Rheumatic fever and rheumatic heart disease: Facts and research progress in Africa

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.

Burden of disease and barriers to comprehensive care for rheumatic heart disease in South Africa: an updated systematic review protocol

INTRODUCTION

Rheumatic heart disease (RHD) is responsible for a significant burden of cardiovascular morbidity and mortality, and remains the most common cause of acquired heart disease among children and young adults in low-income and middle-income countries. Additionally, the global COVID-19 pandemic has forced the emergency restructuring of many health systems, which has had a broad impact on health in general, including cardiovascular disease. Despite significant cost to the health system and estimates from 2015 indicating both high incidence and prevalence of RHD in South Africa, no cohesive national strategy exists. An updated review of national burden of disease estimates, as well as literature on barriers to care for patients with RHD, will provide crucial information to assist in the development of a national RHD programme.

METHODS AND ANALYSIS

Using predefined search terms that capture relevant disease processes from Group A Streptococcal (GAS) infection through to the sequelae of RHD, a search of PubMed, Scopus, ISI Web of Science, Sabinet African Journals, SA Heart and Current and Completed Research databases will be performed. All eligible studies on RHD, acute rheumatic fever and GAS infection published from April 2014 to December 2022 will be included. Vital registration data for the same period from Statistics South Africa will also be collected. A standardised data extraction form will be used to capture results for both quantitative and qualitative analyses. All studies included in burden of disease estimates will undergo quality assessment using standardised tools. Updated estimates on mortality and morbidity as well as a synthesis of work on primary, secondary and tertiary prevention of RHD will be reported.

ETHICS AND DISSEMINATION

No ethics clearance is required for this study. Findings will be disseminated in a peer-reviewed journal and submitted to national stakeholders in RHD.

PROSPERO REGISTRATION NUMBER

CRD42023392782.

The projections of global and regional rheumatic heart disease burden from 2020 to 2030

Background

Rheumatic heart disease (RHD) remains the leading cause of preventable death and disability in children and young adults, killing an estimated 320,000 individuals worldwide yearly.

Materials and methods

We utilized the Bayesian age-period cohort (BAPC) model to project the change in disease burden from 2020 to 2030 using the data from the Global Burden of Disease (GBD) Study 2019. Then we described the projected epidemiological characteristics of RHD by region, sex, and age.

Results

The global age-standardized prevalence rate (ASPR) and age-standardized incidence rate (ASIR) of RHD increased from 1990 to 2019, and ASPR will increase to 559.88 per 100,000 population by 2030. The global age-standardized mortality rate (ASMR) of RHD will continue declining, while the projected death cases will increase. Furthermore, ASPR and cases of RHD-associated HF will continue rising, and there will be 2,922,840 heart failure (HF) cases in 2030 globally. Female subjects will still be the dominant population compared to male subjects, and the ASPR of RHD and the ASPR of RHD-associated HF in female subjects will continue to increase from 2020 to 2030. Young people will have the highest ASPR of RHD among all age groups globally, while the elderly will bear a greater death and HF burden.

Conclusion

In the following decade, the RHD burden will remain severe. There are large variations in the trend of RHD burden by region, sex, and age. Targeted and effective strategies are needed for the management of RHD, particularly in female subjects and young people in developing regions.

Medical Treatment for Rheumatic Heart Disease: A Narrative Review

BACKGROUND

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are rare in high-income countries; however, in Aotearoa New Zealand ARF and RHD disproportionately affect Indigenous Māori and Pacific Peoples. This narrative review explores the evidence regarding non-surgical management of patients with clinically significant valve disease or heart failure due to RHD.

METHODS

Medline, EMBASE and Scopus databases were searched, and additional publications were identified through cross-referencing. Included were 28 publications from 1980 onwards.

RESULTS

Of the available interventions, improved anticoagulation management and a national RHD register could improve RHD outcomes in New Zealand. Where community pharmacy anticoagulant management services (CPAMS) are available good anticoagulation control can be achieved with a time in the therapeutic range (TTR) of more than 70%, which is above the internationally recommended level of 60%. The use of pharmacists in anticoagulation control is cost-effective, acceptable to patients, pharmacists, and primary care practitioners. There is a lack of local data available to fully assess other interventions; including optimal therapy for heart failure, equitable access to specialist RHD care, prevention, and management of endocarditis.

CONCLUSION

As RHD continues to disproportionately affect Indigenous and minority groups, pro-equity tertiary prevention interventions should be fully evaluated to ensure they are reducing disease burden and improving outcomes in patients with RHD.

Global burden of rheumatic heart disease: trends from 1990 to 2019

Background

Rheumatic heart disease (RHD) is a critical public health issue worldwide, and its epidemiological patterns have changed over the decades. This article aimed to estimate the global trends of RHD, and attributable risks from 1990 to 2019.

Methods

Data on RHD burden were explored from the Global Burden of Disease Study 2019. Trends of the RHD burden were estimated using the estimated annual percentage change (EAPC) and age-standardized rate (ASR).

Results

During 1990–2019, increasing trends in the ASR of incidence and prevalence of RHD were observed worldwide, with the respective EAPCs of 0.58 (95% confidence interval [CI] 0.52 to 0.63) and 0.57 (95%CI 0.50 to 0.63). Meanwhile, increasing trends commonly occurred in low and middle Socio-Demographic Index (SDI) regions and countries. The largest increasing trends in the ASR of incidence and prevalence were seen in Fiji, with the respective EAPCs being 2.17 (95%CI 1.48 to 2.86) and 2.22 (95%CI 1.53 to 2.91). However, death and disability-adjusted life years (DALYs) due to RHD showed pronounced decreasing trends of ASR globally, in which the EAPCs were − 2.98 (95%CI − 3.03 to − 2.94) and − 2.70 (95%CI − 2.75 to − 2.65), respectively. Meanwhile, decreasing trends were also observed in all SDI areas and geographic regions. The largest decreasing trends of death were observed in Thailand (EAPC = − 9.55, 95%CI − 10.48 to − 8.61). Among the attributable risks, behavioral risk-related death and DALYs caused by RHD had pronounced decreasing trends worldwide and in SDI areas.

Conclusions

Pronounced decreasing trends of death and DALYs caused by RHD were observed in regions and countries from 1990 to 2019, but the RHD burden remains a substantial challenge globally. The results would inform the strategies for more effective prevention and control of RHD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02829-3.

Predicting ICU Mortality in Rheumatic Heart Disease: Comparison of XGBoost and Logistic Regression

Background

Rheumatic heart disease (RHD) accounts for a large proportion of Intensive Care Unit (ICU) deaths. Early prediction of RHD can help with timely and appropriate treatment to improve survival outcomes, and the XGBoost machine learning technology can be used to identify predictive factors; however, its use has been limited in the past. We compared the performance of logistic regression and XGBoost in predicting hospital mortality among patients with RHD from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database.

Methods

The patients with RHD in the MIMIC-IV database were divided into two groups retrospectively according to the availability of data and its clinical significance based on whether they survived or died. Backward stepwise regression was used to analyze the independent factors influencing patients with RHD, and to compare the differences between the two groups. The XGBoost algorithm and logistic regression were used to establish two prediction models, and the areas under the receiver operating characteristic curves (AUCs) and decision-curve analysis (DCA) were used to test and compare the models. Finally, DCA and the clinical impact curve (CIC) were used to validate the model.

Results

Data on 1,634 patients with RHD were analyzed, comprising 207 who died during hospitalization and 1,427 survived. According to estimated results for the two models using AUCs [0.838 (95% confidence interval = 0.786–0.891) and 0.815 (95% confidence interval = 0.765–0.865)] and DCA, the logistic regression model performed better. DCA and CIC verified that the logistic regression model had convincing predictive value.

Conclusions

We used logistic regression analysis to establish a more meaningful prediction model for the final outcome of patients with RHD. This model might be clinically useful for patients with RHD and help clinicians to provide detailed treatments and precise management.

Rheumatic Heart Disease in Pregnancy: New Strategies for an Old Disease?

RHD in pregnancy (RHD-P) is associated with an increased burden of maternal and perinatal morbidity and mortality. A sequellae of rheumatic fever resulting in heart valve damage if untreated, RHD is twice as common in women. In providing an historical overview, this commentary provides context for prevention and treatment in the 21 st century. Four underlying themes inform much of the literature on RHD-P: its association with inequities; often-complex care requirements; demands for integrated care models, and a life-course approach. While there have been some gains particularly in awareness, strengthened policies and funding strategies are required to sustain improvements in the RHD landscape and consequently improve outcomes. As the principal heart disease seen in pregnant women in endemic regions, it is unlikely that the Sustainable Development Goal 3 target of reduced global maternal mortality ratio can be met by 2030 if RHD is not better addressed for women and girls.

Heart failure can affect everyone: the ESC Geoffrey Rose lecture

The principle of 'sick individuals vs. sick population', a concept pioneered by Geoffrey Rose 35 years ago, is particularly applicable to heart failure (HF). This perspective article summarizes and expands on the Geoffrey Rose lecture given at the European Society of Cardiology meeting held in conjunction with the World Congress of Cardiology, in Paris, 2019. This article focuses on the fact that, clearly, HF not only affects a large spectrum of the population globally, but it occurs in all ages and equally in both genders. Heart failure, in most parts of the world, is clearly not a disease of the elderly. There are multiple and complex pathways leading to HF which include various risk factors (including communicable diseases and exposure to indoor and environmental pollutants), poverty and overcrowding, as well as sub-optimal access to health care systems due to socioeconomic inequities. Reflecting on Geoffrey Rose's concept 35 years later motivates us to confront our global responsibility to address the population distribution of risk factors more effectively, instead of focusing solely on interventions that target high-risk individuals.