Mortality Up, Treatment Falls Short for Rheumatic Heart Disease in Poorer Countries: Registry

Larry Hand

October 07, 2016

CAPE TOWN, SOUTH AFRICA — Patients with rheumatic heart disease living in low- and lower-middle–income countries enrolled in the Global Rheumatic Heart Disease Registry (the REMEDY study) had a poor prognosis and were at increased risk for high mortality and morbidity despite a young age, according to 2-year follow-up data[1].

"Access to essential surgery for patients with symptomatic rheumatic heart disease living in low- and middle-income countries should be a priority for the global cardiovascular community," Dr Bongani M Mayosi (Groote Schuur Hospital, University of Cape Town, South Africa) told heartwire from Medscape.

"In addition, there is also a need to improve the uptake of secondary prophylaxis with penicillin and optimize anticoagulation for patients with rheumatic atrial fibrillation," he said.

Mayosi and colleagues analyzed data on 3343 patients enrolled in REMEDY between January 2010 and November 2012 from 25 centers in 14 countries in Africa and Asia. They had vital status on 2960 (88.5%) patients at 24 months.

The mortality rate was 116.3/1000 patient-years the first year and 65.4/1000 patient-years the second year for patients with a median age of 28 years. Over 2 years, 500 deaths (16.9%) occurred.

Researchers found independent predictors of death to be:

  • Severe valve disease (hazard ratio [HR] 2.36; 95% CI 1.80–3.11).

  • Congestive heart failure (HR 2.16; 95% CI 1.70–2.72).

  • NYHA class 3/4 (HR 1.67; 95% CI 1.32–2.10).

  • Atrial fibrillation (HR 1.40; 95% CI 1.10–1.78).

  • Older age (HR 1.02; 95% CI 1.10–1.02).

In addition, they found older age and previous stroke to independently predict stroke/transient ischemic attack or systemic embolism.

Patients in low- and lower-middle–income countries had higher age- and sex-adjusted mortality than patients in upper-middle–income countries, and valve surgeries were significantly more common in upper-middle–income countries.

Almost half of patients were not taking penicillin, and despite a number of patients having atrial fibrillation, only 70% were taking oral anticoagulants.

Most patients with valve disease needed intervention; however, only 10.3% with severe disease had had surgery or percutaneous procedures.

"Studies on early identification of symptomatic rheumatic heart disease through surveillance of the whole population are now required to test whether mortality and morbidity can be reduced, in addition to the current focus of echocardiographic screening of asymptomatic school children for latent rheumatic heart disease," said Mayosi.

"There is a need for trials of new oral anticoagulants vs warfarin and also the effectiveness of penicillin in adults for the prevention of morbidity and mortality in rheumatic disease," he added.

"Large-scale registries in all endemic countries with a longer follow-up are needed to provide information on the burden of disease associated with rheumatic heart disease in the world," he concluded.

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