Prevalence of rheumatic heart disease among school children in Ethiopia: A multisite echocardiography-based screening

Prevalence and pattern of rheumatic valvular heart disease in Africa: Systematic review and meta-analysis, 2015-2023, population based studies

BACKGROUND

Rheumatic heart disease is a global health concern with a persistently high incidence in developing countries, including Africa. It has a significant economic, morbidity, and mortality burden, particularly for children and young adults during their most productive years. However, in the last ten years, the extent of its impact in Africa has remained unclear. Limited studies conducted on the continent have reported diverse prevalence rates of rheumatic heart disease. As a result of these, the study aimed to aggregate and synthesize findings from population-based studies to offer a comprehensive and updated overview of rheumatic heart disease prevalence and pattern at the African level.

METHODS

The studies were identified through a comprehensive literature search of the electronic databases, including PubMed, Google Scholar, Web searches, and manual searches. The descriptive information for the study is presented in the table, and the quantitative results are presented in forest plots. The Cochrane Q test and I2 test statistic were used to test heterogeneity across studies. The pooled estimate of the prevalence of rheumatic heart disease was computed by a random effects model.

RESULTS

Out of 22 population-based studies analyzed using random-effects, the pooled magnitude of rheumatic heart disease was found to be 18.41/1000 (95% CI: 14.08-22.73/1000). This comprised definite cases of rheumatic heart disease at a prevalence rate of 8.91/1000 (95% CI: 6.50-11.33/1000) and borderline cases at a prevalence rate of 10.69/1000 (95% CI: 7.74-13.65/1000). The combined prevalence of rheumatic heart disease in males was almost equivalent to that in females. Mitral valve regurgitation was the predominant valve affected by rheumatic heart disease, accounting for approximately 73%.

CONCLUSION

This study analysis found the prevalence of rheumatic heart disease in Africa is high. Because of this, policies and interventions should give attention to prioritize continuous population based active surveillance for early detection of cases to the reduction of rheumatic heart disease sequel, especially in the children and adolescent population.

Mirror Image Dextrocardia with Severe Rheumatic Mitral Stenosis Undergone Successful Percutaneous Transvenous Commissurotomy: The First Case in East Africa

Percutaneous transvenous mitral commissurotomy is an established treatment for rheumatic mitral stenosis. Dextrocardic heart can be affected by rheumatic pathology just like the normal heart. However, it is technically demanding to percutaneous interventions especially the septal puncture which should be done in a mirror image of the normal. Here we are reporting a 45 year old woman with severe rheumatic mitral stenosis with dextrocardia with situs inversus totalis. She has undergone a successful percutaneous transvenous mitral commissurotomy.

Prevalence of rheumatic heart disease diagnosed according to the echocardiographic criteria of the World Heart Federation in Africa: A systematic review and meta-analysis

Rheumatic heart disease (RHD) is a chronic complication arising from acute rheumatic fever (ARF), an autoimmune response triggered by group A streptococcal infection. It primarily affects children and young adults in developing countries. RHD continues to show substantial global heterogeneity. Socioeconomic factors lead the virtual disappearance of RHD in industrialized countries with the introduction of penicillin. By contrast, RHD is still endemic in Africa, Asia, South America, and developing communities of Australasia. We provide an estimate of the current prevalence of latent RHD in Africa using the echocardiographic diagnostic criteria of the World Heart Federation (WHF). Systematic review and meta-analysis of 21 studies reporting the prevalence of RHD, encompassing 40.639 patients. Estimated prevalence of RHD was 25.5 cases per 1000 population (P ≤0.02; 95 % CI, 18.1-32.9 per 1000): definite RHD 13.1 cases per 1000 population (95 % CI, 7.7-18.5 per 1000): and borderline 12,4 cases per 1000 population (95 % CI, 7.7-17.0 per 1000). The prevalence of definite RHD was a significantly higher in adults (M = 28.2, SD = 6.1) compared to children (M = 10.3, SD = 9.2), t(17) = 2.6, p = .0179. Prevalence of definite RHD in schools was 7,92 cases per 1000 population (95 % CI, 4,49-11,35 per 1000) and in community was 26,17 cases per 1000 population (95 % CI, 12,27-40,06 per 1000). This meta-analysis may have produced a better estimate of the prevalence of RHD in Africa using only studies performed according to the 2012 WHF, and clearly showed the high prevalence of RHD in the community and in adults.

Echocardiographic Parameters and Complication Profiles Among Adult Patients with Rheumatic Heart Disease at Jimma Medical Center

Background

Despite the fact that patients with rheumatic heart disease (RHD) need early medical attention and follow-up, most patients in developing countries tend to present with debilitating complications. The objective of this study was to evaluate the echocardiographic features of adult individuals diagnosed with RHD and examine the associated complications among patients who started follow-up at Jimma Medical Center's (JMC) cardiac follow-up clinic.

Methods

A prospective cross-sectional study was conducted at JMC between January 5 and April 15, 2023. Echocardiographic patterns were taken by senior cardiologists; socio-demographic variables, anthropometric measurements, and behavioral factors were collected through a structured questioner.

Results

The study recruited a total of 115 participants, of whom 86 (74.8%) were female and 29 (25.2%) were male. The mean age of the patients was 32.31 (SD± 12.16) years. The mitral valve was affected in 98.26% of cases, while the aortic and tricuspid valve abnormalities were diagnosed in 49.5% and 21.7%, respectively. The most frequent combinations of valve lesions were mitral regurgitation (MR) + mitral stenosis (MS) + aortic regurgitation (AR) (15.7%), followed by MR + AR + TR (8.7%). The occurrence of MR+MS+AR was higher in females (17.4%) compared to males (10.3%), whereas the occurrence of MS+MR was higher in males (24.1%) compared to females (20.9%). Females have a severely reduced ejection fraction compared to males (84.8% vs 15.2%, P = 0.044). Nearly two-thirds (63.5%) of individuals experienced RHD-related complications; the most commonly encountered complications were pulmonary hypertension (26.1%) and atrial fibrillation (19.1%).

Conclusion

RHD predominantly affects individuals in their active and productive years, particularly females. Most patients have multiple-valve lesions.

The Impact of a Handheld Ultrasound Device in a Rheumatic Heart Disease Screening Program in Ethiopia

Background: Rheumatic heart disease (RHD) affects 33 million people in low and middle income countries and is the leading cause of cardiovascular death among children and young adults. Penicillin prophylaxis prevents progression in asymptomatic disease. Efforts to expand echocardiographic screening are focusing on simplified protocols, non-physician ultrasonographers, and portable ultrasound devices, including handheld ultrasound. Recent advances support the use of single-view screening protocols. With the increasing availability and low cost of handheld devices, studies are needed to evaluate their performance in these settings. Methods: We conducted a retrospective study comparing the rate of screen positive ultrasounds before and after the use of a handheld ultrasound in an RHD screening program in Ethiopia. We also performed a cross-sectional device comparison in 19 at-risk school-children participating in the rheumatic heart disease screening program. Results: Between March of 2019 and January of 2022, 6631 children were screened for rheumatic heart disease of whom 4029 were screened after the introduction of a handheld device. Before the use of the handheld ultrasound device 291 (11.2%) children had a screen positive ultrasounds compared with 167 (4.1%) afterwards (p<0.001). We also compared non-expert to expert interpretation by device and found a significant difference in interpretation for the Lumify (p=0.025). There was a trend towards shorter jet length by color Doppler in the handheld ultrasound device for both expert and non-expert review. Conclusions: Our study highlights that the screen-positive rate in a RHD screening program is influenced by the device being used in the screening process.

Leveraging School Health Programs in Africa: Integrated Screening for Rheumatic Heart Disease and Dental Caries

Background

Rheumatic heart disease (RHD) and dental caries (DC) disproportionately affect children and young adults in sub-Saharan countries, with major impact on schoolchildren's health and education. DC in children with RHD constitutes an important risk for fatal complications. Our study aimed at assessing the feasibility of simultaneous RHD and DC screening in school environment.

Methods

March 20-24, 2022, we performed an observational descriptive study of schoolchildren in a public school in Maputo City, Mozambique. RHD screening involved two stages: first, a physical examination (including cardiac auscultation and direct observation of the oral cavity), and second, an abbreviated echocardiography performed by a cardiologist. Rapid testing for group A Streptococcus (GAS) was done to every eighth child in the classroom and for those with signs suggesting recent infection, in accordance with the study protocol developed for screening. A multidisciplinary team collected the data. Data were analyzed using descriptive statistics.

Findings

A total of 954 students (median age 9; range 6-15) were screened. One hundred and twenty-five participants were eligible for a rapid antigen test, of which 6 (4.8%) tested positive. On clinical evaluation 52 children (5.3%) presented a heart murmur. Echocardiography on 362 children showed borderline RHD in 35 children and definite RHD in 2 (0.6%); 1 child had a ventricular septal defect. Dental cavities were present in 444 (48.4%), despite 904 out of 917 students reporting brushing of their teeth once to three times daily (98.6%).

Conclusion

School-based integrated oral and cardiovascular screenings and use of rapid tests for GAS carriage provide crucial information to create customized preventive strategies for rheumatic fever (RF) and RHD in low- and middle-income countries (LMICs), in addition to detecting children at very high risk of bacterial endocarditis. The sustainability of such interventions and acceptability by health providers needs to be assessed.

The prevalence of rheumatic heart disease in Ethiopia: a systematic review and meta-analysis

Globally, more than 33 million people are living with rheumatic heart disease (RHD). A high prevalence of the disease is observed in people with poor socio-economic status, overcrowding, and low access to medical facilities. Even though different studies have been conducted in different settings, there is no reliable data regarding RHD prevalence. Therefore, the aim of this systematic review and meta-analysis was to estimate the pooled prevalence of RHD in Ethiopia. PubMed/Medline, SCOPUS, HINARI, and Google Scholar databases were used to search for peer-reviewed articles. Articles published in English between the years 1992 and 2022 September were considered. The pooled prevalence of RHD was calculated using a random-effect model at a 95% confidence interval, including the weight of each study. Finally, statistical meta-analysis STATA version 16.0 software was used to calculate the pooled prevalence of RHD.A total of twelve cross-sectional studies were included in the meta-analysis. Individual study prevalence ranges from 0.32 to 32.78%. The pooled prevalence of RHD was 3.19% (95% CI: 1.46-5.56%). The prevalence was higher among the population who visited hospitals at 5.42% (95% CI: 1.09-12.7%) compared to schoolchildren at 0.73% (95% CI: 0.30-1.34%) and community-based studies at 3.83% (95% CI: 3.16-4.55%). Addis Ababa had the lowest prevalence of RHD (0.75% (95% CI: 0.38-1.25%), whereas the highest prevalence was observed in the Amhara region (8.95% (95% CI: 7.21-11.06%). A significant variation in the overall estimated prevalence of RHD was not observed between males and females.Trial registration Protocol registration (PROSPERO): CRD42021251553, Date of registration May 28 2021.

Rheumatic Heart Disease in East Africa: A Systematic Review and Meta-Analysis

Background

Despite being a grave problem, there is little information on rheumatic heart disease's prevalence in East Africa. Therefore, the purpose of this systematic review and meta-analysis was to estimate the pooled prevalence of rheumatic heart disease in East Africa.

Materials and Methods

A computerized systematic search of using multiple database searching engines was performed in search of relevant English articles from the inception of the databases to December 2019. It was done in accordance with the preferred reporting items for systematic review and meta-analysis (PRISMA) standard. The funnel plot was used to assess publication bias. R and RStudio for Windows were used for all statistical analysis. The random-effect model was used for calculating the pooled estimate of the prevalence of rheumatic heart disease.

Results

The database search retrieved 1073 papers, and 80 articles (78 cross-sectional and two cohort study designs) with a total of 184575 individuals were found to be appropriate for the review. In East Africa, the overall prevalence of rheumatic heart disease was 14.67% (95% CI: 13.99% to 15.35%). In Ethiopia, Uganda, Tanzania, and Sudan, respectively, the subgroup analysis of rheumatic heart disease pooled prevalence was 22% (95% CI: 13% to 36%), 11% (95%t CI: 5% to 20%), 9% (95%t CI: 5% to 16%), and 3% (95%t CI: 1% to 10%), while the pooled prevalence of rheumatic heart disease in adults was 20% (95% CI: 12% to 30%), and in children, it was 4% (95% CI: 2% to 8%).

Conclusions

From this report, the prevalence of rheumatic heart disease in East Africa is very high, affecting about one in seven people. Therefore, future strategies should emphasize preventive measures at appropriate times to minimize the burden of this type of preventable heart disease.

Health-related quality of life and healthcare consultations among adult patients before and after diagnosis with rheumatic heart disease in Namibia

BACKGROUND

Rheumatic Heart Disease (RHD) causes high morbidity and mortality rates among children and young adults, impacting negatively on their health-related quality of life (HRQoL). This study aimed to evaluate the HRQoL and healthcare consultations of adult patients with RHD in Namibia.

METHODS

From June 2019 to March 2020, a questionnaire was administered to 83 RHD patients during routine follow-ups. The EQ-5D-5L instrument was used to assess the health-related quality of life before diagnosis and at the time of the survey. The Ethiopian value set for EQ-5D-5L was used to calculate Quality-Adjusted Life Years (QALY).

RESULTS

Most respondents were women (77%), young adults below the age of 30 years (42%), and individuals who grew up in rural areas (87%). The mean QALY statistically significantly improved from 0.773 pre-diagnosis to 0.942 in the last 12 months (p < 0.001). Sixty-six patients who had surgery reported a better QALY. Healthcare visits statistically significantly increased from on average 1.6 pre-diagnosis to 2.7 days in the last 12 months (p < 0.001). The mean distance to the nearest facility was 55 km, mean cost of transport was N$65, and mean time spent at the clinic was 3.6 h. The median time from diagnosis to the survey was 7 years (quartiles 4 and 14 years).

CONCLUSION

Treatment and surgery can improve HRQoL substantially among RHD patients. Being diagnosed with RHD affects patients living in socioeconomically disadvantaged rural areas through cost and time for healthcare visits. It would be valuable with further research to understand differences between disease severities.

Etiologies and Patterns of Valvular Heart Disease Among Cardiac Patients at the Cardiac Center of Ethiopia During February 2000 to April 2022

Background

The leading global contributor to cardiovascular morbidity and mortality is valvular heart disease. It is on the rise worldwide, including in the developing countries. However, the prevalence, patterns, and etiologies of valvular heart disease have not been well studied in Ethiopia. Hence, the purpose of this study was to evaluate the prevalence, patterns, and etiologies of valvular heart disease at the Cardiac Center of Ethiopia from February 2000 to April 2022.

Methods

This institution-based retrospective cross-sectional study was conducted between February 2000 and April 2022. Data from three thousand two hundred fifty-seven VHD were extracted from the electronic medical records and analyzed using SPSS version 25. Descriptive statistics, such as the frequency, mean ± standard deviation, and cross tabulations, were used to summarize the data.

Results

Of 10,588 total cardiac cases registered and treated at the Cardiac Centre of Ethiopia from February 2000 to April 2022, 30.8% (3257) were diagnosed with VHD. The most typical diagnosis for VHD was multi-valvular involvement, which accounted for 49.5% of cases (1612), followed by pulmonary stenosis (15%) and mitral regurgitation (14.3%). Females were more likely to develop valve diseases than males, being at the highest risk for each identified etiology of valve disease 1928 (59.2%). The majority percentages of the population affected by VHD were between 18 and 44 age category 1473 (45.2%). The most common etiology of VHD was rheumatic 2015 (61.87%), followed by congenital origin 828 (25.42%).

Conclusion

VHD affects nearly one-third of all cardiac cases admitted to the hospital. Multi-valvular involvement is the most commonly diagnosed form of VHD. Rheumatic causes were more prevalent in this study. As found in this study, VHD affects a significant percentage of the population, which in turn could have an impact on the country's economy and deserve attention as a possible means of intervention.

Sub-clinical rheumatic heart disease (RHD) detected by hand-held echocardiogram in children participating in a school-based RHD prevention program in Tanzania

BACKGROUND

Rheumatic Heart Disease (RHD) continues to cause suffering and premature deaths in many sub-Saharan Africa (SSA) countries, where the disease is still endemic. RHD is largely preventable and determining its community burden is an important critical step in any RHD prevention program.

METHODS

We conducted a cross-sectional study of 5-16 years old pupils from 11 primary schools participating in an RHD prevention program in 4 districts in Tanzania, between 2018 and 2019. At the school, all children were invited to participate after receiving consent from their parents/guardians. Participating children filled a questionnaire and were auscultated for cardiac murmurs. Echocardiographic screening was done by two experienced cardiologists, using a hand-held machine (V-Scan, GE®). All positive screening tests were stored for further examination by the same two cardiologists to reach to a consensus of definite, borderline or no RHD, using a modified World Heart Federation (WHF) criterion.

RESULTS

Of the 6895 children invited, 4738 (68.7%) were screened and 4436 (64.3%) had complete data. The mean (SD) age was 10.04 (2.43) years, and 2422 (54.6%) were girls. Fifty three (1.2%) children were found to have a murmur. The proportion of children with trace or mild valvular regurgitation, sub-valvular/chordal thickening and valvular thickening/deformity were 8.3%, 1.3%, and 1.0%, respectively. Sub-clinical RHD was found in 95 children (59 definite and 36 borderline), giving a prevalence of 2.1%, [95% CI 1.7% - 2.6%]. Sub-clinical RHD was independently associated with female sex (aOR 1.83, 95% CI 1.18-2.85, p = 0.007), older age groups (aOR 1.73, 95% CI 1.10-2.72, p = 0.018 for age group 11-14 years; and aOR 3.02 95% CI 1.01-9.05, p = 0.048 for age group 15-16 years), as well as presence of a cardiac murmur, aOR 5.63 95% CI 2.31-13.69, p < 0.0001. None of the studied socio- or economic factors was associated with the presence of sub-clinical RHD in this study.

CONCLUSION

The prevalence of sub-clinical RHD among primary school children in Tanzania is 2.1%, similar to previous reports in SSA. Efforts to prevent and control RHD in our communities are highly warranted.

Characterization of rheumatic heart disease from electrocardiogram recordings

Objective. Rheumatic Heart Disease (RHD) is one of the highly prevalent heart diseases in developing countries that can affect the pericardium, myocardium, or endocardium. Rheumatic endocarditis is a common RHD variant that gradually deteriorates the normal function of the heart valves. RHD can be diagnosed using standard echocardiography or listened to as a heart murmur using a stethoscope. The electrocardiogram (ECG), on the other hand, is critical in the study and identification of heart rhythms and abnormalities. The effectiveness of ECG to identify distinguishing signs of rheumatic heart problems, however, has not been adequately examined. This study addressed the possible use of ECG recordings for the characterization of problems of the heart in RHD patients.Approach. To this end, an extensive ECG dataset was collected from patients suffering from RHD (PwRHD), and healthy control subjects (HC). Bandpass filtering was used at the preprocessing stage. Each data was then standardized by removing its mean and dividing by its standard deviation. Delineation of the onsets and offsets of waves was performed using KIT-IBT open ECG MATLAB toolbox. PR interval, QRS duration, RR intervals, QT intervals, and QTc intervals were computed for each heartbeat. The median values of the temporal parameters were used to eliminate possible outliers due to missed ECG waves. The data were clustered in different age groups and sex. Another categorization was done based on the time duration since the first RHD diagnosis.Main results. In 47.2% of the cases, a PR elongation was observed, and in 26.4% of the cases, the QRS duration was elongated. QTc was elongated in 44.3% of the cases. It was also observed that 62.2% of the cases had bradycardia.Significance. The end product of this research can lead to new medical devices and services that can screen RHD based on ECG which could somehow assist in the detection and diagnosis of the disease in low-resource settings and alleviate the burden of the disease.

Descriptive Analysis of Rheumatic Heart Disease Related Complications in Pediatric Patients at Tertiary Hospital, Addis Ababa, Ethiopia

Introduction

Rheumatic heart disease continues to be a public health problem worldwide. In developing countries such as Ethiopia where rheumatic heart disease is endemic, most of the patients present with complaints related to complications including heart failure, arrhythmias, pulmonary hypertension, stroke, systemic embolic events and infective endocarditis.

Objective

To identify the types and magnitude of complications in pediatric patients with rheumatic heart disease.

Methodology

Hospital-based cross-sectional study was conducted at Saint Paul Hospital Millennium Medical College, pediatric and child health department. All pediatric cardiac patients with rheumatic heart disease seen from January 1, 2018 to December 30, 2021 were included in the study.

Conclusion

The majority of patients presented to our health facility with complications which implies the need for action at the community level to detect the disease at early stage.

Recommendations

We recommend a similar large-scale study to be conducted at the national level and introduce a national RHD registry to better understand the magnitude of the problem, based on which necessary action will be undertaken. There is also a need to assess the proper implementation of screening and preventive RHD programmes.

Prevalence of rheumatic heart disease in Ethiopia: A systematic review and meta-analysis

Objective

This systematic review and meta-analysis aimed to synthesize the available data on rheumatic heart disease in Ethiopia to provide a true figure on the prevalence and distribution of the disease.

Methods

Different articles were selected using search terms by different search engines like PubMed, Scopus, Google Scholars, and ScienceDirect and also by obtaining hard copies of locally published articles. The search for original research articles was conducted from December 1 to December 30, 2022. Finally, the priority reporting items of the systematic review and meta-analysis guidelines were used for the literature search strategy, publication selection, data extraction, and reporting of review results. Data quality was checked by the author for similarity of study design and inclusion and exclusion criteria.

Results

A total of sixteen original research articles were included. Nine included articles were from different cardiac patients and seven of the included articles were from children and asymptomatic population. All research papers were summarized in the table clearly with the key information and findings. The prevalence of rheumatic heart disease in cardiac patients from nine included studies was 49.04 (-30.84, 128.92) whereas the prevalence of rheumatic heart disease in children and asymptomatic participants from seven study included was 2.70 (-1181.99, 1187.39) or 27/1000.

Conclusions

This review and meta-analysis found that the prevalence of rheumatic heart disease in Ethiopia is very high in cardiac patients, children, and the asymptomatic population. Therefore, well-designed and evidence-based national prevention and treatment strategies must be in place to prevent the disease and provide timely treatment for patients.

Rheumatic heart disease knowledge and associated factors among nurses working in cardiac centers at public and private hospitals of Addis Ababa: cross sectional study

Background

It is proposed that the biggest gap in control of rheumatic heart disease is in implementing of ineffective primary and secondary preventive measures. These measures are supposed to be well addressed by nurses. For prevention and proper management, nurses are expected to have full knowledge about rheumatic heart disease. Therefor the main objective of the study was to assess the level of nurse’s knowledge and factors behind regarding RHD in the current study.

Method

Institution based cross sectional study was conducted on nurses working in cardiac centers of public and private hospitals at Addis Ababa from April 1 to 30, 2021. Total sample size is 163 selected by purposive sampling method. Data was entered in to Epi-data version 4.5 and exported to SPSS version 25.0 and was checked for missing values. Data was cleaned. Descriptive statistics such as frequency, mean and percentages were calculated, described and displayed in tables, graphs and charts. Binary logistic regression was done to see the crude significant relation of each independent variable with nurse’s good knowledge score. Significant factors were identified based on multivariate logistics regression in 95% confidence level at P-value less than 0.05.

Result

In the present study about 154 participants were participated. The mean correct answer response of the nurses for knowledge of RHD questions is 12.2 ± 5.2. Only 48.7% of the nurses have good knowledge towards RHD. Being male in gender, having history of sore throat, taking formal education in university or collage, taking in-service training on RHD, having higher wok experience, have found significantly associated with higher odds of nurses’ good knowledge towards RHD.

Conclusion and recommendation

Regular training regarding RHD management should be given to nurses who are working in cardiac centers. Rheumatic heart disease early treatment and prevention should be incorporated and reinforced in to nursing and other health related professions curriculums.

Secondary prevention of rheumatic heart disease in Ethiopia: a multicenter study

BACKGROUND

Ethiopia has a high acute rheumatic fever (ARF) and rheumatic heart disease (RHD) prevalence, and to our knowledge, there are no data on the status of secondary prevention in children with RHD. This study describes the status of secondary RHD prevention.

METHODS

A multicenter, prospective study was performed on children aged 5-17 years with RHD in Ethiopia. Good adherence was defined as at least 80% completion of benzathine penicillin (BPG) or oral Amoxicillin within the previous year. The primary outcome measure was adherence to prophylaxis, expressed as a proportion. Socio-demographics, severity of RHD, and ARF recurrence were evaluated.

RESULTS

A total of 337 children with a mean age of 12.9 ± 2.6 years were included. The majority (73%) had severe aortic/mitral disease. Participants were on BPG (80%) or Amoxicillin (20%) prophylaxis. Female sex (P = 0.04) use of BPG (0.03) and shorter mean duration of prophylaxis in months (48.5 ± 31.5 vs. 60.7 ± 33, respectively, P < 0.008) predicted good adherence. Running out of medications (35%), interrupted follow-up (27%), and the COVID-19 pandemic (26%) were the most common reasons for missing prophylaxis. Recurrence of ARF was higher in participants on Amoxicillin compared with BPG (40% vs. 16%, P < 0.001) and in those with poor adherence compared with good adherence (36.8% vs. 17.9%, respectively, P = 0.005). Type and duration of prophylaxis (OR 0.5, CI = 0.24, 0.9, P = 0.02; OR = 1.1, CI = 1.1, 1.2, P = 0.04, respectively), and sex (OR = 1.9, CI = 1.1, 3.4, P = 0.03) were independent predictors of poor adherence.

CONCLUSION

Poor adherence is prevalent in Ethiopian children living with RHD. Amoxicillin is a suboptimal option for prophylaxis as its use is associated with lower adherence and a higher rate of ARF recurrence.

Addressing the Impact of Noncommunicable Diseases and Injuries (NCDIs) in Ethiopia: Findings and Recommendations from the Ethiopia NCDI Commission

BACKGROUND

Noncommunicable diseases and injuries (NCDIs) are the leading causes of premature mortality globally. Ethiopia is experiencing a rapid increase in NCDI burden. The Ethiopia NCDI Commission aimed to determine the burden of NCDIs, prioritize health sector interventions for NCDIs and estimate the cost and available fiscal-space for NCDI interventions.

METHODS

We retrieved data on NCDI disease burden and concomitant risk factors from the Global Burden of Disease (GBD) Study, complemented by systematic review of published literature from Ethiopia. Cost-effective interventions were identified through a structured priority-setting process and costed using the One Health tool. We conducted fiscal-space analysis to identify an affordable package of NCDI services in Ethiopia.

RESULTS

We find that there is a large and diverse NCDI disease burden and their risk factors such as hypertension and diabetes (these conditions are NCDIs themselves and could be risk factors to other NCDIs), including less common but more severe NCDIs such as rheumatic heart disease and cancers in women. Mental, neurological, chronic respiratory and surgical conditions also contribute to a substantial proportion of NCDI disease burden in Ethiopia. Among an initial list of 235 interventions, the commission recommended 90 top-priority NCDI interventions (including essential surgery) for implementation. The additional annual cost for scaling up of these interventions was estimated at US$550m (about US$4.7 per capita).

CONCLUSIONS

A targeted investment in cost-effective interventions could result in substantial reduction in premature mortality and may be within the projected fiscal space of Ethiopia. Innovative financing mechanisms, multi-sectoral governance, regional implementation, and an integrated service delivery approach mainly using primary health care are required to achieve these goals.

Determinants of Cerebral Palsy in Pediatric Patients in Northern Ethiopia: A Hospital-Based Study

Introduction

Cerebral palsy is the most common neurologic disorder of childhood with lifelong implications in majority of patients. Knowledge of the determinants of cerebral palsy is important for accurate mobilization of resources in obstetric, perinatal, and infant care besides implementation of prevention systems. In Ethiopia, however, this knowledge gap exists as there are no published studies on determinants of cerebral palsy in the country.

Objective

To assess the determinants of cerebral palsy in pediatric patients attending Ayder Comprehensive Specialized Referral Hospital between April 2019 and August 2019.

Methods

An unmatched case-control study was conducted among 50 pediatric cerebral palsy patients and 100 controls, pediatric patients without cerebral palsy or other motor or central nervous system illnesses, attending Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia. The data were analyzed using SPSS version 27.

Results

Significant factors were operative vaginal delivery (AOR: 9.49, 95% CI: 1.31-68.88), central nervous system infections (AOR: 0.02, 95% CI: 0-0.58), neonatal admissions (AOR: 0.13, 95% CI: 0.03-0.61), and unknown maternal education status (AOR: 18.64, 95% CI: 2.15-161.73).

Conclusion

Operative vaginal delivery, central nervous system infections in infancy, neonatal hospital admissions, and unknown maternal education status were found to be significant determinants for cerebral palsy. This knowledge aids focused hospital and regional health bureau development and implementation of prevention strategies for cerebral palsy, besides improvement of obstetric and neonatal healthcare services, and provides baseline data to the scientific community for further research.

Screening for subclinical rheumatic heart disease: addressing borderline disease in a real-world setting

Aims

The World Heart Federation (WHF) criteria identify a large borderline rheumatic heart disease (RHD) category that has hampered the implementation of population-based screening. Inter-scallop separations (ISS) of the posterior mitral valve leaflet, a recently described normal variant of the mitral valve, appears to be an important cause of mild mitral regurgitation (MR) leading to misclassification of cases as WHF ‘borderline RHD’. This study aims to report the findings of the Echo in Africa project, a large-scale RHD screening project in South Africa and determine what proportion of borderline cases would be re-classified as normal if there were a systematic identification of ISS-related MR.

Methods and results

A prospective cross-sectional study of underserved secondary schools in the Western Cape was conducted. Participants underwent a screening study with a handheld (HH) ultrasound device. Children with an abnormal HH study were re-evaluated with a portable laptop echocardiography machine. A mechanistic evaluation was applied in cases with isolated WHF ‘pathological’ MR (WHF ‘borderline RHD’). A total of 5255 participants (mean age 15± years) were screened. A total of 3439 (65.8%) were female. Forty-nine cases of WHF ‘definite RHD’ [9.1 cases/1000 (95% confidence interval, CI, 6.8–12.1 cases/1000)] and 104 cases of WHF ‘borderline RHD’ [19.5 cases/1000 (95% CI, 16.0–23.7 cases/1000)] were identified. Inter-scallop separations-related MR was the underlying mechanism of MR in 48/68 cases classified as WHF ‘borderline RHD’ with isolated WHF ‘pathological’ MR (70.5%).

Conclusion

In a real-world, large-scale screening project, the adoption of a mechanistic evaluation based on the systematic identification of ISS-related MR markedly reduced the number of WHF ‘screen-positive’ cases misclassified as WHF ‘borderline RHD’. Implementing strategies that reduce this misclassification could reduce the cost- and labour burden on large-scale RHD screening programmes.

Prevalence and risk factors for Subclinical Rheumatic Heart Disease among primary school children in Dar es Salaam, Tanzania: a community based cross-sectional study

BACKGROUND

Rheumatic heart disease (RHD) is the most common acquired heart disease occurring in children and adolescents. RHD is associated with significant morbidity and mortality particularly in low and middle- income countries (LMICs) where the burden is estimated to be higher compared to high income countries. Subclinical RHD is the presence of valvular lesion diagnosed by echocardiography in a person with no clinical manifestation of RHD. This study aimed at determining the prevalence, types and factors associated with subclinical RHD among primary school children in Dar Es Salaam, Tanzania.

METHODS

A descriptive community-based cross-sectional study was conducted in primary school children from February to May 2019. A standardized structured questionnaire was used to collect demographic characteristics, history of upper respiratory tract infections (URTIs), anthropometric measurements, and chest auscultation findings. Moreover echocardiographic screening was done to all children recruited into the study. World Heart Federation echocardiographic classification was used to define the types and prevalence of subclinical RHD.

RESULTS

A total of 949 primary school children were enrolled with females being predominant (57.1%). The prevalence of subclinical RHD was 34 per 1000. All the participants had mitral valve disease only whereby 17 had definite disease and 15 had a borderline disease. The associated factors for subclinical RHD were older age of more than 9 years (OR 10.8, 95% CI 1.4-82.2, P = 0.02) having three or more episodes of URTI in previous six months (OR 21, 95% CI 9.6-46, P = 0.00) and poor hygiene (OR 3, 95% CI 1.3-6.8, P = 0.009).

CONCLUSION

Subclinical RHD as detected by echocardiographic screening is prevalent in primary school children, uniformly affects the mitral valve, and is associated with potentially modifiable risk factors. Children with a history of more than three episodes of URTI in six months represents a high-risk population that should be targeted for RHD screening.

Subjective wellbeing among rheumatic heart disease patients at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: observational cross-sectional study

Background

Subjective wellbeing (SWB) is a self-reported positive life judgment and good feeling. RHD, rheumatic heart disease, is a long-term sequel of single or recurrent acute rheumatic fever. There are no studies that assessed SWB in RHD patients. We aimed to assess SWB among RHD subjects enrolled in chronic care at Tikur Anbessa Specialized Hospital (TASH), Ethiopia.

Methods

This observational cross-sectional study employed a validated Amharic WHO-5 wellbeing index to assess SWB. Sociodemographic and clinical data were collected using structured questionnaire. RHD subjects aged 9 years and above were included. Factors associated with SWB were assessed using logistic regression models.

Results

The study included 384 subjects, females 68.2% (262). Children, < 18 years, constituted one third of study subjects, 32.8% (126). Moderate and severe echocardiographic RHD dominated, 85.9% (330) with no associated comorbidity, 84.4% (324). Only 17.2% (66) had surgical or device intervention. Poor SWB was documented in 9.6% of study subjects (95% CI: 6.88–13.04). On multivariable regression, those with younger age RHD diagnosis, < 20 years, had almost three times higher odds of poor SWB, adjusted odds ratio (aOR) 2.69(95% CI: 1.30–5.58, P 0.008). Those with monthly family income of < 1000 Ethiopian Birr had three times higher odds of poor SWB, aOR 2.97(95% CI: 1.24–7.1, P 0.014). Study subjects who had good medication adherence had reduced odds of poor SWB, aOR 0.37(95% CI: 0.18–0.77, P 0.028). Those who received psychologic support from their families also had reduced odds of poor SWB, aOR 0.26(95% CI: 0.11–0.64, P 0.003).

Conclusion

Poor SWB was documented in one-tenth of RHD patients. Family income, younger age at RHD diagnosis, medication adherence and psychological support predicted poor SWB. Poor SWB has to be considered and assessed among RHD patients particularly among those with younger age at RHD diagnosis and poor family income. Further mixed studies are recommended to assess how medication adherence and psychological supports associate with positive SWB among RHD patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07378-0.

Global leadership in paediatric and congenital cardiac care: "global health advocacy, lift as you rise - an interview with Liesl J. Zühlke, MBChB, MPH, PhD"

Professor Liesl Zühlke is the focus of our fifth in a series of interviews in Cardiology in the Young entitled, "Global Leadership in Paediatric and Congenital Cardiac Care". Professor Zühlke (nee Hendricks) was born in Cape Town, South Africa. She would attend medical school in her hometown at University of Cape Town, graduating in 1991. Professor Zühlke then went on to complete a Diploma in Child Health at College of Medicine in Cape Town followed by completion of her Paediatric and Paediatric Cardiology training in 1999 and 2007, respectively. She would subsequently complete her Masters of Public Health (Clinical Research Methods) at the University of Cape Town, completing her dissertation in 2011 on computer-assisted auscultation as a screening tool for cardiovascular disease, under the supervision of Professors Landon Myer and Bongani Mayosi.Professor Zühlke began her clinical position as a paediatric cardiologist in the Department of Paediatrics and Child Health at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa in 2007. In this role, she has been instrumental in developing a transitional clinic at the paediatric hospital, is a team member of the combined cardio-obstetric and grown-up congenital heart disease clinics, each of which are rare in South Africa, with very few similar clinics in Africa. Professor Zühlke would continue her research training, completing her Doctorate at the University of Cape Town in 2015, with her dissertation on the outcomes of asymptomatic and symptomatic rheumatic heart disease under the supervision of Professor Bongani Mayosi and Associate Professor Mark Engel. In 2015, in affiliation with the University of Cape Town and the Department of Paediatrics and the Institute of Child Health, she established The Children's Heart Disease Research Unit, with the goals to conduct, promote and support paediatric cardiac research on the African continent, facilitate Implementation Science and provide postgraduate supervision and training in paediatric cardiac research. In 2018, she would subsequently complete her Master of Science at the London School of Economics in Health Economics, Outcomes and Management of cardiovascular sciences. Professor Zühlke currently serves as the acting Deputy-Dean of Research at the Faculty of Health Sciences, University of Cape Town.Professor Zühlke has achieved the highest leadership positions within cardiology in South Africa, including President of the Paediatric Cardiac Society of South Africa and President of the South African Heart Association. She is internationally regarded as a leader in research related to rheumatic heart disease. Professor Zühlke's work includes patient, family and health advocacy on a global scale, being involved in the development of policies that have been adopted by major global organisations such as the World Health Organization. In addition to her clinical and research efforts, she is highly regarded by students, colleagues and graduates as an effective teacher, mentor and advisor. This article presents our interview with Professor Zühlke, an interview that covers her experience as a thought leader in the field of Paediatric Cardiology, specifically in her work related to rheumatic heart disease, Global Health and paediatric and congenital cardiac care in resource-limited settings.

Rheumatic Heart Disease Screening Based on Phonocardiogram

Rheumatic heart disease (RHD) is one of the most common causes of cardiovascular complications in developing countries. It is a heart valve disease that typically affects children. Impaired heart valves stop functioning properly, resulting in a turbulent blood flow within the heart known as a murmur. This murmur can be detected by cardiac auscultation. However, the specificity and sensitivity of manual auscultation were reported to be low. The other alternative is echocardiography, which is costly and requires a highly qualified physician. Given the disease's current high prevalence rate (the latest reported rate in the study area (Ethiopia) was 5.65%), there is a pressing need for early detection of the disease through mass screening programs. This paper proposes an automated RHD screening approach using machine learning that can be used by non-medically trained persons outside of a clinical setting. Heart sound data was collected from 124 persons with RHD (PwRHD) and 46 healthy controls (HC) in Ethiopia with an additional 81 HC records from an open-access dataset. Thirty-one distinct features were extracted to correctly represent RHD. A support vector machine (SVM) classifier was evaluated using two nested cross-validation approaches to quantitatively assess the generalization of the system to previously unseen subjects. For regular nested 10-fold cross-validation, an f1-score of 96.0 ± 0.9%, recall 95.8 ± 1.5%, precision 96.2 ± 0.6% and a specificity of 96.0 ± 0.6% were achieved. In the imbalanced nested cross-validation at a prevalence rate of 5%, it achieved an f1-score of 72.2 ± 0.8%, recall 92.3 ± 0.4%, precision 59.2 ± 3.6%, and a specificity of 94.8 ± 0.6%. In screening tasks where the prevalence of the disease is small, recall is more important than precision. The findings are encouraging, and the proposed screening tool can be inexpensive, easy to deploy, and has an excellent detection rate. As a result, it has the potential for mass screening and early detection of RHD in developing countries.

High risk of early sub-therapeutic penicillin concentrations after intramuscular benzathine penicillin G injections in Ethiopian children and adults with rheumatic heart disease

Introduction

Intramuscular benzathine penicillin G (BPG) injections are a cornerstone of secondary prophylaxis to prevent acute rheumatic fever (ARF) and rheumatic heart disease (RHD). Uncertainties regarding inter-ethnic and preparation variability, and target exposure profiles of BPG injection are key knowledge gaps for RHD control.

Methods

To evaluate BPG pharmacokinetics (PK) in patients receiving 4-weekly doses in Ethiopia, we conducted a prospective cohort study of ARF/RHD patients attending cardiology outpatient clinics. Serum samples were collected weekly for one month after injection and assayed with a liquid chromatography-mass spectroscopy assay. Concentration-time datasets for BPG were analyzed by nonlinear mixed effects modelling using NONMEM.

Results

A total of 190 penicillin concentration samples from 74 patients were included in the final PK model. The median age, weight, BMI was 21 years, 47 kg and 18 kg/m², respectively. When compared with estimates derived from Indigenous Australian patients, the estimate for median (95% confidence interval) volume of distribution (V/F) was lower (54.8 [43.9–66.3] l.70kg^-1) whilst the absorption half-life (t_1/2-abs2) was longer (12.0 [8.75–17.7] days). The median (IQR) percentage of time where the concentrations remained above 20 ng/mL and 10 ng/mL within the 28-day treatment cycle was 42.5% (27.5–60) and 73% (58.5–99), respectively.

Conclusions

The majority of Ethiopian patients receiving BPG as secondary prophylaxis to prevent RHD do not attain target concentrations for more than two weeks during each 4-weekly injection cycle, highlighting the limitations of current BPG strategies. Between-population variation, together with PK differences between different preparations may be important considerations for ARF/RHD control programs.

Rheumatic heart disease (RHD) is the most common form of acquired heart disease in Ethiopia across all age groups. Monthly benzathine penicillin G (BPG) injections remains the cornerstone of secondary prophylaxis to prevent recurrent acute rheumatic fever (ARF) and progression to RHD, but data supporting the optimal dose and timing of BPG injections is a major knowledge gap for National RHD control programs, particularly amongst the highest risk groups. In this study we measured penicillin concentrations in Ethiopian patients receiving regular BPG injections. It demonstrates that that most Ethiopian patients receiving BPG as secondary prophylaxis to prevent RHD do not maintain target concentrations for more than two weeks during each 4-weekly injection cycle. This study highlights the limitation of the current BPG dosing recommendations and underpin global calls for improved penicillin formulations and better dosing and delivery strategies.

Prevalence of rheumatic heart disease among school children in East Africa: a systematic review and meta-analysis

Introduction

conducting researches and estimating the prevalence of rheumatic heart disease in school children is crucial to develop school-based strategies targeted to decrease the prevalence of this disease. Therefore, this systematic review and meta-analysis were aimed to estimate the overall prevalence of rheumatic heart disease (RHD) among school children in East Africa.

Methods

PubMed/MEDLINE, Google Scholar, Cochrane review, African Journals Online and African Index Medicus databases were searched to identify relevant research articles. The overall prevalence of rheumatic heart disease was pooled based on the weighted inverse variance random-effects model at a 95% confidence interval. The presence of heterogeneity, sensitivity analysis and presence of publication bias was tested. Results were presented with narrative synthesis, tables and forest plots.

Results

a total of thirteen research articles were included in the final analysis. The pooled prevalence of rheumatic heart disease in East African school children was 1.79% (17.9 cases per 1000 children (95% CI=11.6, 24.2; I²=95.1%; p<0.001)). From the subgroup analysis conducted by publication year, a lower prevalence of RHD in school children was reported among studies published after 2015 (six studies; overall prevalence=1.17% (11.7 cases per 1000 school children); with 95% CI=0.60, 1.73%; I²=88.8%; p<0.001). Additionally, the horn of Africa was found to have the lowest prevalence of RHD in school children among East African countries (six studies; overall prevalence=1.59% (15.9 cases per 1000 school children); with 95% CI=0.68, 2.51%; I²=94.2%; p<0.001).

Conclusion

the prevalence of rheumatic heart disease (RHD) among school children in East Africa was considerably higher than the results from high-income countries. Therefore, community education on strep throat and its complications should be implemented through mass media. Rheumatic heart disease preventive strategies should be integrated with schools to reduce the prevalence of RHD among school children.

Prevalence of rheumatic heart disease in a major referral cardiology clinic in Ethiopia: A retrospective cross-sectional study

BACKGROUND

Rheumatic Heart Disease (RHD) remains one of the major causes of death and disability in developing countries. This preventable, treatable but not curable form of cardiovascular disease is needlessly killing scores of children and youth mainly due to the misunderstanding of the burden of the disease in these countries. We sought to describe the prevalence of RHD at one of the major referral cardiology clinics in Ethiopia.

METHODS

This was a retrospective cross-sectional chart review of all patients referred for a cardiopathy at the Tikur Anbessa Referral Cardiac Clinic from June 2015 to August 2018. We excluded records of patients with a non-cardiac diagnosis and those without a clear diagnosis. A predesigned and tested EXCEL form was used to collect the data. The data was encoded directly from the patient record files. MATLAB's statistics toolbox (MATLAB2019b) was used for statistical analysis.

RESULTS

Among the total 7576 records analyzed 59.5% of the patients were women. 83.1% of the data belonged to adult patients with the largest concentration reported in the 18 to 27 age group. 69.7% of the patients were from urban areas. The median age of the study population was 30 (interquartile range = 21-50). 4151 cases were caused by RHD which showed that RHD constituted 54.8% of the cases. The median age for RHD patients was 25 (interquartile range = 19-34). The second most prevalent disease was hypertensive heart disease which constituted 13.6% that was followed by congenital heart disease with 9% prevalence rate.

CONCLUSION

The results of this study indicated the extent of the RHD prevalence in Ethiopia's cardiac hospital was 54.8%. What was more critical was that almost 70% of the RHD patients were mainly the working-age group(19 to 34 years).

Determining the Risk of Developing Rheumatic Heart Disease Following a Negative Screening Echocardiogram

Background: Screening echocardiograms can detect early-stage rheumatic heart disease (RHD), offering a chance to limit progression. Implementation of screening programs is challenging and requires further research. This is the first large-scale study assessing the risk of RHD among previous screen-negative children.

Methods: This retrospective cohort study, conducted in Gulu, Uganda, performed school-based echo screening on children ages 5–18 years. Surveys were used to determine which children underwent initial screening 3–5 years prior. Age, gender, and disease severity were compared between cohorts. Relative risk (RR) of RHD was calculated for those with a prior screen-negative echo (exposed cohort) compared to those undergoing first screening (unexposed cohort).

Results: Echo screening was completed in 75,708 children; 226 were excluded, leaving 1,582 in the exposed cohort and 73,900 in the unexposed cohort. Prevalence of new RHD was 0.6% (10/1,582) and 1% (737/73,900), in the exposed and unexposed cohorts, respectively. The RR of RHD was 0.64 (95% CI 0.3–1.2, p = 0.15), a nearly 40% reduced risk of RHD in those with a prior negative echo. There was no difference in age or gender between RHD cohorts. All cases in the exposed cohort were borderline/mild; 2.6% of cases in the unexposed cohort had moderate/severe disease.

Conclusion: There was no statistical difference in RHD prevalence between previous screen-negative children and children with no prior echocardiogram, however, there was a trend toward decreased risk and severity. This information has important implications for the design of screening programs and the use of screening echocardiograms in endemic RHD regions.

The prevalence of cardiovascular disease in Ethiopia: a systematic review and meta-analysis of institutional and community-based studies

Background

Worldwide cardiovascular disease is the major cause of disability and premature death. This is due to the ascending trend of consuming an unhealthy diet and obesity which increases the risk of hypertension and type 2 diabetes mellitus. Thus this study aimed to determine the pooled prevalence of the cardiovascular disease in Ethiopia.

Methods

Medline, Scopus, and Google Scholar search engines were accessed using medical subject heading (MeSH) terms for studies based in Ethiopia, from 2000 to 2018. However, studies done among a specific group of the population were excluded from the study. Data were extracted by one reviewer and then checked independently by a second reviewer. Studies were qualitatively synthesis in terms of design, quality, study population, outcomes, and result. Sub-group analysis and sensitivity tests were conducted to identify potential influences on the prevalence estimates. Quantitative results were pooled in a statistical meta-analysis using STATA version 14 software.

Result

Nine eligible cross-sectional studies were included in the analysis. The prevalence ranges from 1 to 20%. The pooled prevalence of cardiovascular disease (CVD) was 5% (95% CI: 3–8%). The prevalence was higher in the population who visits hospitals, 8% (95% CI: 4–12%) compared to the general population, 2% (95% CI: 1–5%). There was no significant difference in the overall prevalence of CVD between males and females.

Conclusion

The prevalence of cardiovascular disease was high. A higher prevalence of CVD was found among patients who visited health institutions than the general population and no observed significant sex difference in the prevalence

Interscallop separations of the posterior mitral valve leaflet: a solution to the 'borderline RHD' conundrum?

Objective

The World Heart Federation (WHF) criteria incorporate a Doppler-based system to differentiate between ‘physiological’ and ‘pathological’ mitral regurgitation (MR)—a sole criterion sufficient for the diagnosis of WHF ‘borderline’ rheumatic heart disease (RHD). We have identified that interscallop separations (ISS) of the posterior mitral valve (MV) leaflet, can give rise to pathological MR in an otherwise-normal MV. We aimed to establish and compare the prevalence of ISS-related MR among South African children at high and low risk for RHD.

Methods

A prospective cross-sectional echocardiographic study of 759 school children (aged 13–18) was performed. Cases with MR≥1.5 cm underwent a second comprehensive study to determine the prevalence of RHD according to the WHF guideline and establish the underlying mechanism of MR.

Results

Of 400 high-risk children, two met criteria for ‘definite RHD’ (5 per 1000 (95% CI 1.4 to 18.0); p=0.5) and 11 for ‘borderline RHD’ (27.5 per 1000 (95% CI 15.4 to 48.6)). Of 359 low-risk children, 14 met criteria for borderline RHD (39 per 1000 (95% CI 23.4 to 64.4)). Comprehensive echocardiography identified an underlying ISS as the mechanism of isolated pathological MR in 10 (83.3%) high-risk children and 11 low-risk children (78.5%; p>0.99).

Conclusions

ISS are a ubiquitous finding among South African schoolchildren from all risk profiles and are regularly identified as the underlying mechanism of WHF pathological MR in borderline RHD cases. A detailed MV assessment with an emphasis on ascertaining the underlying mechanism of dysfunction could reduce the reported numbers of screened cases misclassified as borderline RHD.

<p>Clinical, Echocardiographic Characteristics and Management Practices in Patients with Rheumatic Valvular Heart Disease</p>

Background

Rheumatic heart disease (RHD) is the long-term consequence of acute rheumatic fever (ARF), continues unabated among middle-income and low-income countries. Thus, this study aimed to assess clinical characteristics, echocardiographic characteristics, and management practice of RHD patients.

Methods

Hospital-based prospective cross-sectional study was used. The data were collected from medical records of consecutive patients admitted to medical wards during the study period. The data were cleaned and analyzed using SPSS version 20. Descriptive statistics were used to describe the data. Chi-square was used to compare proportions between categorical variables.

Results

Forty-seven patients with a median (IQR) age of 28.0 (17.0-40.0) years were included. Pan systolic murmur was reported in 91.50% of patients. Forty-two (89.4%) of patients were presented with congestive heart failure and 23 (48.9%) with atrial fibrillation. Mitral valve leaflet thickening and calcification with restriction of motion were reported in 91.5% of patients. Mitral regurgitation (MR) (87.2%) and stenosis (MS) (85.1%) were the most common valvular lesions. The combinations of three (MR+MS+TR) 14 (29.8%) and four (MR+MS+TR+AR) 13 (27.7%) valve diseases were most commonly reported. Diuretics (95.7%), anticoagulants (38.3%), digoxin (36.2%), and beta-blockers (34.0%) were among the commonly prescribed medications.

Conclusion

Rheumatic heart disease affected younger adults. Pansystolic murmur was reported in nearly all patients. Congestive heart failure and atrial fibrillation were common clinical presentations. Morphologic changes in mitral valve and pathologic mitral regurgitation were the most common echocardiographic reports. Cardiovascular medications were commonly utilized for symptomatic management of complications Therefore, echocardiography should be done routinely for patients with RHD, focusing on younger adults, to facilitate diagnosis and treatment before complications develop.

Prevalence of rheumatic heart disease in North-Central Nigeria: a school-based cross-sectional pilot study

OBJECTIVES

To present epidemiological data on rheumatic heart disease (RHD), the most common acquired heart disease in children and young adults in low- and middle-income countries, for North-Central Nigeria.

METHODS

In this pilot study, we conducted clinical and echocardiography screening on a cross section of randomly selected secondary schoolchildren in Jos, North-Central Nigeria, from March to September 2016. For outcome classification into borderline or definite RHD, we performed a confirmatory echocardiography using the World Heart Federation criteria for those suspected to have RHD from the screening.

RESULTS

A total of 417 secondary schoolchildren were screened, of whom 247 (59.2%) were female. The median age was 14 years (IQR: 13-15). Clinical screening detected 8/417 children, whereas screening echocardiography detected 42/417 suspected cases of RHD. Definitive echocardiography confirmed 9/417 with RHD corresponding to a prevalence of 21.6 per 1000 (95% CI, 6.7-36.5). All but one of the confirmed RHD cases (8/9) were borderline RHD corresponding to a prevalence of 19.2 per 1000 (95% CI, 8.3-37.5) for borderline RHD and 2.4 per 1000 (95% CI, 0.1-13.3) for definite RHD. RHD was more common in boys and cardiac auscultation missed over 50% of the cases.

CONCLUSIONS

This study showed a high prevalence of RHD among secondary schoolchildren in North-Central Nigeria with a vast predominance of asymptomatic borderline lesions. Larger school-based echocardiography screening using portable or handheld echocardiography aimed at early detection of subclinical RHD should be adopted.

Rheumatic heart disease: current status of diagnosis and therapy

Rheumatic heart disease (RHD) is the only preventable cardiovascular disease which causes significant morbidity and mortality particularly in low- and middle-income countries. Early clinical diagnosis is key, the updated Jones criteria increases the likelihood of diagnosis in endemic settings, including the echo diagnosis of sub-clinical carditis, polyarthralgia and monoarthritis as well as amended thresholds of minor criteria. The mainstay of rheumatic heart valve disease (RHVD) is a thorough clinical and echocardiographic investigation while severe disease is managed with medical, interventional and surgical treatment. In this report we detail some of the more recent epidemiological findings and focus on the diagnostic and interventional elements of the specific valve lesions. Finally, we discuss some of the recent efforts to improve medical and surgical management for this disease. As we are already more than a year from the historic 2018 World Heart Organization Resolution against Rheumatic Fever and Rheumatic Heart Disease, we advocate strongly for renewed efforts to prioritize this disease across the endemic regions of the world.

Simultaneous Occurrence of Sydenham Chorea with Erythema Marginatum: A Case of Rheumatic Fever

Background

Rheumatic fever continues to be a major public health problem in the developing world, being responsible for many morbidities and mortalities. Were it not for its serious effects on the cardiovascular system, and to some extent on the central nervous system, the disease might not have significant consequences. The central nervous system involvement is explained with Sydenham chorea in which case the patient manifests with purposeless and choreiform movements aggravated by stress. Apart from this movement disorder the patient will also demonstrate emotional liability and motor manifestations. It is seen more commonly in children and young adolescent girls. It usually manifests as an isolated phenomenon called pure chorea, without evidence of active rheumatic fever; the other rare form of which is a type of acute rheumatic fever.

Clinical Description

This case report is about a nine-year-old female child presenting with two weeks of complaint of abnormal purposeless, non-rhythmic movement of extremities and the face, with failure to communicate. At presentation, she had non-pruritic skin lesions that had appeared a day prior to admission. The skin lesions were circular, red in color, and painless, involving the abdomen, and lower chest anteriorly, and extending to all extremities and the back. Two months previously she had a history of sore throat and treatment with unspecified P.O. medication. Antistreptolysin O (ASO) antibody was 430 Todd units/mL and the erythrocyte sedimentation rate was 58 mm/h. Echocardiography study revealed carditis (no evidence of chronicity) with moderate to severe MR, mild TR, no pulmonary hypertension, good biventricular function, and no pericardial effusion.

Conclusion

In this case report, we would like to show the central nervous system manifestation of rheumatic fever called Sydenham chorea seen together with erythema marginatum and other features of rheumatic fever.

Rheumatic Fever in Large Cohort of Adolescents in Israel

Background: Acute rheumatic fever (ARF) remains a major worldwide healthcare problem, despite its progressive decline in developed countries. The aims of our study were to estimate the prevalence of ARF among adolescents in Israel and to investigate risk factors.

Methods: The study population consisted of 113,671 consecutive conscripts 16–19 years old, born during 1971–1993, who completed the medical profiling as part of the recruitment process to the IDF. ARF was diagnosed according to Jones criteria at time of illness, with confirmation relying on medical documentation and cardiologist evaluation including echocardiography.

Results: The general prevalence rate of ARF was 0.12%. A downward trend was observed, from 0.19% among those born during 1971–1980 to 0.07% among those born during 1981–1993. Differences in prevalence of ARF were noted in sub-populations based on country of birth and origin—Israel, Ethiopia and the former soviet union (FUSSR). The prevalence rates of valvar disease among ARF+ and ARF– recruits were 15.7% and 0.95%, respectively. In multivariable logistic regression analyses, 4 variables were negatively associated with ARF: later birth year group, female gender, rural residence, youngest child; and 3 were positively associated with ARF: young parents, above normal BMI and valvar disease.

Conclusion: Our study provides support for the documented decline in ARF prevalence and describes socio-demographic and anthropometric risk factors including the association with valvar disease and novel risk factors including above normal BMI and young parents, both warranting further investigation which might help in developing societal level prevention strategies.

Prevalence and progression of rheumatic heart disease: a global systematic review and meta-analysis of population-based echocardiographic studies

This systematic review and meta-analysis aimed to provide a contemporaneous estimate of the global burden of rheumatic heart disease (RHD) from echocardiographic population-based studies. We searched multiple databases between January 01, 1996 and October 17, 2017. Random-effect meta-analysis was used to pool data. We included 82 studies (1,090,792 participant) reporting data on the prevalence of RHD and 9 studies on the evolution of RHD lesions. The pooled prevalence of RHD was 26.1‰ (95%CI 19.2-33.1) and 11.3‰ (95%CI 7.2-16.2) for studies which used the World Heart Federation (WHF) and World Health Organization (WHO) criteria, respectively. The prevalence of RHD varied inversely with the level of a country's income, was lower with the WHO criteria compared to the WHF criteria, and was lowest in South East Asia. Definite RHD progressed in 7.5% (95% CI 1.5-17.6) of the cases, while 60.7% (95% CI 42.4-77.5) of cases remained stable over the course of follow-up. The proportion of cases borderline RHD who progressed to definite RHD was 11.3% (95% CI 6.9-16.5). The prevalence of RHD across WHO regions remains high. The highest prevalence of RHD was noted among studies which used the WHF diagnostic criteria. Definite RHD tends to progress or remain stable over time.

Effect of anaemia on the diagnosis of rheumatic heart disease using World Heart Federation criteria

BACKGROUND

There is overlap between pathological mitral regurgitation seen in borderline rheumatic heart disease using World Heart Federation echocardiography criteria and physiologic regurgitation found in normal children. One possible contributing factor is higher rates of anaemia in endemic countries.

OBJECTIVE

To investigate the contribution of anaemia as a potential confounder in the diagnosis of rheumatic heart disease detected in echocardiographic screening.

METHOD/DESIGN

A novel Server 2012 data warehouse tool was used to incorporate haematology and echocardiography databases. The study included a convenience sample of patients from 5 to 18 years old without structural or functional heart disease that had a haemoglobin value within 1 month prior to an echocardiogram. Echocardiogram images were reviewed to determine presence or absence of World Heart Federation criteria for rheumatic heart disease. The rate of rheumatic heart disease among anaemic and non-anaemic children according to gender- and age-based norms groups was compared.

RESULTS

Of the 935 patients who met the study inclusion criteria, 406 were classified as anaemic. There was no difference in the rate of echocardiograms meeting criteria for borderline rheumatic heart disease in anaemic (2.0%, 95% CI 0.6-3.3%) and non-anaemic children (1.3%, 95% CI 0.3-2.3%). However, there was a statistically significant increase in rates of mitral regurgitation of unclear significance among anaemic versus non-anaemic patients (8.6 versus 3.6%; p = 0.0012).

CONCLUSION

Anaemia does not increase the likelihood of meeting echocardiographic criteria for borderline rheumatic heart disease. Future studies should evaluate for the correlation between anaemia and mitral regurgitation in endemic settings.

Heart Failure in Ethiopian Children: Mirroring the Unmet Cardiac Services

Background

HeartFailure (HF) is a progressive clinical and pathophysiological syndrome caused by cardiovascular and noncardiovascular abnormalities. Childhood HF has not been well studied in Sub-Sharan Africa, particularly in Ethiopia. Hence, this study aimed at describing the pattern and outcome of pediatrics HF at a referral-teaching hospital.

Methods

Medical records of 216 HF children aged 2 months to 14 years, and admitted between January 2014 and January 2016 were reviewed. Clinical information was collected, analyzed and presented in tables and pie charts.

Results

A total of 2000 children were admitted to Hawassa University Hospital during the study period. HF accounted for 10.8% (216) of pediatrics admissions, 51.9% males. The median age of the study subjects was 6 years. Functionally, NYHA/Ross class III and IV consisted 65(30.1%) and 139(64.4%) of HF. Structural heart disease was the commonest cause of HF, 144(66.7%): Rheumatic heart disease (RHD),75(52%), and congenital heart disease (CHD),64(44.5%). Anemia and renal cases contributed to 50(23.1) and 12(5.6%) of HF.CHD was predominantly documented in <5 years. Pneumonia 66(42.9%), and infective endocarditis 29(18.8%) were the common precipitating/comorbid conditions with HF. The case fatality rate of HF was 13.9 %(30).

Conclusion

In this study, HF accounted for a tenth of pediatrics admissions. Structural heart disease was the commonest cause of heart failure. CHD and RHD affected predominantly children of <5 years of age and >5 years of age. Echocardiographic screening of HF cases for structural heart disease and optimal care for patients with underlying structural heart disease are recommended.

Echocardiographic screening of 4107 Nigerian school children for rheumatic heart disease

OBJECTIVE

Echocardiographic screening for Rheumatic Heart Disease (RHD) in Africa has revealed prevalence rates in the range of 0.5-7.4%. There are no recent large population-based studies in Nigeria. The objective of the study was to determine the prevalence of RHD in a large sample of Nigerian school children.

METHODS

Using portable transthoracic echocardiography and auscultation, school children aged 5 years to 16 years in Lagos, Nigeria were screened for RHD. Diagnosis was based on the 2012 World Heart Federation echocardiographic criteria.

RESULTS

The 4107 children screened had mean age of 11.3 years (SD = 2.6) and 2206 (53.7%) were females. There were 38 children with abnormal echocardiograms, of which 11 (0.27%) showed RHD including two cases of definite RHD giving a prevalence of 2.7/1000 [2.9/1000 in the peri-urban, 2.4/1000 in the urban area). Echocardiography detected RHD 10 times better than auscultation [echocardiography 11 (0.27%) vs. auscultation 1 (0.02%); P = 0.003]. The remaining 27 children with abnormal echocardiograms had congenital heart defects (CHD) giving a prevalence of 6.6/1000 for CHD, a yield higher than for RHD.

CONCLUSION

Prevalence of RHD among school children in Lagos, South West Nigeria is low compared to other African countries, possibly due to better access to medical care and antibiotic treatment for infections. Our data provides evidence that RHD prevalence may vary substantially within sub-Saharan Africa, necessitating targeted population-based sampling to better understand disease burden and distribution. Further work is needed to compare within- and between-country RHD prevalence as a basis for programme planning and control efforts.

Prevalence of rheumatic heart disease in Zambian school children

BACKGROUND

The large global burden of rheumatic heart disease (RHD) has come to light in recent years following robust epidemiologic studies. As an operational research component of a broad program aimed at primary and secondary prevention of RHD, we sought to determine the current prevalence of RHD in the country's capital, Lusaka, using a modern imaging-based screening methodology. In addition, we wished to evaluate the practicality of training local radiographers in echocardiography screening methods.

METHODS

Echocardiography was conducted on a random sample of students in 15 schools utilizing a previously validated, abbreviated screening protocol. Through a task-shifting scheme, and in the spirit of capacity-building to enhance local diagnostic and research skills, general radiographers based at Lusaka University Teaching Hospital (UTH) were newly trained to use portable echocardiography devices. Students deemed as screen-positive were referred for comprehensive echocardiography and clinical examination at UTH. Cardiac abnormalities were classified according to standard World Heart Federation criteria.

RESULTS

Of 1102 students that were consented and screened, 53 students were referred for confirmatory echocardiography. Three students had definite RHD, 10 had borderline RHD, 29 were normal, and 11 students were lost to follow-up. The rates of definite, borderline, and total RHD were 2.7 per 1000, 9.1 per 1000, and 11.8 per 1000, respectively. Anterior mitral valve leaflet thickening and chordal thickening were the most common morphological defects. The pairwise kappa test showed fair agreement between the local radiographers and an echocardiographer quality assurance specialist.

CONCLUSION

The prevalence of asymptomatic RHD in urban communities in Zambia is within the range of results reported in other sub-Saharan African countries using the WHF criteria. Task-shifting local radiographers to conduct echocardiography was feasible. The results of this study will be used to inform ongoing efforts in Zambia to control and eventually eliminate RHD.

TRIAL REGISTRATION

The study was registered on clinicaltrials.gov ( #NCT02661763 ).

Valvular Heart Disease in a Young Israeli Ethiopian Immigrant Population From the Gondar Region With Implications for Rheumatic Heart Disease

Background

Rheumatic heart disease (RHD) among Ethiopian school children was recently found to be 1.4%. Immigration of the Jewish population from the Gondar region to Israel created an opportunity for further enquiry.

Methods

A cross-sectional study of the cardiac status of 113,671 adolescent recruits aged 16-19 years from the northern district of Israel who completed the medical profiling process over a 22-year period.

Results

140 recruits had a history of rheumatic fever (0.12%), although none from an Ethiopian origin (n = 1,719). The prevalence of valvular heart disease clinically and confirmed echocardiographically in Ethiopian recruits was not different from the total population (0.81 and 0.93%, respectively). However, the prevalence was higher in those migrating to Israel in their 13th year or older (2.09%), compared to those migrating at a younger age or born in Israel (0.49%).

Conclusion

The Ethiopian teenage Israeli population from Gondar had a high rate of auscultation positive and echocardiographically confirmed valvular disease that suggested a high rate of RHD (~1.6%), despite no relevant past history. Our findings also suggested that for the younger Ethiopian immigrants or Israeli born subjects of Ethiopian origin, the improved medical care may well reduce the prevalence of valvular heart disease to that of the rest of the local population.

Participation in research improves overall patient management: insights from the Global Rheumatic Heart Disease registry (REMEDY)

Background

Rheumatic heart disease (RHD) is a major public health problem in low– and middle–income countries (LMICs), with a paucity of high–quality trial data to improve patient outcomes. Investigators felt that involvement in a recent large, observational RHD study impacted positively on their practice, but this was poorly defined.

Aim

The purpose of this study was to document the experience of investigators and research team members from LMICs who participated in a prospective, multi–centre study, the global Rheumatic Heart Disease Registry (REMEDY), conducted in 25 centres in 14 countries from 2010 to 2012.

Methods

We conducted an online survey of site personnel to identify and quantify their experiences. Telephone interviews were conducted with a subset of respondents to gather additional qualitative data. We asked about their experiences, positive and negative, and about any changes in RHD management practices resulting from their participation in REMEDY as a registry site.

Results

The majority of respondents in both the survey and telephone interviews indicated that participation as a registry site improved their management of RHD patients. Administrative changes included increased attention to follow–up appointments and details in patient records. Clinical changes included increased use of penicillin prophylaxis, and more frequent INR monitoring and contraceptive counselling.

Conclusions

Our study demonstrates that participation in clinical research on RHD can have a positive impact on patient management. Furthermore, REMEDY has led to increased patient awareness and improved healthcare workers’ knowledge and efficiency in caring for RHD patients.

A systematic review of epidemiology, treatment and prognosis of heart failure in adults in Ethiopia

BACKGROUND

Systematic characterization of heart failure in adults in Ethiopia is lacking currently. In this review, we sought to summarize the available scientific evidence on the epidemiology, treatment and prognosis of heart failure in adults in Ethiopia.

METHODS

A systematic review of PUBMED, EMBASE and SCOPUS was conducted for studies published between January 1990 and July 2017. Studies reporting on incidence, prevalence, treatment or prognosis of heart failure in individuals older than 14 years of age were included.

RESULTS

The search yielded 66 articles, out of which nine were found to be eligible for inclusion in this review. There are no studies reporting the incidence or prevalence of heart failure in the adult population in Ethiopia. There are, however, indications that heart failure might be a significant burden in the country, and typically affects middle-aged adults. Valvular heart disease, predominantly related to rheumatic heart disease, is the most commonly identified heart failure cause across the included studies. There are very limited data on treatment and prognosis.

CONCLUSION

There is limited scientific evidence on the epidemiology, treatment and prognosis of heart failure in adults in Ethiopia. Further studies are needed for the better understanding of the burden and treatment of heart failure in the adult population in Ethiopia.

Heart disease in East Timor: cross-sectional analysis of 474 patients attending Timor-Leste's first cardiology service

BACKGROUND

East Timor is a developing country and is a close neighbour of Australia. The prevalence of cardiac disease is unknown.

AIMS

To describe the prevalence and patterns of cardiac disease in patients attending the first cardiology service of Timor-Leste.

METHODS

A cross-sectional retrospective analysis was performed of demographic and clinical data of 474 unique patients referred to outpatient cardiology clinics conducted in East Timor from 2003 to 2016.

RESULTS

Mean age was 29.9 ± 18.5 years, with females significantly younger than males (28.8 ± 16.9 vs 32.3 ± 20.6 years). Congenital cardiac disease patients were the youngest (15.5 ± 13.9 years) and cardiomyopathy patients the oldest (46.7 ± 17.8 years). Of patients with rheumatic heart disease, the majority had mitral stenosis (59.4%) and multi-valvular involvement (61.6%). Of note, 28.3% of patients with rheumatic heart disease presented with severe mitral stenosis. Amongst congenital heart disease patients, the most common diagnosis was atrial or ventricular septal defects (61% combined). A total of 19.2% of patients either required immediate referral for intervention or palliation for their cardiac disease. Patients referred to Australia for treatment were significantly younger (19.7 ± 11.7 years) than all other outcome groups.

CONCLUSION

Amongst young East Timorese, rheumatic heart disease and unrepaired congenital cardiac defects impose a significant burden. One-fifth of patients present to clinics with severe disease requiring urgent referral for surgery or palliation.

Screening for rheumatic heart disease: is a paradigm shift required?

This focused review presents a critical appraisal of the World Heart Federation criteria for the echocardiographic diagnosis of rheumatic heart disease (RHD) and its performance in African RHD screening programmes. It identifies various logistical and methodological problems that negatively influence the current guideline’s performance. The authors explore novel RHD screening methodology that could address some of these shortcomings and if proven to be of merit, would require a paradigm shift in the approach to the echocardiographic diagnosis of subclinical RHD.

Spectrum of cardiovascular diseases in six main referral hospitals of Ethiopia

Background

The spectrum of cardiovascular diseases varies between and within countries, depending on the stage of epidemiological transition and risk factor profiles. Understanding this spectrum requires regional and national data for each region or country. This study was designed to determine the spectrum of cardiovascular diseases in six university hospitals in Ethiopia.

Methods

This is a cross-sectional study of the spectrum of cardiovascular diseases in six main referral/teaching hospitals located in different parts of the country. Consecutive patients visiting the follow-up cardiac clinics of these hospitals from 1 January to 30 June 2015 were included in the study. Data were collected on a pretested questionnaire.

Results

A total of 6275 patients (58.5% females) were included in the study. Nearly 61% of the patients were from urban areas. The median age was 33 years (IQR 14-55 years). Valvular heart disease was the most common diagnosis, accounting for 40.5% of the cases. Of 2541 patents with valvular heart disease, 2184 (86%) were cases of chronic rheumatic heart disease.

Conclusion

Our study shows that chronic rheumatic valvular heart disease is the most common cardiovascular diagnosis among patients seen at cardiology clinics of six referral/teaching hospitals in the country, followed by congenital heart diseases. Hypertensive and ischaemic heart diseases also accounted for a significant proportion of the cases. Therefore, strategies directed towards primary and secondary prevention of acute rheumatic fever as well as prevention of risk factors for hypertension and ischaemic heart disease may need to be strengthened.

Cardiovascular disease in Africa: epidemiological profile and challenges

From a global perspective, the large and diverse African population is disproportionately affected by cardiovascular disease (CVD). The historical balance between communicable and noncommunicable pathways to CVD in different African regions is dependent on external factors over the life course and at a societal level. The future risk of noncommunicable forms of CVD (predominantly driven by increased rates of hypertension, smoking, and obesity) is a growing public health concern. The incidence of previously rare forms of CVD such as coronary artery disease will increase, in concert with historically prevalent forms of disease, such as rheumatic heart disease, that are yet to be optimally prevented or treated. The success of any strategies designed to reduce the evolving and increasing burden of CVD across the heterogeneous communities living on the African continent will be dependent upon accurate and up-to-date epidemiological data on the cardiovascular profile of every major populace and region. In this Review, we provide a contemporary picture of the epidemiology of CVD in Africa, highlight key regional discrepancies among populations, and emphasize what is currently known and, more importantly, what is still unknown about the CVD burden among the >1 billion people living on the continent.

Prevalence of valvular heart diseases and associated risk factors in Han, Uygur and Kazak population in Xinjiang, China

Background

Valvular heart diseases (VHD) is very common in clinical practice and has became the subject of growing attention in the field of cardiovascular medicine. Our aim was to assess the prevalence and correlates of VHD in the general population in Xinjiang, China.

Methods

Using a 4-stage stratified cluster random sampling method, a total of 14618 participants were recruited in the Cardiovascular Risk Survey (CRS) study. The participants’ personal information, medical history were assessed by questionnaire. VHD was diagnosed by transthoracic echocardiography. We carried out the statistical analysis utilizing SPSS Statistics version 19.0.

Results

In the total study group, VHD was observed in 1397 (9.65%) individuals. The prevalence rates of VHD in Han, Uygur and Kazak group are 13.51%, 2.71% and 12.29% respectively. The prevalence rates of VHD increased strikingly with age (all P < 0.001). The results of multinomial regression analysis indicated that VHD were related to age in Han group, to age smoking and hypertension in Uygur group, to age and hypertension in Kazak group.

Conclusion

Our research provides a unique prevalence rate of VHD in Xinjiang natural population. The result suggests that VHD are notably common in this population (9.65%) and increase with age. There exists significant difference of prevalence rate between ethnics. The main risk factors of VHD are age, hypertension and smoking. Valvular heart diseases should be regarded as a serious and growing public-health problem.