endemic countries. Objective: To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD. Design, Setting, and Participants: Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs. Main Outcomes and Measures: The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality, heart failure (HF) hospitalization, stroke, recurrent rheumatic fever, and infective endocarditis. This study analyzed event rates by World Bank country income groups and determined the predictors of mortality using multivariable Cox models. Results: Between August 2016 and May 2022, a total of 13696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41478 patient-years), 1943 patients died (15% overall; 4.7% per patient-year). Most deaths were due to vascular causes (1312 [67.5%]), mainly HF or sudden cardiac death. The number of patients undergoing valve surgery (604 [4.4%]) and HF hospitalization (2% per year) was low. Strokes were infrequent (0.6% per year) and recurrent rheumatic fever was rare. Markers of severe valve disease, such as congestive HF (HR, 1.58 [95% CI, 1.50-1.87]; P <.001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P <.001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P <.001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P <.001) or valvuloplasty (HR, 0.24 [95% CI, 0.06-0.95]; P =.042) were associated with lower mortality. Higher country income level was associated with lower mortality after adjustment for patient-level factors. Conclusions and Relevance: Mortality in RHD is high and is correlated with the severity of valve disease. Valve surgery and valvuloplasty were associated with substantially lower mortality. Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation.

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Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
Translational Health Science and Technology Institute, Faridabad, India
Division of Cardiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
Population Health Research Institute, McMaster University, Hamilton, ON, Canada
International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
St. Elizabeth Catholic General Hospital, Shisong Cardiac Centre, Kumbo, Cameroon
Beijing Anzhen Hospital, Beijing, China
Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, Mexico
Kenyatta National Teaching & Referral Hospital, Department of Cardiology, Nairobi, Kenya
Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
College of Medicine, University of Philippines, Manila, Philippines
Asfendiyarov Kazakh National Medical University, Health Research Institute, Almaty, Kazakhstan
Mehalla Heart Center, El Mahalla El Kubra, Egypt
Alzaiem Alazhari University, Khartoum, Sudan
University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
Kamuzu Central Hospital, Lilongwe, Malawi
College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
Jimma University Medical Center, Jimma, Ethiopia
Rawalpindi Institute of Cardiology, Punjab, Rawalpindi, Pakistan
Uganda Heart Institute, Kampala, Uganda
Department of Cardiology, Suez Canal University, Ismailia, Egypt
Princess Marina Hospital, University of Botswana, Gaborone, Botswana
University Teaching Hospital, Lusaka, Zambia
Cardiology Unit, Department of Medicine, University of Ibadan, University College Hospital, Oyo State, Ibadan, Nigeria
College of Medicine Sciences, National University of Concepción, Concepción, Paraguay
University Teaching Hospital of Kigali, Kigali, Rwanda
B.P. Koirala Institute of Health Sciences, Dharan, Nepal
Medical Research Council of South Africa, Division of Pediatric Cardiology, Department of Pediatrics, Red Cross Childrens Hospital Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

Department of Cardiology
Translational Health Science and Technology Institute
Division of Cardiology
Population Health Research Institute
International Research Center
Department of Cardiology
St. Elizabeth Catholic General Hospital
Beijing Anzhen Hospital
Muhimbili University of Health and Allied Sciences
Instituto Nacional de Cardiología Ignacio Chávez
Kenyatta National Teaching & Referral Hospital
Faculty of Medicine
College of Medicine
Asfendiyarov Kazakh National Medical University
Mehalla Heart Center
Alzaiem Alazhari University
University of Zimbabwe
Kamuzu Central Hospital
College of Medicine and Health Sciences
Jimma University Medical Center
Rawalpindi Institute of Cardiology
Uganda Heart Institute
Department of Cardiology
Princess Marina Hospital
University Teaching Hospital
Cardiology Unit
College of Medicine Sciences
University Teaching Hospital of Kigali
B.P. Koirala Institute of Health Sciences
Medical Research Council of South Africa

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