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Karthikeyan G, Ntsekhe M, Islam S, Rangarajan S, Avezum A, Benz A, Cabral TTJ, Changsheng M, Chillo P, Gonzalez-Hermosillo JA, Gitura B, Damasceno A, Dans AML, Davletov K, Elghamrawy A, ElSayed A, Fana GT, Gondwe L, Haileamlak A, Kayani AM, Lwabi P, Maklady F, Molefe-Baikai OJ, Musuku J, Ogah OS, Paniagua M, Rusingiza E, Sharma SK, Zuhlke L, Connolly S, Yusuf S. Mortality and Morbidity in Adults With Rheumatic Heart Disease. JAMA 2024:2819427. [PMID: 38837131 PMCID: PMC11154374 DOI: 10.1001/jama.2024.8258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/18/2024] [Indexed: 06/06/2024]
Abstract
Importance Rheumatic heart disease (RHD) remains a public health issue in low- and middle-income countries (LMICs). However, there are few large studies enrolling individuals from multiple endemic countries. Objective To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD. Design, Setting, and Participants Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs. Main Outcomes and Measures The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality, heart failure (HF) hospitalization, stroke, recurrent rheumatic fever, and infective endocarditis. This study analyzed event rates by World Bank country income groups and determined the predictors of mortality using multivariable Cox models. Results Between August 2016 and May 2022, a total of 13 696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12 967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41 478 patient-years), 1943 patients died (15% overall; 4.7% per patient-year). Most deaths were due to vascular causes (1312 [67.5%]), mainly HF or sudden cardiac death. The number of patients undergoing valve surgery (604 [4.4%]) and HF hospitalization (2% per year) was low. Strokes were infrequent (0.6% per year) and recurrent rheumatic fever was rare. Markers of severe valve disease, such as congestive HF (HR, 1.58 [95% CI, 1.50-1.87]; P < .001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P < .001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P < .001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P < .001) or valvuloplasty (HR, 0.24 [95% CI, 0.06-0.95]; P = .042) were associated with lower mortality. Higher country income level was associated with lower mortality after adjustment for patient-level factors. Conclusions and Relevance Mortality in RHD is high and is correlated with the severity of valve disease. Valve surgery and valvuloplasty were associated with substantially lower mortality. Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation.
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Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi
- Translational Health Science and Technology Institute, Faridabad, India
| | - Mpiko Ntsekhe
- Division of Cardiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Shofiqul Islam
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Alexander Benz
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | | | | | - Philly Chillo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Bernard Gitura
- Kenyatta National Teaching & Referral Hospital, Department of Cardiology, Nairobi, Kenya
| | | | | | - Kairat Davletov
- Asfendiyarov Kazakh National Medical University, Health Research Institute, Almaty, Kazakhstan
| | | | | | | | | | - Abraham Haileamlak
- College of Medicine and Health Sciences, University of Rwanda, Kigali
- Jimma University Medical Center, Jimma, Ethiopia
| | | | | | - Fathi Maklady
- Department of Cardiology, Suez Canal University, Ismailia, Egypt
| | | | - John Musuku
- University Teaching Hospital, Lusaka, Zambia
| | - Okechukwu Samuel Ogah
- Cardiology Unit, Department of Medicine, University of Ibadan/University College Hospital, Ibadan, Oyo State, Nigeria
| | - Maria Paniagua
- College of Medicine Sciences, National University of Concepción, Concepción, Paraguay
| | | | | | - Liesl Zuhlke
- Medical Research Council of South Africa, Division of Pediatric Cardiology, Department of Pediatrics, Red Cross Children’s Hospital Faculty of Health Sciences, University of Cape Town, Cape Town
| | - Stuart Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Providência R, Aali G, Zhu F, Katairo T, Ahmad M, Bray JJH, Pelone F, Khanji MY, Marijon E, Cassandra M, Celermajer DS, Shokraneh F. Handheld echocardiography for the screening and diagnosis of rheumatic heart disease: a systematic review to inform WHO guidelines. Lancet Glob Health 2024; 12:e983-e994. [PMID: 38762298 DOI: 10.1016/s2214-109x(24)00127-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/29/2024] [Accepted: 03/08/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Early detection and diagnosis of acute rheumatic fever and rheumatic heart disease are key to preventing progression, and echocardiography has an important diagnostic role. Standard echocardiography might not be feasible in high-prevalence regions due to its high cost, complexity, and time requirement. Handheld echocardiography might be an easy-to-use, low-cost alternative, but its performance in screening for and diagnosing acute rheumatic fever and rheumatic heart disease needs further investigation. METHODS In this systematic review and meta-analysis, we searched Embase, MEDLINE, LILACS, and Conference Proceedings Citation Index-Science up to Feb 9, 2024, for studies on the screening and diagnosis of acute rheumatic fever and rheumatic heart disease using handheld echocardiography (index test) or standard echocardiography or auscultation (reference tests) in high-prevalence areas. We included all studies with useable data in which the diagnostic performance of the index test was assessed against a reference test. Data on test accuracy in diagnosing rheumatic heart disease, acute rheumatic fever, or carditis with acute rheumatic fever (primary outcomes) were extracted from published articles or calculated, with authors contacted as necessary. Quality of evidence was appraised using GRADE and QUADAS-2 criteria. We summarised diagnostic accuracy statistics (including sensitivity and specificity) and estimated 95% CIs using a bivariate random-effects model (or univariate random-effects models for analyses including three or fewer studies). Area under the curve (AUC) was calculated from summary receiver operating characteristic curves. Heterogeneity was assessed by visual inspection of plots. This study was registered with PROSPERO (CRD42022344081). FINDINGS Out of 4868 records we identified 11 studies, and two additional reports, comprising 15 578 unique participants. Pooled data showed that handheld echocardiography had high sensitivity (0·87 [95% CI 0·76-0·93]), specificity (0·98 [0·71-1·00]), and overall high accuracy (AUC 0·94 [0·84-1·00]) for diagnosing rheumatic heart disease when compared with standard echocardiography (two studies; moderate certainty of evidence), with better performance for diagnosing definite compared with borderline rheumatic heart disease. High sensitivity (0·79 [0·73-0·84]), specificity (0·85 [0·80-0·89]), and overall accuracy (AUC 0·90 [0·85-0·94]) for screening rheumatic heart disease was observed when pooling data of handheld echocardiography versus standard echocardiography (seven studies; high certainty of evidence). Most studies had a low risk of bias overall. Some heterogeneity was observed for sensitivity and specificity across studies, possibly driven by differences in the prevalence and severity of rheumatic heart disease, and level of training or expertise of non-expert operators. INTERPRETATION Handheld echocardiography has a high accuracy and diagnostic performance when compared with standard echocardiography for diagnosing and screening of rheumatic heart disease in high-prevalence areas. FUNDING World Health Organization. TRANSLATIONS For the Chinese, French, Italian, Persian, Portuguese, Spanish and Urdu translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Rui Providência
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.
| | - Ghazaleh Aali
- Cochrane Heart, Institute of Health Informatics, University College London, London, UK
| | - Fang Zhu
- Systematic Review Consultants, Nottingham, UK
| | | | - Mahmood Ahmad
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Cardiology Department, Royal Free London NHS Foundation Trust, London, UK
| | - Jonathan J H Bray
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ferruccio Pelone
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK
| | - Mohammed Y Khanji
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, London, UK
| | - Eloi Marijon
- Paris Cardiovascular Research Centre, INSERM U970, European Georges Pompidou Hospital, Paris, France
| | - Miryan Cassandra
- Cardiology Department, Hospital Dr Ayres de Menezes, São Tomé, São Tomé and Príncipe
| | - David S Celermajer
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Farhad Shokraneh
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Systematic Review Consultants, Nottingham, UK
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