Cardiovascular complications in newly diagnosed rheumatic heart disease patients at Mulago Hospital, Uganda

Cardiac strain findings in children with latent rheumatic heart disease detected by echocardiographic screening

BACKGROUND

Identification of patients with latent rheumatic heart disease by echocardiography presents a unique opportunity to prevent disease progression. Myocardial strain is a more sensitive indicator of cardiac performance than traditional measures of systolic function.

OBJECTIVE

The objective of this study was to test the hypothesis that abnormalities in myocardial strain may be present in children with latent rheumatic heart disease.

METHODS

Standard echocardiography images with electrocardiogram gating were obtained from Ugandan children found to have latent rheumatic heart disease as well as control subjects. Traditional echocardiography measures of systolic function were obtained, and offline global longitudinal strain analysis was performed. Comparison between groups was performed using strain as a continuous (Mann-Whitney U-test) and categorical (cut-off 5th percentile for age) variable.

RESULTS

Our study included 14 subjects with definite rheumatic heart disease, 13 with borderline rheumatic heart disease, and 112 control subjects. None of the subjects had abnormal left ventricular size or ejection fraction. Global longitudinal strain was lower than the 5th percentile in 44% of the subjects with any rheumatic heart disease (p=0.002 versus controls) and 57% of the subjects with definite rheumatic heart disease (p=0.03). The mean absolute strain values were significantly lower when comparing subjects with any rheumatic heart disease with controls (20.4±3.95 versus 22.4±4.35, p=0.025) and subjects with definite rheumatic heart disease with controls (19.9±4.25 versus 22.4±4.35, p=0.033).

CONCLUSION

Global longitudinal strain is decreased in subjects with rheumatic heart disease in the absence of abnormal systolic function. Larger studies with longer-term follow-up are required to determine whether there is a role for strain to help better understand the pathophysiology of latent rheumatic heart disease.

The Health Systems Barriers and Facilitators for RHD Prevalence: An Epidemiological Meta-Analysis From Uganda and Tanzania

BACKGROUND

Rheumatic heart disease (RHD) is an important and preventable cause of cardiovascular disease.

OBJECTIVES

As part of a recent RHD initiative in Uganda and Tanzania, we systematically reviewed group A streptococcal disease (GAS), acute rheumatic fever (ARF), and RHD in these countries.

METHODS

Using a systematic review and meta-analysis/meta-synthesis, we searched PubMed, Embase, and grey literature for quantitative and qualitative studies conducted in Uganda and Tanzania that included individuals affected by GAS, ARF, and RHD. We pre-specified 3 sets of outcomes: 1) disease epidemiology; 2) barriers and facilitators to health care; and 3) stakeholder identification and engagement. Study descriptors, outcomes, and interest, and quality assessments were recorded. For the first objective, we conducted random-effects meta-analyses. For the second objective, we produced a narrative synthesis of themes. No studies contained data on the third objective.

RESULTS

Of 293 records identified, 12 met our inclusion criteria (9 for objective 1 and 3 for objective 2). Most quantitative studies were at moderate or high risk of bias, and only 1 of 2 qualitative studies was high quality. We estimated the prevalence of RHD to be 17.9 (95% confidence interval [CI]: 4.0 to 41.2) per 1,000 individuals. The most frequent nonfatal sequelae were heart failure, pulmonary hypertension, and atrial fibrillation. Case-fatality rates in medical and surgical wards were 17% (95% CI: 13% to 21%) and 27% (95% CI: 18% to 36%), respectively. Barriers and facilitators to GAS and RHD care were identified in the domains of individual knowledge, family support, provider communication and knowledge, and system design.

CONCLUSIONS

RHD remains endemic in Tanzania and Uganda, and symptomatic RHD is associated with high rates of morbidity and mortality. We have identified critical data gaps in the areas of GAS and ARF epidemiology as well as health care utilization patterns and their determinants.

Rheumatic heart disease in Uganda: predictors of morbidity and mortality one year after presentation

BACKGROUND

Rheumatic heart disease (RHD), the long-term consequence of rheumatic fever, accounts for most cardiovascular morbidity and mortality among young adults in developing countries. However, data on contemporary outcomes from resource constrained areas are limited.

METHODS

A prospective cohort study of participants aged 5-60 years with established RHD was conducted in Kampala, Uganda, in which clinical exam, echocardiography, electrocardiography (ECG), and laboratory evaluation were done every 3 months and every 4-week benzathine penicillin prophylaxis was prescribed. Participants were followed up for 12 months and outcomes and predictors of morbidity and mortality were assessed using Kaplan Meier curves and Cox proportional hazards models.

RESULTS

Of 449 subjects, 66.8% (300/449) were females, median age was 30 (interquartile range 20). 73.7% (331/449) had atleast one follow up visit. Among these, 35% (116/331) developed decompensated heart failure and, 63.7% (211/331) developed atrial fibrillation. Heart failure was associated with poor penicillin adherence (OR = 3.3, CI 2-5.4, p = 0.001), and left ventricular end diastolic diameter greater than 55 mm (OR = 3.16, CI 1.73-5.76, p = 0.001). Atrial fibrillation was associated with left atrial diameter >40 mm (OR = 7.5, CI 2.4-9.8, p = 0.001). There were 59 deaths with a 1-year mortality rate of 17.8%. Most deaths occurred within the first three months of presentation. Subjects whose average adherence to benzathine penicillin was <80% had significantly greater mortality (31% vs. 9%, log rank p < 0.001). In multivariate analysis, the risk of death among those with poor penicillin adherence was 3.81 times higher than those with better adherence (HR = 3.81, CI 1.92-7.63, p = 0.001). Other predictors of 1 year mortality included heart failure (HR 8.36, CI 3.28-21.31, p = 0.001) and left ventricular end diastolic diameter greater than 55 mm (HR = 1.93, CI 1.07-3.49, p = 0.02).

CONCLUSION

In this study of RHD in Uganda, morbidity and mortality within 1 year of presentation were higher than in recently published from other low and middle income countries. Suboptimal adherence to benzathine penicillin injections was associated with incident heart failure and mortality over 1 year. Future studies should test interventions to improve adherence among patients with advanced disease who are at the highest risk of mortality.

Pediatric cardiovascular care in Uganda: Current status, challenges, and opportunities for the future

In many developing countries, concerted action against common childhood infectious diseases has resulted in remarkable reduction in infant and under-five mortality. As a result, pediatric cardiovascular diseases are emerging as a major contributor to childhood morbidity and mortality. Pediatric cardiac surgery and cardiac catheterization interventions are available in only a few of Sub-Saharan African countries. In Uganda, open heart surgeries (OHSs) and interventional procedures for pediatric cardiovascular disease are only possible at the Uganda Heart Institute (UHI), having been started with the help of expatriate teams from the years 2007 and 2012, respectively. Thereafter, independent OHS and cardiac catheterization have been possible by the local team at the UHI since the year 2009 and 2013, respectively. The number of OHSs independently performed by the UHI team has progressively increased from 10 in 2010 to 35 in 2015, with mortality rates ranging from 0% to 4.1% over the years. The UHI pediatric catheterization team has independently performed an increasing number of procedures each year from 3 in 2013 to 55 in 2015. We herein describe the evolution and current status of pediatric cardiovascular care in Uganda, highlighting the unique aspects of its establishment, existing constraints, and future plans.

Screening-detected rheumatic heart disease can progress to severe disease

OBJECTIVES

Echocardiography is a sensitive test for rheumatic heart disease (RHD) screening; however the natural history of RHD detected on screening has not been established. We aimed to evaluate the progression of screening-detected RHD in Fiji.

METHODS

All young people previously diagnosed with RHD through screening, with echocardiograms available for review, were eligible. All baseline echocardiograms were reported again. Participants underwent follow-up echocardiography. A paediatric cardiologist determined the diagnosis using the World Heart Federation criteria and assessed the severity of regurgitation and stenosis.

RESULTS

Ninety-eight participants were recruited (mean age, 17 years; median duration of follow-up, 7.5 years). Two other children had died from severe RHD. Fourteen of 20 (70%) definite RHD cases persisted or progressed, including four (20%) requiring valve surgery. Four (20%) definite RHD cases improved to borderline RHD and two (10%) to normal. Four of 17 (24%) borderline cases progressed to definite RHD (moderate: 2; severe: 2) and two (12%) improved to normal. Four of the 55 cases reclassified as normal at baseline progressed to borderline RHD. Cases with a follow-up interval >5 years were more likely to improve (37% vs 6%, p=0.03).

CONCLUSIONS

The natural history of screening-detected RHD is not benign. Most definite RHD cases persist and others may require surgery or succumb. Progression of borderline cases to severe RHD demonstrates the need for monitoring and individualised consideration of prophylaxis. Robust health system structures are needed for follow-up and delivery of secondary prophylaxis if RHD screening is to be scaled up.

The Impact of Echocardiographic Screening for Rheumatic Heart Disease on Patient Quality of Life

OBJECTIVE

To assess the impact of rheumatic heart disease (RHD) on child-reported health-related quality of life (HRQOL) in the context of a Ugandan school-based echocardiographic screening program. Echocardiography-based screening has emerged as a tool for the early detection of RHD, but little is known about its impact on those screened.

STUDY DESIGN

Participants included 358 children from Gulu and 28 children from Kampala Uganda. The Pediatric Quality of Life Inventory Version 4.0 was used to assess HRQOL in 4 groups of children: Gulu prescreen, Gulu postscreen, Gulu previously linked to care, and Kampala previously linked to care. Children in the pre- and postscreen groups were selected from a single school before and after screening occurred and matched by age and sex. Children previously linked to care were recruited from previous screening studies.

RESULTS

When the echocardiogram was normal, there was no difference in HRQOL in the prescreen and postscreen groups. In the postscreen group, identification of latent RHD resulted in lower physical (75.3 vs 68.3, P = .03) and emotional (71.7 vs 63.4, P < .01) HRQOL, despite a lack of symptoms. The Kampala group had longer linkage to care (42 months vs 6 months, P < .01) and demonstrated greater HRQOL scores compared with the Gulu-linked group (70.7 vs 77.8, P < .01) and the combined Gulu cohort (77.8 vs 69.4, P = .02).

CONCLUSIONS

Echocardiography-based screening for RHD does not diminish HRQOL in Ugandan children; rather, a diminished HRQOL score may be associated with being identified as RHD positive. Further investigation is needed to understand if longer linkage to care may ultimately normalize or improve HRQOL.

Long-Term Outcomes From Acute Rheumatic Fever and Rheumatic Heart Disease: A Data-Linkage and Survival Analysis Approach

Background:

We investigated adverse outcomes for people with acute rheumatic fever (ARF) and rheumatic heart disease (RHD) and the effect of comorbidities and demographic factors on these outcomes.

Methods:

Using linked data (RHD register, hospital, and mortality data) for residents of the Northern Territory of Australia, we calculated ARF recurrence rates, rates of progression from ARF to RHD to severe RHD, RHD complication rates (heart failure, endocarditis, stroke, and atrial fibrillation), and mortality rates for 572 individuals diagnosed with ARF and 1248 with RHD in 1997 to 2013 (94.9% Indigenous).

Results:

ARF recurrence was highest (incidence, 3.7 per 100 person-years) in the first year after the initial ARF episode, but low-level risk persisted for >10 years. Progression to RHD was also highest (incidence, 35.9) in the first year, almost 10 times higher than ARF recurrence. The median age at RHD diagnosis in Indigenous people was young, especially among males (17 years). The development of complications was highest in the first year after RHD diagnosis: heart failure incidence rate per 100 person-years, 9.09; atrial fibrillation, 4.70; endocarditis, 1.00; and stroke, 0.58. Mortality was higher among Indigenous than non-Indigenous RHD patients (hazard ratio, 6.55; 95% confidence interval, 2.45–17.51), of which 28% was explained by comorbid renal failure and hazardous alcohol use. RHD complications and mortality rates were higher for urban than for remote residents.

Conclusions:

This study provides important new prognostic information for ARF/RHD. The residual Indigenous survival disparity in RHD patients, which persisted after accounting for comorbidities, suggests that other factors contribute to mortality, warranting further research.

Targeted Echocardiographic Screening for Latent Rheumatic Heart Disease in Northern Uganda: Evaluating Familial Risk Following Identification of an Index Case

Background

Echocardiographic screening for detection of latent RHD has shown potential as a strategy to decrease the burden of disease. However, further research is needed to determine optimal implementation strategies. RHD results from a complex interplay between environment and host susceptibility. Family members share both and relatives of children with latent RHD may represent a high-risk group. The objective of this study was to use echocardiographic family screening to determine the relative risk of RHD among first-degree relatives of children with latent RHD compared to the risk in first-degree relatives of healthy peers.

Methodology/Principal Findings

Previous school-based screening data were used to identify RHD positive children and RHD negative peers. All first-degree relatives ≥ 5 years were invited for echocardiography screening (2012 World Heart Federation Criteria). Sixty RHD positive cases (30 borderline/30 definite RHD) and 67 RHD negative cases were recruited. A total of 455/667 (68%) family members were screened. Definite RHD was more common in childhood siblings of RHD positive compared to RHD negative (p = 0.05). Children with any RHD were 4.5 times as likely to have a sibling with definite RHD, a risk that increased to 5.6 times when considering only cases with definite RHD. Mothers of RHD positive and RHD negative cases had an unexpectedly high rate of latent RHD (9.3%).

Conclusions/Significance

Siblings of RHD positive cases with RHD are more likely to have definite RHD and the relative risk is highest if the index case has definite RHD. Future screening programs should consider implementation of sibling screening following detection of an RHD positive child. Larger screening studies of adults are needed, as data on prevalence of latent RHD outside of childhood are sparse. Future studies should prioritize implementation research to answer questions of how RHD screening can best be integrated into existing healthcare structures, ensuring practical and sustainable screening programs.

Rheumatic heart disease (RHD) affects at least 33 million people, most of who live in low-resource environments. RHD is a cumulative process and there exists a latent period between early valve damage and presentation with symptoms. Echocardiographic screening (ultrasound of the heart) has proven highly sensitive for latent RHD detection, but implementation research is needed to effectively develop sustainable public health strategies. Critical to this research is determining whom to screen. As family members have both a shared environment and shared genetic susceptibility, they may represent a high-risk group that could be targeted once a case of RHD is identified. We conducted an echocardiographic family screening study to determine the risk of RHD in families with and without an RHD positive child and found that siblings of children with latent RHD are more likely to have latent RHD themselves. Our data suggest that siblings may represent a particularly high-risk group that could be targeted for echocardiographic screening. Future studies are needed to answer questions of how RHD screening can best be integrated into existing healthcare structures, ensuring practical and sustainable RHD screening programs.

Rheumatic heart disease echocardiographic screening: approaching practical and affordable solutions

Rheumatic heart disease (RHD) affects at least 32.9 million people worldwide and ranks as a leading cause of death and disability in low-income and middle-income countries (LMICs). Echocardiographic screening has been demonstrated to be a powerful tool for early RHD detection, and holds potential for global RHD control. However, national screening programmes have not emerged. Major barriers to implementation include the lack of human and financial resources in LMICs. Here, we focus on recent research advances that could make echocardiographic screening more practical and affordable, including handheld echocardiography devices, simplified screening protocols and task shifting of echocardiographic screening to non-experts. Additionally, we highlight some important remaining questions before echocardiographic screening can be widely recommended, including demonstration of cost-effectiveness, assessment of the impact of screening on children and communities, and determining the importance of latent RHD. While a single strategy for echocardiographic screening in all high-prevalence areas is unlikely, we believe recent advancements are bringing the public health community closer to developing sustainable programmes for echocardiographic screening.

Acute rheumatic fever and rheumatic heart disease

Acute rheumatic fever (ARF) is the result of an autoimmune response to pharyngitis caused by infection with group A Streptococcus. The long-term damage to cardiac valves caused by ARF, which can result from a single severe episode or from multiple recurrent episodes of the illness, is known as rheumatic heart disease (RHD) and is a notable cause of morbidity and mortality in resource-poor settings around the world. Although our understanding of disease pathogenesis has advanced in recent years, this has not led to dramatic improvements in diagnostic approaches, which are still reliant on clinical features using the Jones Criteria, or treatment practices. Indeed, penicillin has been the mainstay of treatment for decades and there is no other treatment that has been proven to alter the likelihood or the severity of RHD after an episode of ARF. Recent advances - including the use of echocardiographic diagnosis in those with ARF and in screening for early detection of RHD, progress in developing group A streptococcal vaccines and an increased focus on the lived experience of those with RHD and the need to improve quality of life - give cause for optimism that progress will be made in coming years against this neglected disease that affects populations around the world, but is a particular issue for those living in poverty.

Proportion of patients in the Uganda rheumatic heart disease registry with advanced disease requiring urgent surgical interventions

INTRODUCTION

Since the establishment of the Uganda Rheumatic Heart Registry, over 900 patients have been enrolled. We sought to stratify the patients in the registry according to disease severity and optimal management strategy.

METHODS

We reviewed data of 618 patients who had enrolled in the Registry between March 2010 and February 2013. The 67 patients who had died were excluded leaving 551 patients who were recruited. The optimum management strategy was determined according to the 2012 European Society of Cardiology guidelines on the management of valvular heart disease.

RESULTS

Out of the 551 patient's records evaluated, 398 (72.3%) required invasive intervention, with 332(60.3%) patients requiring surgery and 66 (12.0%) requiring percutaneous mitral commissurotomy (PMC). This leaves only 27.7% of patients who required only medical management. Currently, majority of the patients (498, 90.4%) in the registry are on medical treatment. Of the 60.3% requiring surgical intervention, only 8.0% (44 patients) underwent valvular surgery and 5(1.0%) patients of the 66 (12.0%) underwent PMC successfully.

CONCLUSION

There is a high proportion of patients with severe disease that require surgical treatment yet they cannot access this therapy due to absence of local expertise.

Fifteen-minute consultation: rheumatic fever

OBJECTIVE

To present a structured approach for an outpatient consultation or inpatient assessment of a child with possible rheumatic fever.

METHOD

Review of literature and description of diagnostic and therapeutic approach.

CONCLUSIONS

A focused history and examination is key to establish the cause and draw a management plan for rheumatic fever.

Rationale and design of the Pan African Pulmonary hypertension Cohort (PAPUCO) study: implementing a contemporary registry on pulmonary hypertension in Africa

INTRODUCTION

Pulmonary hypertension (PH) is a devastating, progressive disease with increasingly debilitating symptoms and usually shortened overall life expectancy due to a narrowing of the pulmonary vasculature and consecutive right heart failure. Little is known about PH in Africa, but limited reports suggest that PH is more prevalent in Africa compared with developed countries due to the high prevalence of risk factors in the region.

METHODS AND ANALYSIS

A multinational multicentre registry-type cohort study was established and tailored to resource-constraint settings to describe disease presentation, disease severity and aetiologies of PH, comorbidities, diagnostic and therapeutic management, and the natural course of PH in Africa. PH will be diagnosed by specialist cardiologists using echocardiography (right ventricular systolic pressure >35 mm Hg, absence of pulmonary stenosis and acute right heart failure), usually accompanied by shortness of breath, fatigue, peripheral oedema and other cardiovascular symptoms, ECG and chest X-ray changes in keeping with PH as per guidelines (European Society of Cardiology and European Respiratory Society (ESC/ERS) guidelines). Additional investigations such as a CT scan, a ventilation/perfusion scan or right heart catheterisation will be performed at the discretion of the treating physician. Functional tests include a 6 min walk test and the Karnofsky Performance Score. The WHO classification system for PH will be applied to describe the different aetiologies of PH. Several substudies have been implemented within the registry to investigate specific types of PH and their outcome at up to 24 months. Data will be analysed by an independent institution following a data analyse plan.

ETHICS AND DISSEMINATION

All local ethics committees of the participating centres approved the protocol. The data will be disseminated through peer-reviewed journals at national and international conferences and public events at local care providers.

Cardiovascular risk factor burden in Africa and the Middle East: the Africa Middle East Cardiovascular Epidemiological (ACE) study

BACKGROUND

Increased urbanization in the developing world parallels a rising burden of chronic diseases. Developing countries account for ∼ 80% of global cardiovascular (CV) deaths, but contribute a paucity of systematic epidemiological data on CV risk factors.

OBJECTIVE

To estimate the prevalence of CV risk factors in rural and urban cohorts attending general practice clinics in the Africa and Middle East (AfME) region.

METHODS

In a cross-sectional epidemiological study, the presence of CV risk factors (hypertension, diabetes mellitus (diabetes), dyslipidemia, obesity, smoking and abdominal obesity) were evaluated in stable adult outpatients attending general practice primary care clinics. A rural population was defined as isolated (>50 km or lack of easy access to commuter transportation) from urban centers.

RESULTS

4,378 outpatients were systematically recruited from 94 clinics across 14 AfME countries. Mean age was 46 ± 14 years and 52% of outpatients were female. A high prevalence of dyslipidemia (70%) and abdominal obesity (68%) were observed, followed by hypertension (43%) and diabetes (25%). The vast majority of outpatients (92%) had at least one modifiable CV risk factor, many (74%) had more than one, and half (53%) had 3 or more. These findings were observed in both genders and across urban and rural centers. Among outpatients with pre-existing hypertension or dyslipidemia, many were not at their target blood pressure or LDL-cholesterol goals.

CONCLUSION

Cardiovascular risk factors are highly prevalent among relatively young, stable outpatients attending general practice clinics across AfME. The findings support opportunistic screening for CV risk factors whenever outpatients visit a general practitioner and provide an opportunity for early identification and management of CV risk factors, including lifestyle interventions.

Potential use of NOACs in developing countries: pros and cons

PURPOSE

Although vitamin K antagonists (VKAs) are effective for long-term thromboprophylaxis in atrial fibrillation (AF), their limitations have led to widespread underutilisation, especially in the developing world. Novel oral anticoagulants (NOACs) have emerged as promising alternatives to VKAs, although there are some particular considerations and challenges to their introduction in developing countries. This review summarises the current state of antithrombotic management of AF in the developing world, explores the early evidence for the NOACs and describes some of the special considerations that must be taken into account when considering the role of the NOACs within developing countries' health care systems.

METHODS

A literature search was conducted via PubMed and Google Scholar to find articles published in English between the years 2000 to 2014. Search terms used were "atrial fibrillation", "oral anticoagulants", "warfarin", "NOACs", "dabigatran", "rivaroxaban", "apixaban", "edoxaban", "time in therapeutic range", "International Normalized Ratio" "cost-effectiveness", "stroke", "adverse-drug reactions" and "drug-drug interactions", together with the individual names of developing countries as listed by the World Bank. We reviewed the results of randomized clinical trials, relevant retrospective and prospective studies, case-studies and review articles.

RESULTS

Many developing countries lack or have sporadic data on the quality of AF management, making it difficult to anticipate the potential impact of NOACs in these settings. The utilisation of anticoagulants for AF appears highly variable in developing countries. Given the issues associated with VKA therapy in many developing countries, NOACs offer some potential advantages; however, there is insufficient evidence to advocate the widespread replacement of warfarin at present. VKAs may continue to have a role in selected patients or countries, especially if alternative monitoring strategies can be utilised.

CONCLUSION

The evaluation of the introduction of NOACs should consider safety, budget concerns and the quality of oral anticoagulation care achieved by each country. Prospective registries will be important in developing countries to better elucidate the comparative safety, efficacy and cost-effectiveness of NOACs and VKAs as NOACs are introduced into practice.