Access to surgery where rheumatic heart disease is endemic a barrier to improving survival
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Key takeaways:
- Most rheumatic heart disease deaths were attributable to heart failure.
- Surgical and interventional procedures reduced mortality from rheumatic heart disease.
- Procedural rates were lowest in low-income countries.
Much of the mortality in rheumatic heart disease was attributable to heart failure, and was significantly reduced by interventional treatment, which may stand as a barrier to improving mortality in lower-income countries, data show.
An analysis of the large international Investigation of Rheumatic Atrial Fibrillation Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies (INVICTUS) program was published in JAMA.
“Rheumatic heart disease causes more than 300,000 deaths annually, mainly in low- and middle-income countries. In 2018, the member states of the World Health Organization adopted a global resolution on rheumatic fever and rheumatic heart disease, calling for high-quality data that would improve understanding of disease epidemiology to help in the effort to reduce morbidity and mortality due to the disease. However, there are no globally representative data on contemporary populations living with rheumatic heart disease,” Ganesan Karthikeyan, DM, of the department of cardiology at the All India Institute of Medical Sciences, New Delhi, Translational Health Science and Technology Institute in Faridabad, India, and colleagues wrote. “Because HF due to structural valve disease is the primary cause of morbidity and mortality in patients with rheumatic heart disease, such data are needed to guide policy and practice in low- and middle-income countries.”
The INVICTUS program
To this end, the INVICTUS program was designed to evaluate the incidence and predictors of clinical outcomes of rheumatic heart disease in regions where the disease is endemic.
The present study from the INVICTUS program includes 13,696 patients enrolled from August 2016 to May 2022 at 138 sites in 24 low- and middle-income countries (mean age, 43 years; 72% women).
The primary outcome was all-cause mortality. Secondary outcomes included cause-specific mortality, HF hospitalization, stroke, recurrent rheumatic fever and infective endocarditis.
During a median of 3.2 years, 15% of patients died, translating to approximately 4.7% of the study population per patient-year.
Overall, 67.5% of deaths were due to vascular causes, of which 77% were due to HF or sudden cardiac death.
Approximately 85% of patients with rheumatic heart disease had moderate or severe disease involving the mitral valve; 25.9% had significant disease involving at least two valves; and less than 2.5% had significant aortic stenosis. Only 4.4% underwent valve surgery and 2% per year experienced an HF hospitalization. Stroke and recurrent rheumatic fever were both rare.
In the setting of rheumatic heart disease, indicators of severe valve disease including congestive HF (HR = 1.58; 95% CI, 1.5-1.87; P < .001), pulmonary hypertension (HR = 1.52; 95% CI, 1.37-1.69; P < .001) and atrial fibrillation (HR = 1.3; 95% CI, 1.15-1.46; P < .001) were associated with increased mortality risk.
Surgical treatment (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 both associated with lower mortality risk; however, fewer patients living in low-middle (4%; P < .0001) and low-income countries (3.3%; P < .001) underwent valve surgery compared with those in upper-middle income countries (7.2%).
Moreover, 30-day mortality after HF hospitalization was significantly higher in low (41.2%) and low-middle (43.7%) compared with upper-middle income countries (31.3%).
Implementation of findings via existing disease programs
“We also observed that nearly one-fifth of the variation in the use of valve surgery and 28% of the variation in the use of mitral valvuloplasty was attributable to country income status, partly explaining the higher mortality associated with low-income status,” the researchers wrote. “These findings are in alignment with published data highlighting the limited access to surgical and catheter-based interventions in lower-income countries, resulting in patients not receiving necessary and timely lifesaving treatment.
“The data indicate that prioritizing tertiary care (focusing mainly on outpatient and inpatient management of HF) and surgical and interventional services for patients with clinical rheumatic heart disease are likely to improve outcomes,” the researchers wrote. “Population-level interventions should probably include secondary prophylaxis to cover younger patients with less severe disease who may benefit from it. Given the resource constraints in poor countries, it may be optimal to implement these intervention bundles through existing child health or other communicable and noncommunicable disease programs, rather than creating additional vertical programs dedicated to rheumatic heart disease.”
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