Mortality and Morbidity in Adults With Rheumatic Heart Disease
Authors: Karthikeyan Ganesan , Ntsekhe Mpiko , Islam Shofiqul , Rangarajan Sumathy , Avezum Alvaro , Benz Alexander , Cabral Tantchou Tchoumi Jacques , Changsheng Ma , Chillo Philly , Gonzalez-Hermosillo J. Antonio , Gitura Bernard , Damasceno Albertino , Dans Antonio Miguel L. , Davletov Kairat , Elghamrawy Alaa , ElSayed Ahmed , Fana Golden Tafadzwa , Gondwe Lillian , Haileamlak Abraham , Kayani Azhar Mahmood , Lwabi Peter , Maklady Fathi , Molefe-Baikai Onkabetse Julia , Musuku John , Ogah Okechukwu Samuel , Paniagua Maria , Rusingiza Emmanuel , Sharma Sanjib Kumar , Zuhlke Liesl , Connolly Stuart , Yusuf Salim ,   INVICTUS Investigators, Goepamang Monkgogi , Mwita Julius , Ramos Auristela , Tarasoutchi Flavio , Paixao Milena Ribeiro , Kirschbaum Marcelo , Pezzute Lopes Mariana , Avila Walkiria , Maia Lilia , Nakazone Marcelo , Costa Osana , Lemos Maria , Oliveira Livia , Ferreira Jose , Saraiva Jose Francisco Kerr , Costa Midia , Marengo Marina , Dutra Oscar , Guimaraes Raphael , Vaz Humberto , Zimmerman Sergio Luiz , Souza Weimar , Queiroz Weimar , Souza Adriana , Vidotti Maria Helena , de Paula Jose Guilherme , Fazolli Guilherme , Hernandes Mauro , Torati Jose Luiz , Pantano Grazielly , Pelarin Vanessa , Arantes Flavia , Silva Rodrigo , Cardoso Monique , Reis Gilmar , Franca Cesar , Quadros Tulio , Giorgeto Flavio , Elmiro Resende , Aguinaldo Silva , Minelli Cesar , Anshoma Helen Mbuoh , Ambassa Jean Claude , Mfevkev Kuate Liliane , Nganou Gninotio Chris Nadege , Ntep Gweth Ngo Youmba , Anastase Dzudie , Florent Armel Djomou Ngongang , Keptukoua Lionel Nana , Du Xin , Hu Rong , Wu Jiahui , Lv Qiang , Cui Jing , Qing Yu , Xudong Zhu , Su Wei , Xiaomei Wang , Shiyi Chen , Zhipeng Zhang , Wang Qi , Zheng Xin , Pengfei Liu , Rang Cheng , Xie Sitao , Liu Chongwen , Wang Hailong , Wang Shudong , Zhang Xuxia , Lian Yinzhu , Wang Rui , Mingfu Ma , Li Lan Dou , Tan Yunlian , Zhang Shouyan , Yunfei Gu , Jianfeng Chen , Hao Wang , Pengyu Wu , Hong Luan , Fu Li , Yongbin Xu , Jundan Xiao , Qingfu Li , Sun Jinpo , Pei Cui , Niu Yanbo , Wu Yidi , Yang Honghua , Li Xin , Yang Chunyan , Shi Yanhui , Wu Chenglin , Qu Yandong , Zhao Mingzhong , Cheng Yong , Yuan Yiqiang , Huang Qiong , Kong Xiuzhen , Zhao Zhizhong , Heng Qixia , Shi Xinjing , Zhang Jing , Ying Liu , Xin Gao , Yu Zhaoping , Wu Xi , Hunayu Guo , Xiaoying Wang , Zhang Wei , Li Chichang , Zhongtao Wang , Ding Hao , Huang Min , Jinguo Zhao , Yu Mingshui , Cao Cuiling , Zhu Xiaoli , Shi Xiaoqin , Eltamawy Khalid , Arafa Osama , Youssif Mahmoud , Kassem Aly , Saleh Omar , Hussam Al Shair Mohamed , Maghraby Khaled , Shaheen Sameh , Abouelhoda Aly Ahmed , Gharib Suliman , Sadek Ramadan , Abd El Hady Yasser , Asefa Elsah , Gudina Esayas Kebede , Habte Michael Ermias , Dukessa Gemechu Tadesse , Duguma Markos , Yadeta Dejuma , Alemu Berhanu N , Abebe Sintayehu , Assefa Tamrat , Mekonnen Desalew , Seleshi Tigist , Fekadu Chala , Hailu Abraha , Tesfay Hagazi , Hailu Berhane Yohannes , Kahsay Hagos , Gidey Kibreab , Gebrehawaria Teklay , Berhane Samuel , Kamil Teshome Abegaz , Shifa Tariku Egeno , Hirigo Agete Tedewos , Teshome Sisay Tesfaye , Yirdaw Seyife Kibru , Singh Sandeep , Naik Nitish , Siddharthan Deepti , Yadav Satyavir , Gupta Mohit , MP Girish , Sharma Ajay , Pandit Bhagya Narayan , Sudeep Kumar , Aditya Kapoor , Pradhan Akshyaya , Sethi Rishi , Chaudhry Gaurav , Virendra Yaday , Smriti Agarwal , Manjnath Cholenahally , Narayanappa Surya Prakash , Satvic Cholenahally , Devegowda Lachikarthman , Meena Chandra Bhan , Bagarhatta Rajiv , Sharma Shashi Mohan , Kunal Shekhar , Kumar Nutan , Mereke Alibek , Ogola Elijah , Sugut Wilson , Barasa Felix , Gikonyo Anthony , Omondi Stephen , Sinyiza Frank , Chipolombwe John , Phiri Tamara , Rodriguez Chavez Laura Leticia , Gutierrez Ernesto , Mazon Flores Fransisco , Rodriguez Edgar , Lara Vaca Susano , Cabra Juan , Saavedra Sandra , De los Rios Manuel , Ruvalcaba Gilmer , Lopez Esteban , Alcocer Marco , Ramirez Ana , Llamas Guillermo , Hernandez Paola , Delgado Angelica , Muholove Ana , Mateus Angela , Mocumbi Ana , Agarwal Jyoti , Chhetri Roshan , Tripathi Prashant Mani , Adhikari Chandra Mani , Shakya Urmila , Prajapati Dipanker , Manandhar Reeju , Nepal Rajesh , Dhungana Sahadeb Prasad , Ghimire Rinku , Khanal Sunil Babu , Gautam Samir , Khan Mazhar , KC Bishal , Laudari Shankar , Gupta Madhu , Regmi Shyam Raj , Dhital Bishnu Mani , Regmi Sudhir , Adhikari Krishna , Koirala Bhagawan , Gajurel Ratnamani , Shrestha Hemant , Thapa Sanjeev , AKINTUNDE ADESEYE , Olunuga Taiwo , Adesina Julius , Sani Mahmoud , Bode-Thomas Fidelia , Okeahialam Basil , Yilgwan Christopher , Amusa Ganiyu , IGE Olukemi , Danbauchi Solomon , Adeoye Abiodun Moshood , Umuerri Ejiroghene , Mbakwem Amam , Amadi Casmir , Kushimo Oyewole , Isa Muhammad , Abdullahi Muhammad Awwal , Oguanobi Nelson , Zahid Zohaib Ullah , Ali Jabar , Hafizullah Mohammad , Memon Feroz , Kazi Shazia , Kayani Azhar Mahmood , Rehman Adeel , Khan Faisal Abdul Wajid , Tarique Aftab Ahmad , Sattar Abdul , Hayat Mallick Nadeem , Ali Syed Asif , Mayans Veronica , Pereira Luciano , Alderete Jose , Galeano Javier , Moran Salinas Alberto , Falcón Rocío del Pilar , Escalada Gustavo , Cabral Luz , Fatecha Liz , Bogado de Atobe Gladys , Gutierrez Carlos , Delmas Cesar , Coronel Claudine , Ibarrola Dahiana , Magno Jose Donato , Evangelista Lauren Kay , Abola Maria Teresa , Padua Leahdette , Mendoza-Reyes Christie , Sulit Dennis Jose , Mercado Ma Jojo , Sigua Cabaddu Candy Angelica , Cruz Josefina , Ganza Gapira Jean Marie Vianney , Dusingizimana Vincent , Cupido Blanche , Lawrenson John , NAICKER KISHENDREE , CIROTA JACQUELINE RACHELLE , Karen Sliwa Hahnle , Thomas Baby Mookenthottathil , Thomas Kandathil Mathew , KHULILE MOEKETSI , Alomatu Samuel Yao , MNTLA PINDILE , MPHAHLELE MAKGOTSANE , Ratsela Andrew , Manga Pravin , Fourie Doné , Hemus Allana , Makotoko Ellen M , ALAM A K M NOWSHAD , Nethononda Richard , Nunkoo Theema , Meel Ruchika , Askar Elsadig , Elfaki Amna , Mohamed Lana , ElSayed Mohammed , Hagahmed Alia , Mohammed Sumia , Algaali Hiba , Eltalib Khalid , Badawe Tagwa S. I. , Kbashi Inas Hassab Elrasoul , Elhassan Huda Hamid , Hamza Maysa , Ahmed Molhim M.I. , Elhussain Rayan , Mutwali Rufaida , Ahmed Medani Mohammad Qurashi , Mohamed Nazar F.A. , Elamin Hwida A.M. , Elmadih Manal H.A. , Abdelgader Maha , Yousif Magdi (Gameel) , Elfatih Tagwa , Elshazali Osama Hafiz , Esawi Elaf Esmaeel , Mohammed Awad A.M.A. , Hassan Omer I.A. , Mahgoub Khansa , Maki Maarib , A.M.Abozaid Omaima , Majani Naiz , Mtullo Emmanuel Stephano , Kabakama Clement , Mwakyula Issakwisa , Meda John , Okello Emmy , Chansa Pamela , Mumba Ngosa , Goma Fastone , Musemwa Caroline , Gwini Rudo 
Published: June 2024

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 &amp;lt; .001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P &amp;lt; .001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P &amp;lt; .001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P &amp;lt; .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.