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Elisa E, Bramantono B, Arfijanto MV, Rusli M, Sandra DY, Sutanto H. Structural heart disease in the tropics: A comprehensive review. Curr Probl Cardiol 2024; 50:102975. [PMID: 39706389 DOI: 10.1016/j.cpcardiol.2024.102975] [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: 12/16/2024] [Accepted: 12/17/2024] [Indexed: 12/23/2024]
Abstract
Structural heart disease (SHD) remains a significant global health challenge, disproportionately impacting populations in tropical regions where the burden of infectious diseases, limited healthcare infrastructure, and socio-economic disparities exacerbate the issue. The tropics are uniquely affected by conditions such as rheumatic heart disease (RHD), endomyocardial fibrosis, tropical cardiomyopathies, and pericardial diseases, often resulting from or complicated by endemic infections like malaria, dengue, tuberculosis, and parasitic diseases. Moreover, Human Immunodeficiency Virus-Associated Cardiac Disease (HIVAC) represents an emerging concern in regions with high HIV prevalence, adding complexity to the interplay between infectious and structural cardiac conditions. Despite the significant morbidity and mortality associated with SHD in these areas, research and clinical focus have often been inadequate, underscoring the need for a comprehensive synthesis of available evidence to guide future efforts. This review aims to provide a detailed examination of SHD in the tropics, with a focus on valvular, myocardial, and pericardial diseases linked to tropical infections and conditions. It highlights the epidemiology, pathophysiology, and clinical presentation of key diseases, including RHD, endocarditis, Chagas disease, and HIVAC, as well as other less commonly recognized tropical cardiomyopathies and pericardial disorders. The review also explores diagnostic challenges, advances in imaging and molecular tools, and the role of public health interventions and policy in addressing these conditions. By synthesizing current knowledge and identifying gaps, this review aims to inform research priorities, improve clinical care, and support the development of tailored prevention and management strategies for SHD in resource-constrained tropical settings.
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Affiliation(s)
- Elisa Elisa
- Internal Medicine Study Program, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia; Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia
| | - Bramantono Bramantono
- Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia; Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia.
| | - Muhammad Vitanata Arfijanto
- Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia; Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
| | - Musofa Rusli
- Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia; Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
| | - Debi Yulia Sandra
- Internal Medicine Study Program, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia; Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia
| | - Henry Sutanto
- Internal Medicine Study Program, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia; Department of Internal Medicine, Dr. Soetomo General Academic Hospital, Surabaya 60286, Indonesia
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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 PMCID: PMC11330716 DOI: 10.1016/j.ahj.2024.05.012] [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] [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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Katzenellenbogen JM, Bond‐Smith D, Seth RJ, Dempsey K, Cannon J, Stacey I, Wade V, de Klerk N, Greenland M, Sanfilippo FM, Brown A, Carapetis JR, Wyber R, Nedkoff L, Hung J, Bessarab D, Ralph AP. Contemporary Incidence and Prevalence of Rheumatic Fever and Rheumatic Heart Disease in Australia Using Linked Data: The Case for Policy Change. J Am Heart Assoc 2020; 9:e016851. [PMID: 32924748 PMCID: PMC7792417 DOI: 10.1161/jaha.120.016851] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/10/2020] [Indexed: 12/30/2022]
Abstract
Background In 2018, the World Health Organization prioritized control of acute rheumatic fever (ARF) and rheumatic heart disease (RHD), including disease surveillance. We developed strategies for estimating contemporary ARF/RHD incidence and prevalence in Australia (2015-2017) by age group, sex, and region for Indigenous and non-Indigenous Australians based on innovative, direct methods. Methods and Results This population-based study used linked administrative data from 5 Australian jurisdictions. A cohort of ARF (age <45 years) and RHD cases (<55 years) were sourced from jurisdictional ARF/RHD registers, surgical registries, and inpatient data. We developed robust methods for epidemiologic case ascertainment for ARF/RHD. We calculated age-specific and age-standardized incidence and prevalence. Age-standardized rate and prevalence ratios compared disease burden between demographic subgroups. Of 1425 ARF episodes, 72.1% were first-ever, 88.8% in Indigenous people and 78.6% were aged <25 years. The age-standardized ARF first-ever rates were 71.9 and 0.60/100 000 for Indigenous and non-Indigenous populations, respectively (age-standardized rate ratio=124.1; 95% CI, 105.2-146.3). The 2017 Global Burden of Disease RHD prevalent counts for Australia (<55 years) underestimate the burden (1518 versus 6156 Australia-wide extrapolated from our study). The Indigenous age-standardized RHD prevalence (666.3/100 000) was 61.4 times higher (95% CI, 59.3-63.5) than non-Indigenous (10.9/100 000). Female RHD prevalence was double that in males. Regions in northern Australia had the highest rates. Conclusions This study provides the most accurate estimates to date of Australian ARF and RHD rates. The high Indigenous burden necessitates urgent government action. Findings suggest RHD may be underestimated in many high-resource settings. The linked data methods outlined here have potential for global applicability.
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Affiliation(s)
| | | | | | - Karen Dempsey
- Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia
| | | | | | - Vicki Wade
- Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia
| | - Nicholas de Klerk
- The University of Western AustraliaPerthAustralia
- Telethon Kids InstitutePerthAustralia
| | | | | | - Alex Brown
- Telethon Kids InstitutePerthAustralia
- South Australian Medical Research InstituteAdelaideAustralia
- The University of AdelaideAustralia
| | | | - Rosemary Wyber
- Telethon Kids InstitutePerthAustralia
- The George Institute for Global HealthSydneyNew South WalesAustralia
| | - Lee Nedkoff
- The University of Western AustraliaPerthAustralia
| | - Joe Hung
- The University of Western AustraliaPerthAustralia
| | | | - Anna P. Ralph
- Menzies School of Health ResearchCharles Darwin UniversityDarwinAustralia
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