Acquired heart disease in low-income and middle-income countries

A Global Perspective on Socioeconomic Determinants of Cardiovascular Health

Cardiovascular disease (CVD) is the leading cause of mortality in the world. From 2005 to 2008, the World Health Organization (WHO) planned an initiative to reduce the mortality rate of CVD by 2030 by addressing health, finance, transport, education, and agriculture in these communities. Plans were underway by many countries to meet the goals of the WHO initiative. However, in 2020, the COVID-19 pandemic derailed these goals, and many health systems suffered as the world battled the viral pandemic. The pandemic made health inequities even more prominent and necessitated a different approach to understanding and improving the socioeconomic determinants of health (SDOH). WHO initiated a special initiative to improve SDOH globally. This paper is an update on what other regions across the globe are doing to decrease, more specifically, the impact of socioeconomic determinants of cardiovascular health. Our review highlights how countries and regions such as Canada, the United States, India, Southeast Asia, the Middle East, and Africa are uniquely affected by various socioeconomic factors and how these countries are attempting to counter these obstacles by creating policies and protocols to facilitate an infrastructure that promotes screening and treatment of CVD. Ultimately, interventions directed toward populations that have been economically and socially marginalized may aid in reducing the disease and financial burden associated with CVD.

Health-related quality of life of people with heart failure in low- and middle-income countries: a systematic review and meta-analysis

PURPOSE

Heart failure is a global health concern and associated with poor health-related quality of life and increased mortality. There is a disproportionate burden on patients and health systems in low- and middle-income countries. This systematic review and meta-analysis estimates the health-related quality of life of people with heart failure in low- and middle-income countries.

METHODS

A systematic literature search was conducted to identify relevant studies from January 2012 to November 2022 using the following databases: MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, Scopus and JBI EBP database. Study screening, quality appraisal and data extraction were conducted using JBI methodology. A random-effects model was used to perform the meta-analysis. Heterogeneity was assessed using the I2 statistic. All statistical analyses were done in STATA version 17.

RESULTS

A total of 33 studies with 5612 participants were included in this review. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Short-Form-36 questionnaire (SF-36) were the most used instruments across 19 and 8 studies, respectively. The pooled mean MLHFQ and SF-36 scores using the random-effects model were 46.08 (95% CI 35.06, 57.10) and 41.23 (95% CI 36.63, 45.83), respectively. In a subgroup analysis using both instruments, the highest health-related quality-of-life scores occurred in studies with inpatient participants.

CONCLUSION

The overall health-related quality of life of people with heart failure in low- and middle-income countries is poor. Strategies should be strategically developed to improve the health-related quality of life of people with heart failure in these countries.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022377781.

Tuberculous Pericarditis in Childhood: A Case Report and a Systematic Literature Review

Tuberculous pericarditis (TBP) is an important cause of pericarditis worldwide while being infrequent in childhood, especially in low-TB-incidence countries. We report a case of TBP and provide a systematic review of the literature, conducted by searching PubMed, Scopus, and Cochrane to find cases of TBP in pediatric age published in the English language between the year 1990 and the time of the search. Of the 587 search results obtained, after screening and a backward citation search, 45 studies were selected to be included in this review, accounting for a total of 125 patients. The main signs and symptoms were fever, cough, weight loss, hepatomegaly, dyspnea, and increased jugular venous pressure or jugular vein turgor. A definitive diagnosis of TBP was made in 36 patients, either thanks to microbiological investigations, histological analysis, or both. First-line antitubercular treatment (ATT) was administered in nearly all cases, and 69 children underwent surgical procedures. Only six patients died, and only two died of TBP. TBP in childhood is relatively uncommon, even in high-TB-prevalence countries. Clinical manifestations, often suggestive of right-sided cardiac failure, are subtle, and diagnosis is challenging. TBP has an excellent prognosis in childhood; however, in a significant proportion of cases, invasive surgical procedures are necessary.

Improving the heart team: An interdisciplinary team and integrated practice unit

Heart Team emerged as an important tool in the cardiovascular care, improving the efficiency of decision-making process. In addition to the benefits in patient care, it symbolizes a new culture and mindset. However, beyond the clinical condition, in low/middle-income countries other concerns arise regarding patient's background and these demands are, usually, as challenging as the medical treatment. New models have been proposed face these demands and to assure a holistic care by Integrated Practice Units. Optimization and reorganization of already existing resources and promotion of interdisciplinary and holistic care may be an effective manner to improve outcomes despite socioeconomic barriers.

Societies of Futures Past: Examining the History and Potential of International Society Collaborations in Addressing the Burden of Rheumatic Heart Disease in the Developing World

This paper explores the role and place of national, regional, and international society collaborations in addressing the major global burden of rheumatic heart disease (RHD). On the same order of HIV, RHD affects over 40 million people worldwide. In this article, we will outline the background and current therapeutic landscape for cardiac surgery in low- and middle-income countries (LMICs) including the resource-constrained settings within which RHD surgery often occurs. This creates numerous challenges to delivering adequate surgical care and post-operative management for RHD patients, and thus provides some context for a growing movement for and applicability of structural heart approaches, innovative valve replacement technologies, and minimally invasive techniques in this setting. Intertwined and building from this context will be the remainder of the paper which elaborates how national, regional, and international societies have collaborated to address rheumatic heart disease in the past (e.g., Drakensberg Declaration, World Heart Federation Working Group on RHD) with a focus on primary and secondary prevention. We then provide the recent history and context of the growing movement for how surgery has become front and center in the discussion of addressing RHD through the passing of the Cape Town Declaration.

The Immune and Inflammatory Basis of Acquired Pediatric Cardiac Disease

Children with acquired heart disease face significant health challenges, including a lifetime of strict medical management, multiple cardiac surgeries, and a high mortality risk. Though the presentation of these conditions is diverse, a unifying factor is the role of immune and inflammatory responses in their development and/or progression. For example, infectious agents have been linked to pediatric cardiovascular disease, leading to a large health burden that disproportionately affects low-income areas. Other implicated mechanisms include antibody targeting of cardiac proteins, infection of cardiac cells, and inflammation-mediated damage to cardiac structures. These changes can alter blood flow patterns, change extracellular matrix composition, and induce cardiac remodeling. Therefore, understanding the relationship between the immune system and cardiovascular disease can inform targeted diagnostic and treatment approaches. In this review, we discuss the current understanding of pediatric immune-associated cardiac diseases, challenges in the field, and areas of research with potential for clinical benefit.

What Lies Ahead for Young Hearts in the 21st Century - Is It Double Trouble of Acute Rheumatic Fever and Kawasaki Disease in Developing Countries?

Rheumatic heart disease (RHD), the principal long-term sequel of acute rheumatic fever (ARF), has been a major contributor to cardiac-related mortality in general population, especially in developing countries. With improvement in health and sanitation facilities across the globe, there has been almost a 50% reduction in mortality rate due to RHD over the last 25 years. However, recent estimates suggest that RHD still results in more than 300,000 deaths annually. In India alone, more than 100,000 deaths occur due to RHD every year (Watkins DA et al., N Engl J Med, 2017). Children and adolescents (aged below 15 years) constitute at least one-fourth of the total population in India. Besides, ARF is, for the most part, a pediatric disorder. The pediatric population, therefore, requires special consideration in developing countries to reduce the burden of RHD. In the developed world, Kawasaki disease (KD) has emerged as the most important cause of acquired heart disease in children. Mirroring global trends over the past two decades, India also has witnessed a surge in the number of cases of KD. Similarly, many regions across the globe classified as “high-risk” for ARF have witnessed an increasing trend in the incidence of KD. This translates to a double challenge faced by pediatric health care providers in improving cardiac outcomes of children affected with ARF or KD. We highlight this predicament by reviewing the incidence trends of ARF and KD over the last 50 years in ARF “high-risk” regions.

The use of cardiac valve procedures for rheumatic heart disease in Australia; a cross-sectional study 2002-2017

Background

Australia, although a high income economy, carries a significant burden of rheumatic heart disease (RHD). Acute rheumatic fever (ARF) and RHD are endemic in the Indigenous population. Immigrants from low/lower-income countries (‘non-Indigenous high-risk’) are also at increased risk compared with ‘non-Indigenous low-risk’ Australians. This study describes the utilisation of surgical and percutaneous procedures for RHD-related valve disease among patients aged less than 50 years, from 2002 to 2017.

Methods

A descriptive study using data from the ‘End RHD in Australia: Study of Epidemiology (ERASE) Project’ linking RHD Registers and hospital inpatient data from five states/territories, and two surgical databases. Trends across three-year periods were determined and post-procedural all-cause 30-day mortality calculated.

Results

A total of 3900 valves interventions were undertaken in 3028 procedural episodes among 2487 patients. Over 50% of patients were in the 35–49 years group, and 64% were female. Over 60% of procedures for 3-24 year-olds were for Indigenous patients. There were few significant changes across the study period other than downward trends in the number and proportion of procedures for young Indigenous patients (3–24 years) and ‘non-Indigenous/low risk’ patients aged ≥35 years. Mitral valve procedures predominated, and multi-valve interventions increased, including on the tricuspid valve. The majority of replacement prostheses were mechanical, although bioprosthetic valve use increased overall, being highest among females <35 years and Indigenous Australians. All-cause mortality (n = 42) at 30-days was 1.4% overall (range 1.1–1.7), but 2.0% for Indigenous patients.

Conclusions

The frequency of cardiac valve procedures, and 30-day mortality remained steady across 15 years. Some changes in the distribution of procedures in population groups were evident. Replacement procedures, the use of bioprosthetic valves, and multiple-valve interventions increased. The challenge for Australian public health officials is to reduce the incidence, and improve the early detection and management of ARF/RHD in high-risk populations within Australia.

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Epidemic RHD in Indigenous Australians drives RHD-related cardiac valve procedures.

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30-day mortality post-procedural is low in those under 50 years.

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Bioprosthetic valve replacements higher in young women, and increasing in older patients.

Congenital Heart Disease in Low- and Lower-Middle-Income Countries: Current Status and New Opportunities

PURPOSE OF REVIEW

The paper summarises the most recent data on congenital heart disease (CHD) in low- and lower-middle-income countries (LLMICs). In addition, we present an approach to diagnosis, management and interventions in these regions and present innovations, research priorities and opportunities to improve outcomes and develop new programs.

RECENT FINDINGS

The reported birth prevalence of CHD in LLMICs is increasing, with clear evidence of the impact of surgical intervention on the burden of disease. New methods of teaching and training are demonstrating improved outcomes. Local capacity building remains the key. There is a significant gap in epidemiological and outcomes data in CHD in LLMICs. Although the global agenda still does not address the needs of children with CHD adequately, regional initiatives are focusing on quality improvement and context-specific interventions. Future research should focus on epidemiology and the use of innovative thinking and partnerships to provide low-cost, high-impact solutions.

Acquired heart disease in children is not necessarily rheumatic

Acquired heart diseases (AHD) cause significant morbidity and mortality in children. There are limited studies on their burden in children. We conducted a retrospective study of 85 consecutive children diagnosed with AHD using clinical evaluation and echocardiography at Medical College, Kanpur, India to determine the aetiology and outcome of AHD in children. We found rheumatic heart disease (RHD) in one-third, cardiomyopathies or myocarditis combined in a further third and the remaining third were other causes, including pericardial diseases and metabolic or genetic disorders. These latter diseases were frequently misdiagnosed, causing significant morbidity and mortality. Hence, in children of all age groups presenting with unexplained shock, dyspnoea, hepatomegaly and ascites, cardiac status should be carefully and critically evaluated so that non-rheumatic AHD may not be missed.