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Zühlke L, Karthikeyan G, Engel ME, Rangarajan S, Mackie P, Cupido-Katya Mauff B, Islam S, Daniels R, Francis V, Ogendo S, Gitura B, Mondo C, Okello E, Lwabi P, Al-Kebsi MM, Hugo-Hamman C, Sheta SS, Haileamlak A, Daniel W, Goshu DY, Abdissa SG, Desta AG, Shasho BA, Begna DM, ElSayed A, Ibrahim AS, Musuku J, Bode-Thomas F, Yilgwan CC, Amusa GA, Ige O, Okeahialam B, Sutton C, Misra R, Abul Fadl A, Kennedy N, Damasceno A, Sani MU, Ogah OS, Elhassan TOHM, Mocumbi AO, Adeoye AM, Mntla P, Ojji D, Mucumbitsi J, Teo K, Yusuf S, Mayosi BM. Clinical Outcomes in 3343 Children and Adults With Rheumatic Heart Disease From 14 Low- and Middle-Income Countries. Circulation 2016; 134:1456-1466. [DOI: 10.1161/circulationaha.116.024769] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 09/20/2016] [Indexed: 11/16/2022]
Abstract
Background:
There are few contemporary data on the mortality and morbidity associated with rheumatic heart disease or information on their predictors. We report the 2-year follow-up of individuals with rheumatic heart disease from 14 low- and middle-income countries in Africa and Asia.
Methods:
Between January 2010 and November 2012, we enrolled 3343 patients from 25 centers in 14 countries and followed them for 2 years to assess mortality, congestive heart failure, stroke or transient ischemic attack, recurrent acute rheumatic fever, and infective endocarditis.
Results:
Vital status at 24 months was known for 2960 (88.5%) patients. Two-thirds were female. Although patients were young (median age, 28 years; interquartile range, 18–40), the 2-year case fatality rate was high (500 deaths, 16.9%). Mortality rate was 116.3/1000 patient-years in the first year and 65.4/1000 patient-years in the second year. Median age at death was 28.7 years. Independent predictors of death were severe valve disease (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.80–3.11), congestive heart failure (HR, 2.16; 95% CI, 1.70–2.72), New York Heart Association functional class III/IV (HR, 1.67; 95% CI, 1.32–2.10), atrial fibrillation (HR, 1.40; 95% CI, 1.10–1.78), and older age (HR, 1.02; 95% CI, 1.01–1.02 per year increase) at enrollment. Postprimary education (HR, 0.67; 95% CI, 0.54–0.85) and female sex (HR, 0.65; 95% CI, 0.52–0.80) were associated with lower risk of death. Two hundred and four (6.9%) patients had new congestive heart failure (incidence, 38.42/1000 patient-years), 46 (1.6%) had a stroke or transient ischemic attack (8.45/1000 patient-years), 19 (0.6%) had recurrent acute rheumatic fever (3.49/1000 patient-years), and 20 (0.7%) had infective endocarditis (3.65/1000 patient-years). Previous stroke and older age were independent predictors of stroke/transient ischemic attack or systemic embolism. Patients from low- and lower-middle–income countries had significantly higher age- and sex-adjusted mortality than patients from upper-middle–income countries. Valve surgery was significantly more common in upper-middle–income than in lower-middle– or low-income countries.
Conclusions:
Patients with clinical rheumatic heart disease have high mortality and morbidity despite being young; those from low- and lower-middle–income countries had a poorer prognosis associated with advanced disease and low education. Programs focused on early detection and the treatment of clinical rheumatic heart disease are required to improve outcomes.
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Affiliation(s)
- Liesl Zühlke
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Ganesan Karthikeyan
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Mark E. Engel
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Sumathy Rangarajan
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Pam Mackie
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Blanche Cupido-Katya Mauff
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Shofiqul Islam
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Rezeen Daniels
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Veronica Francis
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Stephen Ogendo
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Bernard Gitura
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Charles Mondo
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Emmy Okello
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Peter Lwabi
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Mohammed M. Al-Kebsi
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Christopher Hugo-Hamman
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Sahar S. Sheta
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Abraham Haileamlak
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Wandimu Daniel
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Dejuma Yadeta Goshu
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Senbeta G. Abdissa
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Araya G. Desta
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Bekele A. Shasho
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Dufera M. Begna
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Ahmed ElSayed
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Ahmed S. Ibrahim
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - John Musuku
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Fidelia Bode-Thomas
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Christopher C. Yilgwan
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Ganiyu A. Amusa
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Olukemi Ige
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Basil Okeahialam
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Christopher Sutton
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Rajeev Misra
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Azza Abul Fadl
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Neil Kennedy
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Albertino Damasceno
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Mahmoud U. Sani
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Okechukwu S. Ogah
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Taiwo OlunugaHuda H. M. Elhassan
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Ana Olga Mocumbi
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Abiodun M. Adeoye
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Phindile Mntla
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Dike Ojji
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Joseph Mucumbitsi
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Koon Teo
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Salim Yusuf
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
| | - Bongani M. Mayosi
- From Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa (L.Z., M.E.E., B.C., R.D., V.F., B.M.M.); Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa (L.Z., C.H.-H.); Department of Cardiology, All India Institute of Medical Sciences, New Delhi (G.K.); Population Health Research Institute, Hamilton Health Sciences and McMaster University
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