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 outcomewas 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 byWorld 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. |
