Urgent treatment, action important to reduce rheumatic heart disease burden worldwide

Issue: June 2012

In low- and middle-income countries, rheumatic heart disease is significantly undertreated and is associated with high mortality and major morbidity. Two studies presented at the World Congress of Cardiology address the prevalence of rheumatic heart disease in Africa, India and the Middle East.

Preliminary data from the global Rheumatic Heart Disease Global Registry (REMEDY) suggest that patients with rheumatic heart disease in Africa and India are not receiving the surgery they need or secondary prevention with penicillin, and many patients are unaware of their target anticoagulation levels.

During a 10-month period, 579 patients with a primary diagnosis of rheumatic heart disease confirmed by echocardiography were studied. Only 41% underwent surgery. As the pilot results included a large tertiary academic center, this finding does not reflect the lack of surgery available at the majority of enrolling centers; in fact, more than 85% of the enrolling centers do not have surgery available on a regular basis for rheumatic heart disease patients, the researchers said in a press release. Of the remaining patients, 29% had mitral valve disease, 8% had aortic valve disease and 3% had involvement of both mitral and aortic valves. Twenty-two percent of patients were in atrial fibrillation and 54% were in congestive HF. Of the patients in atrial flutter or AF, 65% were taking oral anticoagulation. In addition, 71% of patients in atrial flutter or AF were unaware of their target INR. Also, 6 months before enrollment in REMEDY, 14% of these patients did not have an INR measurement and 78% were not at their INR target.

Thirty-six percent of patients were on secondary prophylaxis with penicillin, although all patients had moderate or severe disease, and only 20% who underwent valve replacement surgery were on secondary prophylaxis.

In another study presented at the World Congress of Cardiology, researchers in Yemen found that patients with rheumatic heart disease are being admitted to the hospital too late to prevent the need for cardiac surgery.

Researchers assessed patient symptoms, physical signs, blood tests, chest X-rays, electrocardiogram and electrocardiography from June 2008 to February 2009 at the Al-Gomhori Teaching Hospital in Yemen.

Of patients admitted with rheumatic heart disease, 43% had rheumatic mitral stenosis and more than half were considered to have severe stenosis. Study results showed that more women were prone to rheumatic mitral valve stenosis vs. men. Pulmonary hypertension, pulmonary congestion and AF were common conditions among patients. Longer hospitalization stay was associated with AF, stroke and infective endocarditis.

Forty-five of 87 patients were severely stenosed, which increased left atrial dilation, transmitral gradient and pulmonary artery systolic pressure. Left atrial dilation did not influence the tendency of AF. Researchers found normal left ventricular systolic function in 89.7% of patients and case fatality in 9.2%. Nearly 53% of patients were recommended for percutaneous balloon mitral valvuloplasty, 29% were recommended for valve replacement surgery and 18% were entered into a follow-up program without interventional therapy of any kind.

“These results clearly demonstrate that RHD patients are seeking treatment from their doctors in the very late stages of their disease,” researcher Abdulkader A. Sharafaddeen, MD, of the Al-Gomhori Teaching Hospital, said in a press release. “But the management of these patients is costly. This money could be rather used much more efficiently in preventing and screening for the disease in its early stages.”

For more information:

Sharafaddeen AA. Abstract #P095.
Sharafaddeen AA. Abstract #P095.
Both presented at: the World Congress of Cardiology; April 18-21, 2012; Dubai, United Arab Emirates.

Disclosure: The researchers report no relevant financial disclosures.