article · JAMA
A prospective observational study conducted across 138 hospital sites in 24 low- and middle-income countries followed 13,696 adults with rheumatic heart disease over a median of 3.2 years. Most participants were women, with an average age of 43 years. Over the follow-up period, 15% of patients died, corresponding to a mortality rate of 4.7% per patient-year. Vascular complications, particularly heart failure and sudden cardiac death, accounted for over two thirds of all deaths. Factors indicating severe valve damage, including congestive heart failure, pulmonary hypertension, and atrial fibrillation, strongly correlated with increased risk of death. Only 4.4% of patients underwent valve surgery, despite surgical intervention and valvuloplasty being associated with an approximate 75% reduction in mortality. Patients in higher-income nations experienced lower mortality rates, highlighting an urgent requirement to expand surgical and interventional services alongside medical therapies.
Rheumatic heart disease remains a devastating condition in developing nations, disproportionately affecting young adults and women. Although preventive antibiotic therapies exist, many patients already live with advanced valve damage. Demonstrating that surgical intervention dramatically cuts mortality highlights where healthcare systems must focus, directing international health agencies, hospital networks, and policymakers toward funding and establishing specialised cardiovascular surgical capacity in endemic regions.
The abstract does not indicate an application pathway, focusing instead on observational clinical outcomes and the necessity of expanding surgical access.
AI-generated from the published abstract. Always read the original work before citing.
Importance: Rheumatic heart disease (RHD) remains a public health issue in low- and middle-income countries (LMICs). However, there are few large studies enrolling individuals from multiple endemic countries. Objective: To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD. Design, Setting, and Participants: Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs. Main Outcomes and Measures: The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality, heart failure (HF) hospitalization, stroke, recurrent rheumatic fever, and infective endocarditis. This study analyzed event rates by World Bank country income groups and determined the predictors of mortality using multivariable Cox models. Results: Between August 2016 and May 2022, a total of 13 696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12 967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41 478 patient-years), 1943 patients died (15% overall; 4.7% per patient-year). Most deaths were due to vascular causes (1312 [67.5%]), mainly HF or sudden cardiac death. The number of patients undergoing valve surgery (604 [4.4%]) and HF hospitalization (2% per year) was low. Strokes were infrequent (0.6% per year) and recurrent rheumatic fever was rare. Markers of severe valve disease, such as congestive HF (HR, 1.58 [95% CI, 1.50-1.87]; P < .001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P < .001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P < .001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P < .001) or valvuloplasty (HR, 0.24 [95% CI, 0.06-0.95]; P = .042) were associated with lower mortality. Higher country income level was associated with lower mortality after adjustment for patient-level factors. Conclusions and Relevance: Mortality in RHD is high and is correlated with the severity of valve disease. Valve surgery and valvuloplasty were associated with substantially lower mortality. Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation.
This page summarises published work. The authoritative version sits with the publisher.
DOI: 10.1001/jama.2024.8258
Is something wrong with this record? Report it or request removal.
Discussion
Have you built on this work, tried to replicate it, or seen it applied in practice? Share what you know. Verified researchers and MARATTO™ domain experts can open a discussion, and any member can reply. Contributions are reviewed before they appear.
No discussion yet. Open the first thread.
New to MARATTO™? Create a free account.
