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Rwebembera J, Ndagire E, Carvalho N, Webel AR, Sable C, Okello E, Sarnacki R, Spaziani AM, Mucunguzi A, Engelman D, Grobler A, Steer A, Beaton A. Intramuscular versus enteral penicillin prophylaxis to prevent progression of rheumatic heart disease: Study protocol for a noninferiority randomized trial (the GOALIE trial). Am Heart J 2024; 275:74-85. [PMID: 38797460 DOI: 10.1016/j.ahj.2024.05.012] [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: 03/13/2024] [Revised: 05/21/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Rheumatic Heart Disease (RHD) persists as a major cardiovascular driver of mortality and morbidity among young people in low-and middle-income countries. Secondary antibiotic prophylaxis (SAP) with penicillin remains the cornerstone of RHD control, however, suboptimal treatment adherence undermines most secondary prevention programs. Many of the barriers to optimal SAP adherence are specific to the intramuscular form of penicillin and may potentially be overcome by use of oral penicillin. This noninferiority trial is comparing the efficacy of intramuscular to oral penicillin SAP to prevent progression of mild RHD at 2 years. METHODS/DESIGN The Intramuscular vs Enteral Penicillin Prophylaxis to Prevent Progression of Rheumatic Heart Disease (GOALIE) trial is randomizing Ugandan children aged 5 to 17 years identified by echocardiographic screening with mild RHD (Stage A or B as defined by 2023 World Heart Federation criteria) to Benzathine Benzyl Penicillin G (BPG arm, every-28-day intramuscular penicillin) or Phenoxymethyl Penicillin (Pen V arm, twice daily oral penicillin) for a period of 2 years. A blinded echocardiography adjudication panel of 3 RHD experts and 2 cardiologists is determining the echocardiographic stage of RHD at enrollment and will do the same at study completion by consensus review. Treatment adherence and study retention are supported through peer support groups and case management strategies. The primary outcome is the proportion of children in the Pen V arm who progress to more advanced RHD compared to those in the BPG arm. Secondary outcomes are patient-reported outcomes (treatment acceptance, satisfaction, and health related quality of life), costs, and cost-effectiveness of oral compared to intramuscular penicillin prophylaxis for RHD. A total sample size of 1,004 participants will provide 90% power to demonstrate noninferiority using a margin of 4% with allowance for 7% loss to follow-up. Participant enrollment commenced in October 2023 and final participant follow-up is expected in December 2026. The graphical abstract (Fig. 1) summarizes the flow of echocardiographic screening, participant enrollment and follow-up. DISCUSSION The GOALIE trial is critical in global efforts to refine a pragmatic approach to secondary prevention for RHD control. GOALIE insists that the inferiority of oral penicillin be proven contemporarily and against the most important near-term clinical outcome of progression of RHD severity. This work also considers other factors that could influence the adoption of oral prophylaxis and change the calculus for acceptable efficacy including patient-reported outcomes and costs. TRIAL REGISTRATION ClinicalTrials.gov: NCT05693545.
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Affiliation(s)
- Joselyn Rwebembera
- Division of Adult Cardiology, Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda.
| | - Emma Ndagire
- Division of Paediatric Cardiology, Department of Paediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Natalie Carvalho
- Economics of Global Health and Infectious Diseases Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Allison R Webel
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, Washington
| | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Emmy Okello
- Division of Adult Cardiology, Department of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Rachel Sarnacki
- Global Cardiology Research Initiative, Children's National Hospital, Washington, DC
| | - Alison M Spaziani
- Global Cardiology Research Initiative, Children's National Hospital, Washington, DC
| | - Atukunda Mucunguzi
- Department of Finance and Administration, Rheumatic Heart Disease Research Collaborative in Uganda, Uganda Heart Institute, Kampala, Uganda
| | - Daniel Engelman
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Children's Global Health Initiative, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Anneke Grobler
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - Andrew Steer
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Children's Global Health Initiative, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Andrea Beaton
- Department of Paediatrics, School of Medicine, University of Cincinnati, Cincinnati, OH; Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH
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Morais H, da Silva Ferreira H. Prevalence of rheumatic heart disease diagnosed according to the echocardiographic criteria of the World Heart Federation in Africa: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00494-9. [PMID: 38777673 DOI: 10.1016/j.carrev.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/02/2024] [Accepted: 05/18/2024] [Indexed: 05/25/2024]
Abstract
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.
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Affiliation(s)
- Humberto Morais
- Department of Cardiology, Hospital Militar Principal/Instituto Superior, Luanda, Angola
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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de Loizaga S, Benashley L, Hoekzema J, Ahmed N, Alexander C, Bolger A, Evers PD, Hill GD, Nakagaayi D, Nashio JT, Nunes MCP, Sable C, Tacuri LM, Danforth K, Beaton A, Close R. Deployment of Point-of-Care Echocardiography to Improve Cardiac Diagnostic Access Among American Indians. J Am Heart Assoc 2024; 13:e031231. [PMID: 38226505 PMCID: PMC10926791 DOI: 10.1161/jaha.123.031231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/08/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND American Indians face significant barriers to diagnosis and management of cardiovascular disease. We sought to develop a real-world implementation model for improving access to echocardiography within the Indian Health Service, the American Indian Structural Heart Disease Partnership. METHODS AND RESULTS The American Indian Structural Heart Disease Partnership was implemented and evaluated via a 4-step process of characterizing the system where it would be instituted, building point-of-care echocardiography capacity, deploying active case finding for structural heart disease, and evaluating the approach from the perspective of the clinician and patient. Data were collected and analyzed using a parallel convergent mixed methods approach. Twelve health care providers successfully completed training in point-of-care echocardiography. While there was perceived usefulness of echocardiography, providers found it difficult to integrate screening point-of-care echocardiography into their workday given competing demands. By the end of 12 months, 6 providers continued to actively utilize point-of-care echocardiography. Patients who participated in the study felt it was an acceptable and effective approach. They also identified access to transportation as a notable challenge to accessing echocardiograms. Over the 12-month period, a total of 639 patients were screened, of which 36 (5.6%) had a new clinically significant abnormal finding. CONCLUSIONS The American Indian Structural Heart Disease Partnership model exhibited several promising strategies to improve access to screening echocardiography for American Indian populations. However, competing priorities for Indian Health Service providers' time limited the amount of integration of screening echocardiography into outpatient practice. Future endeavors should explore community-based solutions to develop a more sustainable model with greater impact on case detection, disease management, and improved outcomes.
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Affiliation(s)
- Sarah de Loizaga
- Cincinnati Children’s Hospital Medical CenterCincinnatiOH
- University of CincinnatiCincinnatiOH
| | | | - Jacob Hoekzema
- Cincinnati Children’s Hospital Medical CenterCincinnatiOH
| | | | - Craig Alexander
- Cincinnati Children’s Hospital Medical CenterCincinnatiOH
- University of CincinnatiCincinnatiOH
| | - Ann Bolger
- Department of MedicineUniversity of CaliforniaSan FranciscoCA
| | | | - Garick D. Hill
- Cincinnati Children’s Hospital Medical CenterCincinnatiOH
- University of CincinnatiCincinnatiOH
| | | | | | - Maria Carmo Pereira Nunes
- Hospital das Clinicas da UFMGBelo HorizonteMinas GeraisBrazil
- Departamento de Clinica MedicaFaculdade de Medicina da Universidade Federal de Minas GeraisBelo HorizonteMinas GeraisBrazil
| | | | - Luz Marina Tacuri
- Hospital das Clinicas da UFMGBelo HorizonteMinas GeraisBrazil
- Departamento de Clinica MedicaFaculdade de Medicina da Universidade Federal de Minas GeraisBelo HorizonteMinas GeraisBrazil
| | | | - Andrea Beaton
- Cincinnati Children’s Hospital Medical CenterCincinnatiOH
- University of CincinnatiCincinnatiOH
| | - Ryan Close
- Indian Health Service HospitalWhiteriverAZ
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Ogungbe O, Longenecker CT, Beaton A, de Loizaga S, Brant LCC, Turkson Ocran RN, Bastani P, Sarfo FS, Commodore‐Mensah Y. Advancing Cardiovascular Health Equity Globally Through Digital Technologies. J Am Heart Assoc 2024; 13:e031237. [PMID: 38226506 PMCID: PMC10926780 DOI: 10.1161/jaha.123.031237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/30/2023] [Indexed: 01/17/2024]
Abstract
Cardiovascular diseases (CVDs) remain the leading cause of death and disability worldwide. Digital health technologies are important public health interventions for addressing the burden of cardiovascular disease. In this article, we discuss the importance of translating digital innovations in research-funded projects to low-resource settings globally to advance global cardiovascular health equity. We also discuss current global cardiovascular health inequities and the digital health divide within and between countries. We present various considerations for translating digital innovations across different settings across the globe, including reciprocal innovation, a "bidirectional, co-constituted, and iterative exchange of ideas, resources, and innovations to address shared health challenges across diverse global settings." In this case, afferent reciprocal innovations may flow from high-income countries toward low- and middle-income countries, and efferent reciprocal innovations may be exported to high-income countries from low- and middle-income countries with adaptation. Finally, we discuss opportunities for bidirectional learning between local and global institutions and highlight examples of projects funded through the American Heart Association Health and Innovation Strategically Funded Research Network that have been adapted to lower-resource settings or have the potential to be adapted to lower-resource settings.
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Affiliation(s)
| | - Chris T. Longenecker
- Division of Cardiology and Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Andrea Beaton
- Heart Institute, Cincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Sarah de Loizaga
- Heart Institute, Cincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- University of Cincinnati College of MedicineCincinnatiOHUSA
| | - Luisa Campos Caldeira Brant
- Faculty of Medicine and Telehealth Center, Hospital das ClínicasUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Ruth‐Alma N. Turkson Ocran
- Beth Israel Deaconess Medical Center, Division of General MedicineBostonMAUSA
- Havard Medical SchoolBostonMAUSA
| | - Pouya Bastani
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Fred Stephen Sarfo
- Division of Neurology, Department of MedicineKwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Yvonne Commodore‐Mensah
- Johns Hopkins School of NursingBaltimoreMDUSA
- Department of EpidemiologyBloomberg School of Public HealthBaltimoreMDUSA
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Nakagaayi D, Pulle J, Otim I, Akiya OC, Otto OH, Danforth K, Longenecker CT, Ollberding N, Sarnacki R, Nakitto M, Buonfiglio S, Rwebembera J, Sable C, Sherr K, Su Y, Webel A, Beaton A, Okello E, Watkins D. A decentralized delivery program for rheumatic heart disease treatment and prevention in Uganda. Nat Med 2024; 30:12-13. [PMID: 38167934 PMCID: PMC11160171 DOI: 10.1038/s41591-023-02646-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Doreen Nakagaayi
- Department of Adult Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda.
| | - Jafesi Pulle
- Department of Research, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Isaac Otim
- Department of Research, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | | | | | - Kristen Danforth
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Chris T Longenecker
- Department of Global Health, University of Washington, Seattle, WA, USA
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Nicholas Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Miriam Nakitto
- Department of Research, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Samantha Buonfiglio
- Department of Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joselyn Rwebembera
- Department of Adult Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Craig Sable
- Children's National Hospital, Washington, DC, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Yanfang Su
- School of Nursing, University of Washington, Seattle, WA, USA
| | - Allison Webel
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Andrea Beaton
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Emmy Okello
- Department of Adult Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - David Watkins
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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Karthikeyan G, Watkins D, Bukhman G, Cunningham MW, Haller J, Masterson M, Mensah GA, Mocumbi A, Muhamed B, Okello E, Sotoodehnia N, Machipisa T, Ralph A, Wyber R, Beaton A. Research priorities for the secondary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report. BMJ Glob Health 2023; 8:e012468. [PMID: 37914183 PMCID: PMC10618973 DOI: 10.1136/bmjgh-2023-012468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/14/2023] [Indexed: 11/03/2023] Open
Abstract
Secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) involves continuous antimicrobial prophylaxis among affected individuals and is recognised as a cornerstone of public health programmes that address these conditions. However, several important scientific issues around the secondary prevention paradigm remain unresolved. This report details research priorities for secondary prevention that were developed as part of a workshop convened by the US National Heart, Lung, and Blood Institute in November 2021. These span basic, translational, clinical and population science research disciplines and are built on four pillars. First, we need a better understanding of RHD epidemiology to guide programmes, policies, and clinical and public health practice. Second, we need better strategies to find and diagnose people affected by ARF and RHD. Third, we urgently need better tools to manage acute RF and slow the progression of RHD. Fourth, new and existing technologies for these conditions need to be better integrated into healthcare systems. We intend for this document to be a reference point for research organisations and research sponsors interested in contributing to the growing scientific community focused on RHD prevention and control.
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Affiliation(s)
| | - David Watkins
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Program in Global Noncommunicable Diseases and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - John Haller
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Mary Masterson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - George A Mensah
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Ana Mocumbi
- Non-Communicable Diseases Division, Instituto Nacional de Saúde, Marracuene, Mozambique
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Babu Muhamed
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Emmy Okello
- Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, University of Washington, Seattle, Washington, USA
| | - Tafadzwa Machipisa
- Cape Heart Institute (CHI), Department of Medicine, University of Cape Town, Rondebosch, South Africa
- Clinical Research Laboratory & Biobank-Genetic & Molecular Epidemiology Laboratory (CRLB-GMEL), Population Health Research Institute, Hamilton, Ontario, Canada
| | - Anna Ralph
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Rosemary Wyber
- END RHD Program, Telethon Kids Institute, Perth, Western Australia, Australia
- National Centre for Aboriginal and Torres Strait Islander Wellbeing Research, Canberra, Australian Capital Territory, Australia
| | - Andrea Beaton
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Mebrahtom G, Hailay A, Aberhe W, Zereabruk K, Haile T. Rheumatic Heart Disease in East Africa: A Systematic Review and Meta-Analysis. Int J Rheumatol 2023; 2023:8834443. [PMID: 37767221 PMCID: PMC10522432 DOI: 10.1155/2023/8834443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/01/2023] [Accepted: 08/14/2023] [Indexed: 09/29/2023] Open
Abstract
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.
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Affiliation(s)
- Guesh Mebrahtom
- Department of Adult Health Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
| | - Abrha Hailay
- Department of Adult Health Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
| | - Woldu Aberhe
- Department of Adult Health Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
| | - Kidane Zereabruk
- Department of Adult Health Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
| | - Teklehaimanot Haile
- Department of Maternity and Neonatal Nursing, School of Nursing, Aksum University, Aksum, Ethiopia
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Webb R, Culliford-Semmens N, ChanMow A, Doughty R, Tilton E, Peat B, Stirling J, Gentles TL, Wilson NJ. High burden of rheumatic heart disease confirmed by echocardiography among Pacific adults living in New Zealand. Open Heart 2023; 10:openhrt-2023-002253. [PMID: 37121603 DOI: 10.1136/openhrt-2023-002253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/29/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Despite numerous echocardiographic screening studies of children in high incidence acute rheumatic fever (ARF)/rheumatic heart disease (RHD) communities, little is known about the prevalence of RHD in adults in these populations.We sought to determine the prevalence of RHD in an urban area of South Auckland, New Zealand, where previous studies had shown the prevalence of RHD in children to be around 2%. METHODS A cross-sectional screening study was conducted between 2014 and 2016. Echocardiography clinics were conducted at an urban Pacific-led primary healthcare clinic in New Zealand. Eligible persons aged 16-40 years were recruited according to a stratified randomised approach. Echocardiograms were performed with a standardised image acquisition protocol and reported by cardiologists. RESULTS There were 465 individuals who underwent echocardiograms. The overall prevalence of RHD (define and borderline) was 56 per 1000 (95% CI 36 to 78 per 1000). Definite RHD was found in 10 individuals (4 of whom were already under cardiology review at a hospital clinic) with a prevalence of 22 per 1000 (95% CI 9 to 36 per 1000). Non-rheumatic cardiac abnormalities were found in 29 individuals. CONCLUSIONS There is a high burden of both rheumatic and non-rheumatic cardiac abnormalities in this population. Rates described in New Zealand are as high as lower-middle-income countries in Africa. Addressing knowledge gaps regarding the natural history of RHD detected by echocardiography in adults is a priority issue for the international RHD community.
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Affiliation(s)
- Rachel Webb
- Department of Paediatrics: Child and Youth Health, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- Kidz First Children's Hospital, Te Whatu Ora, Counties Manukau, Auckland, New Zealand
- Department of Paediatric Infectious Diseases, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Nicola Culliford-Semmens
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Andrew ChanMow
- South Seas Health Care Integrated Family Health Centre, Manukau, New Zealand
| | - Robert Doughty
- Department of Medicine, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Elizabeth Tilton
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Briar Peat
- Department of Medicine, South Auckland Clinical School, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - John Stirling
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Thomas L Gentles
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
| | - Nigel J Wilson
- Department of Paediatric and Congenital Cardiac Services, Te Whatu Ora, Starship Children's Hospital, Auckland, New Zealand
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1155] [Impact Index Per Article: 1155.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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11
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Miller KM, Carapetis JR, Cherian T, Hay R, Marks M, Pickering J, Cannon JW, Lamagni T, Romani L, Moore HC, Van Beneden CA, Barth DD, Bowen AC, Carapetis J, Van Beneden C, Kaslow D, Cherian T, Lamagni T, Engel M, Cannon J, Moore H, Bowen A, Seale A, Kang G, Watkins D, Kariuki S. Standardization of Epidemiological Surveillance of Group A Streptococcal Impetigo. Open Forum Infect Dis 2022; 9:S15-S24. [PMID: 36128409 PMCID: PMC9474945 DOI: 10.1093/ofid/ofac249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Impetigo is a highly contagious bacterial infection of the superficial layer of skin. Impetigo is caused by group A Streptococcus (Strep A) and Staphylococcus aureus, alone or in combination, with the former predominating in many tropical climates. Strep A impetigo occurs mainly in early childhood, and the burden varies worldwide. It is an acute, self-limited disease, but many children experience frequent recurrences that make it a chronic illness in some endemic settings. We present a standardized surveillance protocol including case definitions for impetigo including both active (purulent, crusted) and resolving (flat, dry) phases and discuss the current tests used to detect Strep A among persons with impetigo. Case classifications that can be applied are detailed, including differentiating between incident (new) and prevalent (existing) cases of Strep A impetigo. The type of surveillance methodology depends on the burden of impetigo in the community. Active surveillance and laboratory confirmation is the preferred method for case detection, particularly in endemic settings. Participant eligibility, surveillance population and additional considerations for surveillance of impetigo, including examination of lesions, use of photographs to document lesions, and staff training requirements (including cultural awareness), are addressed. Finally, the core elements of case report forms for impetigo are presented and guidance for recording the course and severity of impetigo provided.
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Affiliation(s)
- Kate M Miller
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia , Perth, Western Australia , Australia
| | - Jonathan R Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia , Perth, Western Australia , Australia
- Perth Children’s Hospital , Perth, Western Australia , Australia
| | | | - Roderick Hay
- St John’s Institute of Dermatology, King’s College London , United Kingdom
| | - Michael Marks
- Clinical Research Department, Faculty of Infectious Diseases, London School of Hygiene and Tropical Medicine , London , United Kingdom
- Hospital for Tropical Diseases, University College , London , United Kingdom
- Division of Infection and Immunity, University College London , London , United Kingdom
| | - Janessa Pickering
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia , Perth, Western Australia , Australia
| | - Jeffrey W Cannon
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia , Perth, Western Australia , Australia
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health , Boston, Massachusetts , USA
| | - Theresa Lamagni
- United Kingdom Health Security Agency , London , United Kingdom
| | - Lucia Romani
- The Kirby Institute, University of New South Wales Sydney , Sydney , Australia
- Murdoch Children’s Research Group , Melbourne , Australia
| | - Hannah C Moore
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia , Perth, Western Australia , Australia
| | - Chris A Van Beneden
- CDC Foundation, Centers for Disease Control and Prevention , Atlanta, Georgia , USA
| | - Dylan D Barth
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia , Perth, Western Australia , Australia
| | - Asha C Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia , Perth, Western Australia , Australia
- Perth Children’s Hospital , Perth, Western Australia , Australia
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Zimmerman M, Kitooleko S, Okello E, Ollberding N, Sinha P, Mwambu T, Sable C, Beaton A, Longenecker C, Lwabi P. Clinical outcomes of children with rheumatic heart disease. Heart 2022; 108:633-638. [PMID: 35110387 PMCID: PMC9221000 DOI: 10.1136/heartjnl-2021-320356] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/19/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To evaluate the long-term clinical outcomes of children with rheumatic heart disease (RHD) in Uganda, and determine characteristics that predict adverse outcomes. METHODS This retrospective cohort study evaluated the risk of death in Ugandan children with clinical RHD from 2010 to 2018; enrolling children aged 5-18 years old from an existing registry. Demographic data and clinical data (baseline complications, RHD severity, cardiac interventions) were collected. The primary outcome was survival. Univariable and multivariable hazard ratios (HR) were obtained from Cox proportional hazards regression. Survival probabilities were developed using Kaplan-Meier curves; log-rank tests compared survival based on cardiac interventions, disease severity and time of enrolment. RESULTS 612 cases met inclusion criteria; median age 12.8 years (IQR 5.3), 37% were male. Thirty-one per cent (187 of 612) died during the study period; median time to death 7.8 months (IQR 18.3). In univariable analysis, older age (HR 1.26, 95% CI=1.0 to 1.58), presence of baseline complications (HR 2.06, 95% CI=1.53 to 2.78) and severe RHD (HR 5.21, 95% CI=2.15 to 12.65) were associated with mortality. Cardiac intervention was associated with a lower risk of mortality (HR 0.06, 95% CI=0.02 to 0.24). In multivariable models, baseline complications (HR 1.78, 95% CI=1.31 to 2.41), severe RHD (HR 4.58, 95% CI=1.87 to 11.23) and having an intervention (HR 0.05, 95% CI=0.01 to 0.21) remained statistically significant. Kaplan-Meier survival curves demonstrated >25% mortality in the first 30 months, with significant differences in mortality based on intervention status and severity of disease. CONCLUSIONS The mortality rate of children with clinical RHD in Uganda exceeds 30%, over an 8-year time frame, despite in-country access to cardiac interventions. Children at highest risk were those with cardiac complications at baseline and severe RHD.
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Affiliation(s)
- Meghan Zimmerman
- Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | | | - Emmy Okello
- Cardiology, Uganda Heart Institute, Kampala, Uganda
- Makerere University, Kampala, Uganda
| | - Nicholas Ollberding
- Rehabilitation, Exercise, and Nutrition Sciences, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Pranava Sinha
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Pediatric Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Tom Mwambu
- Cardiology, Uganda Heart Institute, Kampala, Uganda
- Makerere University, Kampala, Uganda
| | - Craig Sable
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Pediatric Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Andrea Beaton
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Chris Longenecker
- Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Peter Lwabi
- Cardiology, Uganda Heart Institute, Kampala, Uganda
- Makerere University, Kampala, Uganda
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Rwebembera J, Nascimento BR, Minja NW, de Loizaga S, Aliku T, dos Santos LPA, Galdino BF, Corte LS, Silva VR, Chang AY, Dutra WO, Nunes MCP, Beaton AZ. Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum. Pathogens 2022; 11:pathogens11020179. [PMID: 35215123 PMCID: PMC8878614 DOI: 10.3390/pathogens11020179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts. The neglect of RHD which persisted for a semi-centennial was further driven by competing infectious diseases, particularly the human immunodeficiency virus (HIV) pandemic. However, over the last two-decades, slowly at first but with building momentum, there has been a resurgence of interest in RF/RHD. In this narrative review, we present the advances that have been made in the RF/RHD continuum over the past two decades since the re-awakening of interest, with a more concise focus on the last decade’s achievements. Such primary advances include understanding the genetic predisposition to RHD, group A Streptococcus (GAS) vaccine development, and improved diagnostic strategies for GAS pharyngitis. Echocardiographic screening for RHD has been a major advance which has unearthed the prevailing high burden of RHD and the recent demonstration of benefit of secondary antibiotic prophylaxis on halting progression of latent RHD is a major step forward. Multiple befitting advances in tertiary management of RHD have also been realized. Finally, we summarize the research gaps and provide illumination on profitable future directions towards global eradication of RHD.
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Affiliation(s)
- Joselyn Rwebembera
- Department of Adult Cardiology (JR), Uganda Heart Institute, Kampala 37392, Uganda
- Correspondence: or ; Tel.: +256-779010527
| | - Bruno Ramos Nascimento
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Neema W. Minja
- Rheumatic Heart Disease Research Collaborative in Uganda, Uganda Heart Institute, Kampala 37392, Uganda;
| | - Sarah de Loizaga
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
| | - Twalib Aliku
- Department of Paediatric Cardiology (TA), Uganda Heart Institute, Kampala 37392, Uganda;
| | - Luiza Pereira Afonso dos Santos
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Bruno Fernandes Galdino
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Luiza Silame Corte
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Vicente Rezende Silva
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Andrew Young Chang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Walderez Ornelas Dutra
- Laboratory of Cell-Cell Interactions, Institute of Biological Sciences, Department of Morphology, Federal University of Minas Gerais, Belo Horizonte 30130-100, MG, Brazil;
- National Institute of Science and Technology in Tropical Diseases (INCT-DT), Salvador 40170-970, BA, Brazil
| | - Maria Carmo Pereira Nunes
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Andrea Zawacki Beaton
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
- Cincinnati Children’s Hospital Medical Center, The Heart Institute, Cincinnati, OH 45229, USA
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14
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2369] [Impact Index Per Article: 1184.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Abstract
PURPOSE OF REVIEW Rheumatic heart disease (RHD) is a neglected disease of poverty, which presents challenges for patients, communities, and health systems. These effects are magnified in low resource countries, which bear the highest disease burden. When considering the impact of RHD, it is imperative that we widen our lens in order to better understand how RHD impacts the over 40 million people currently living with this preventable condition and their communities. We aimed to perform an updated literature review on the global impact of RHD, examining a broad range of aspects from disease burden to impact on healthcare system to socioeconomic implications. RECENT FINDINGS RHD accounts for 1.6% of all cardiovascular deaths, resulting in 306,000 deaths yearly, with a much higher contribution in low- and middle-income countries, where 82% of the deaths occurred in 2015. RHD can result in severe health adverse outcomes, markedly heart failure, arrhythmias, stroke and embolisms, and ultimately premature death. Thus, preventive, diagnostic and therapeutic interventions are required, although insufficiently available in undersourced settings. As examples, anticoagulation management is poor in endemic regions - and novel oral anticoagulants cannot be recommended - and less than 15% of those in need have access to interventional procedures and valve replacement in Africa. RHD global impact remains high and unequally distributed, with a marked impact on lower resourced populations. This preventable disease negatively affects not only patients, but also the societies and health systems within which they live, presenting broad challenges and high costs along the pathway of prevention, diagnosis, and management.
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16
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Chang AY, Rwebembera J, Bendavid E, Okello E, Barry M, Beaton AZ, Haeffele C, Webel AR, Kityo C, Longenecker CT. Clinical Outcomes, Echocardiographic Findings, and Care Quality Metrics for People Living with HIV and Rheumatic Heart Disease in Uganda. Clin Infect Dis 2021; 74:1543-1548. [PMID: 34382644 DOI: 10.1093/cid/ciab681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Rheumatic Heart Disease (RHD) affects 41 million people worldwide, mostly in low- and middle-income countries, where it is co-endemic with HIV. HIV is also a chronic inflammatory disorder associated with cardiovascular complications, yet the epidemiology of patients affected by both diseases is poorly understood. METHODS Utilizing the Uganda National RHD Registry, we described the echocardiographic findings, clinical characteristics, medication prescription rates, and outcomes of all 73 people carrying concurrent diagnoses of HIV and RHD between 2009 and 2018. These individuals were compared to an age- and sex-matched cohort of 365 subjects with RHD only. RESULTS The median age of the HIV-RHD group was 36 years (IQR 15) and 86% were women. The HIV-RHD cohort had higher rates of prior stroke/transient ischemic attack (12% vs 5%, p=0.02) than the RHD-only group, with this association persisting following multivariable adjustment (OR 3.08, p=0.03). Prevalence of other comorbidities, echocardiographic findings, prophylactic penicillin prescription rates, retention in clinical care, and mortality were similar between the two groups. CONCLUSIONS Patients living with RHD and HIV in Uganda are a relatively young, predominantly female group. Although RHD-HIV comorbid individuals have higher rates of stroke, their similar all-cause mortality and RHD care quality metrics (such as retention in care) compared to those with RHD alone suggest rheumatic heart disease defines their clinical outcome more than HIV does. We believe this study to be one of the first reports of the epidemiologic profile and longitudinal outcomes of patients who carry diagnoses of both conditions.
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Affiliation(s)
- Andrew Y Chang
- Stanford Cardiovascular Institue, Stanford University, Stanford, CA, USA.,Department of Medicine, Stanford University, Stanford, CA, USA.,Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA.,Center for Innovation in Global Health, Stanford University, Stanford, CA, USA
| | | | - Eran Bendavid
- Department of Medicine, Stanford University, Stanford, CA, USA.,Center for Innovation in Global Health, Stanford University, Stanford, CA, USA
| | - Emmy Okello
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | - Michele Barry
- Department of Medicine, Stanford University, Stanford, CA, USA.,Center for Innovation in Global Health, Stanford University, Stanford, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Andrea Z Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center & The University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Christiane Haeffele
- Stanford Cardiovascular Institue, Stanford University, Stanford, CA, USA.,Department of Medicine, Stanford University, Stanford, CA, USA
| | - Allison R Webel
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Chris T Longenecker
- University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
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17
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Kotit S, Phillips DIW, Afifi A, Yacoub M. The "Cairo Accord"- Towards the Eradication of RHD: An Update. Front Cardiovasc Med 2021; 8:690227. [PMID: 34277735 PMCID: PMC8282907 DOI: 10.3389/fcvm.2021.690227] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/07/2021] [Indexed: 01/18/2023] Open
Abstract
Rheumatic heart disease (RHD) is the most common cause of acquired heart disease in children and young adults. It continues to be prevalent in many low- and middle-income countries where it causes significant morbidity and mortality. Following the 2017 Cairo conference "Rheumatic Heart Disease: from Molecules to the Global Community," experts from 21 countries formulated an approach for addressing the problem of RHD: "The Cairo Accord on Rheumatic Heart Disease." The Accord attempts to set policy priorities for the eradication of acute rheumatic fever (ARF) and RHD and builds on a recent series of policy initiatives and calls to action. We present an update on the recommendations of the Cairo Accord and discuss recent progress toward the eradication of RHD, including contributions from our own Aswan Rheumatic Heart Disease Registry (ARGI).
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Affiliation(s)
| | - David I. W. Phillips
- Developmental Origins of Health and Disease Division, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | | | - Magdi Yacoub
- Aswan Heart Centre, Aswan, Egypt
- Heart Science Centre, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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18
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Scheel A, Mirabel M, Nunes MCP, Okello E, Sarnacki R, Steer AC, Engelman D, Zimmerman M, Zühlke L, Sable C, Beaton A. The inter-rater reliability and individual reviewer performance of the 2012 world heart federation guidelines for the echocardiographic diagnosis of latent rheumatic heart disease. Int J Cardiol 2021; 328:146-151. [PMID: 33186665 DOI: 10.1016/j.ijcard.2020.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND In 2012, the World Heart Federation (WHF) published guidelines for the echocardiographic diagnosis of rheumatic heart disease (RHD). This study assesses individual reviewer performance and inter-rater agreement and reliability on the presence of any RHD, as well classification of RHD based on the 2012 WHF criteria. METHODS Four cardiologists individually reviewed echocardiograms in the context of a randomized clinical trial (ClinicalTrials.gov:NCT03346525) and participated in a blinded adjudication panel. Panel decision was the reference standard for diagnosis. Performance of individual reviewers to panel adjudication was compared through sensitivity and specificity analyses and inter-rater reliability was assessed between individual panelists using Fleiss free marginal multirater kappa. RESULTS Echocardiograms from 784 children had two independent reports and panel adjudication. The accuracy of independent reviewers for any RHD had high sensitivity (94%, 95% CI 93-95%) and moderate specificity (62%, 95% CI 53-70%). Sensitivity and specificity for definite RHD was 61.3 (95% CI, 55.3-67.1) and 93.1 (95% CI, 91.6-94.4), with 86.8 (84.7-88.7) and 65.8 (61.0-70.4) for borderline RHD. There was moderate inter-rater agreement (κ = 0.66) on the presence of any RHD while agreement for specific 2012 WHF classification was only fair (κ = 0.51). CONCLUSIONS The 2012 WHF guidelines are moderately reproducible when used by expert cardiologists. More cases of RHD were diagnosed by an consensus panel than by individual reviewers. A revision to the criteria is now warranted to further increase the reliability of the WHF criteria.
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Affiliation(s)
- Amy Scheel
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30329, USA.
| | - Mariana Mirabel
- Université de Paris, Paris Cardiovascular Research Center PARCC, INSERM, 56 Rue Leblanc, 75015 Paris, France; Cardio-oncology unit, AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, 75015 Paris, France.
| | - Maria Carmo Pereira Nunes
- School of Medicine of the Federal University of Minas Gerais, Av. Prof. Alfredo Balena, 190 - Santa Efigênia, Belo Horizonte, MG 30130-100, Brazil.
| | - Emmy Okello
- The Uganda Heart Institute, Block C, Mulago Hospital Complex, Kampala, Uganda
| | - Rachel Sarnacki
- Children's National Hospital, 111 Michigan Ave, NW, Washington, DC, 20010, USA.
| | - Andrew C Steer
- Tropical Diseases, Murdoch Children's Research Institute, Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, 50 Flemington Road Parkville, Victoria, Australia.
| | - Daniel Engelman
- Tropical Diseases, Murdoch Children's Research Institute, Flemington Road, Parkville, Victoria 3052, Australia; Department of Paediatrics, University of Melbourne, 50 Flemington Road Parkville, Victoria, Australia.
| | - Meghan Zimmerman
- Dartmouth Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03766, USA
| | - Liesl Zühlke
- Red Cross War Memorial Children's Hospital, University of Cape Town, Klipfontein Rd, Rondebosch, Cape Town 7700, South Africa
| | - Craig Sable
- Children's National Hospital, 111 Michigan Ave, NW, Washington, DC, 20010, USA.
| | - Andrea Beaton
- Cincinnati Children's Hospital Medical Center, The Heart Institute, 3333 Burnet Ave, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45229, USA.
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Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 3027] [Impact Index Per Article: 1009.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Zimmerman M, Scheel A, DeWyer A, Nambogo JL, Otim IO, Tompsett A, Rwebembera J, Okello E, Sable C, Beaton A. Determining the Risk of Developing Rheumatic Heart Disease Following a Negative Screening Echocardiogram. Front Cardiovasc Med 2021; 8:632621. [PMID: 33644137 PMCID: PMC7906984 DOI: 10.3389/fcvm.2021.632621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/18/2021] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Meghan Zimmerman
- Children's Hospital at Dartmouth Hitchcock, Lebanon, PA, United States.,Dartmouth College, Hanover, IN, United States
| | - Amy Scheel
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Alyssa DeWyer
- School of Medicine, Virginia Tech Carilion, Roanoke, VA, United States
| | | | | | | | | | | | - Craig Sable
- Children's National Hospital, Washington, DC, United States
| | - Andrea Beaton
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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21
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Ndagire E, Kawakatsu Y, Nalubwama H, Atala J, Sarnacki R, Pulle J, Kyarimpa R, Mwima R, Kansiime R, Okello E, Lwabi P, Beaton A, Sable C, Watkins D. Examining the Ugandan health system's readiness to deliver rheumatic heart disease-related services. PLoS Negl Trop Dis 2021; 15:e0009164. [PMID: 33591974 PMCID: PMC7909659 DOI: 10.1371/journal.pntd.0009164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 02/26/2021] [Accepted: 01/20/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda. METHODOLOGY/PRINCIPAL FINDINGS This was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare. CONCLUSIONS/SIGNIFICANCE Uganda's readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.
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Affiliation(s)
- Emma Ndagire
- Uganda Heart Institute, Kampala, Uganda
- Children’s National Hospital, Division of Cardiology, Washington, District of Columbia, United States of America
| | - Yoshito Kawakatsu
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | | | - Rachel Sarnacki
- Children’s National Hospital, Division of Cardiology, Washington, District of Columbia, United States of America
| | | | | | | | | | | | | | - Andrea Beaton
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Craig Sable
- Children’s National Hospital, Division of Cardiology, Washington, District of Columbia, United States of America
- George Washington University School of Medicine, Washington, District of Columbia, United States of America
| | - David Watkins
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Division of General Internal Medicine, University of Washington, Seattle, Washington, United States of America
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Kumar RK, Antunes MJ, Beaton A, Mirabel M, Nkomo VT, Okello E, Regmi PR, Reményi B, Sliwa-Hähnle K, Zühlke LJ, Sable C. Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e337-e357. [PMID: 33073615 DOI: 10.1161/cir.0000000000000921] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.
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Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020; 141:e139-e596. [PMID: 31992061 DOI: 10.1161/cir.0000000000000757] [Citation(s) in RCA: 4758] [Impact Index Per Article: 1189.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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