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Observational Study

Mortality and Morbidity in Adults With Rheumatic Heart Disease

Ganesan Karthikeyan et al. JAMA. .

Abstract

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Benz reported receiving personal fees from Bristol Myers Squibb and AstraZeneca outside the submitted work and participating in an educational program supported by Boston Scientific (Fellowship Herzrhythmus). Dr Cabral reported receiving personal fees from Population Health Research Institute during the conduct of the study. Dr Chillo reported receiving grants from Hamilton Health Sciences during the conduct of the study. Dr Damasceno reported receiving personal fees from Merck Sharp & Dohme and participating in an advisory meeting outside the submitted work. Dr Kayani reported receiving nonfinancial support from Rawalpindi Institute of Cardiology during the conduct of the study and outside the submitted work. Dr Molefe-Baikai reported receiving grants from Hamilton Health Sciences during the conduct of the study. Dr Musuku reported receiving a University Teaching Hospital participation fee during the conduct of the study. Dr Zuhlke reported receiving funding from the South African Medical Research Council (SAMRC) through its Division of Research Capacity Development under the Mid-Career Scientist Programme from funding received from the South African National Treasury; receiving support from the National Research Foundation of South Africa, the UK Medical Research Council (MRC), and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement via the African Research Leader Award (MR/S005242/1). Dr Connolly reported receiving grants from Bayer during the conduct of the study. Dr Yusuf reported receiving grants from Bayer during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Determinants of Mortality in Rheumatic Heart Disease
Variables associated with increased mortality after adjustment for baseline variables include the performance of valvuloplasty or surgery during follow-up and country income group. HRs are based on mutually adjusted multivariable Cox regression model. HR indicates hazard ratio; TIA, transient ischemic attack. aHR for secondary prophylaxis estimated from the fully adjusted model but restricted to those aged 40 years or younger.
Figure 2.
Figure 2.. Incidence of Clinical Outcomes by Country Income Group
Crude incidence rate of clinical outcomes during follow-up. TIA indicates transient ischemic attack.
See this image and copyright information in PMC

Comment in

  • doi: 10.1001/jamacardio.2024.1852

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