Mortality and Morbidity in Adults With Rheumatic Heart Disease
Ganesan Karthikeyan, Mpiko Ntsekhe, Shofiqul Islam, Sumathy Rangarajan, Álvaro Avezum, Alexander P. Benz, Tantchou Tchoumi Jacques Cabral, Changsheng Ma, Philly Chillo, Jesús Antonio González-Hermosillo, Bernard Gitura, Albertino Damasceno, Antonio Miguel L. Dans, Kairat Davletov, Alaa Elghamrawy, Ahmed ElSayed, Golden Tafadzwa Fana, Lillian Gondwe, Abraham Haileamlak, Azhar Mahmood Kayani, Peter Lwabi, Fathi Maklady, Onkabetse Julia Molefe‐Baikai, John Musuku, Okechukwu S. Ogah, María Paniagua, Emmanuel Rusingiza, Sanjib Kumar Sharma, Liesl Zühlke, Stuart J. Connolly, Salim Yusuf, INVICTUS Investigators, Monkgogi Goepamang, Julius Chacha Mwita, Auristela Isabel de Oliveira Ramos, Flávio Tarasoutchi, Milena Ribeiro Paixão, Marcelo Kirschbaum, Mariana Pezzute Lopes, Walkíria Samuel Ávila, Lília Nigro Maia, Marcelo Arruda Nakazone, Osana Costa, Maria Carmen Lemos, Lívia Costa de Oliveira, Jose Ferreira, José Francisco Kerr Saraiva, Midia Costa, Marina Marengo, Óscar Pereira Dutra, R.M. Guimarães, Humberto Vaz, Sergio Luiz Zimmerman, Weimar Kunz Sebba Barroso, Weimar Queiroz, Adriana Ferreira de Souza, Maria H Vidotti, Jose Guilherme de Paula, Guilherme Fazolli, Mauro Esteves Hernandes, Jose Luiz Torati, Grazielly Pantano, Vanessa Pelarin, Flavia Arantes, Rodrigo Otávio Silveira Silva, Monique Cardoso, Gilmar Reis, César França, Túlio Fonseca e Silva Quadros, Flavio Giorgeto, Resende Elmiro, Silva Aguinaldo, César Minelli, Helen Mbuoh Anshoma, Jean Claude Ambassa, Liliane Mfevkev Kuate, Chris Nadege Nganou Gninotio, Ngo Youmba Ntep Gweth, Dzudie Anastase, D. Armel, Lionel Nana Keptukoua, Xin Du, Rong Hu, Jiahui Wu, Qiang Lv, Jing Cui, Qing Yu, Xudong Zhu, Wei Su, Wang Xiaomei, Shiyi Chen, Zhipeng Zhang, Qi Wang, Xin Zheng, Pengfei Liu, Cheng Rang, Sitao Xie, Chongwen Liu, Hailong Wang, Shudong Wang
Abstract
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.