Mortality and Morbidity in Adults With Rheumatic Heart Disease

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 i...

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Published in:	JAMA : the journal of the American Medical Association Vol. 332; no. 2; p. 133
Main Authors:	Karthikeyan, Ganesan, Ntsekhe, Mpiko, Islam, Shofiqul, Rangarajan, Sumathy, Avezum, Alvaro, Benz, Alexander, Cabral, Tantchou Tchoumi Jacques, Changsheng, Ma, Chillo, Philly, Gonzalez-Hermosillo, J. Antonio, Gitura, Bernard, Damasceno, Albertino, Dans, Antonio Miguel L, Davletov, Kairat, Elghamrawy, Alaa, ElSayed, Ahmed, Fana, Golden Tafadzwa, Gondwe, Lillian, Haileamlak, Abraham, Kayani, Azhar Mahmood, Lwabi, Peter, Maklady, Fathi, Molefe-Baikai, Onkabetse Julia, Musuku, John, Ogah, Okechukwu Samuel, Paniagua, Maria, Rusingiza, Emmanuel, Sharma, Sanjib Kumar, Zuhlke, Liesl, Connolly, Stuart, Yusuf, Salim
Format:	Journal Article
Language:	English
Published:	United States American Medical Association 09-07-2024
Subjects:	Adult Anticoagulants Cardiovascular disease Cardiovascular diseases Cause of Death Congestive heart failure Developing Countries Endocarditis Endocarditis - mortality Female Fever Heart diseases Heart Failure - complications Heart Failure - mortality Hospitalization - statistics & numerical data Humans Hypertension Income Male Middle Aged Morbidity Mortality Observational studies Patients Prophylaxis Proportional Hazards Models Prospective Studies Public health Rheumatic fever Rheumatic Fever - complications Rheumatic Fever - mortality Rheumatic heart disease Rheumatic Heart Disease - complications Rheumatic Heart Disease - mortality Risk assessment Stroke Stroke - epidemiology Stroke - mortality Surgery
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Summary:	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 13 696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12 967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41 478 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.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 ObjectType-Undefined-3
ISSN:	0098-7484 1538-3598 1538-3598
DOI:	10.1001/jama.2024.8258