The Global Burden of Rheumatic Heart Disease: Population-Related Differences (It is Not All the Same!)

Shifts in Clinical Characteristics, Treatment, and Outcome for Rheumatic Mitral Stenosis: Insights From a 20-Year Multicentre Registry Study in Korea

BACKGROUND

The rapid economic development of South Korea provides a unique model to study changes in the clinical characteristics, treatment approaches, and clinical outcomes of patients with rheumatic mitral stenosis (MS) relative to socioeconomic growth.

METHODS

From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, 2,337 patients diagnosed with moderate or severe rheumatic MS between January 2001 and December 2020 were analyzed. Patients were grouped into consecutive 5-year intervals based on their year of diagnosis. Clinical characteristics, echocardiographic data, and clinical outcomes were assessed.

RESULTS

Over 20 years, the severity of mitral stenosis increased from 79.1% to 90.2%; similarly, the average age at diagnosis increased from 54.3 to 63.0 years (all P < 0.001). Comorbidities such as hypertension and atrial fibrillation increased (6.3% to 29.5% and 41.4% to 46.9%, respectively; all P for trend < 0.05). The rate of mitral intervention within five years after diagnosis increased from 31.2% to 47.4% (P for trend < 0.001). However, clinical outcomes of rheumatic mitral stenosis deteriorated over time in the composite outcomes (log-rank test, P < 0.001). Conversely, the incidence of stroke remained stable (60.6-73.7%; P < 0.001), which might be attributed to the increased use of anticoagulation therapy.

CONCLUSION

This study observed an increase in patient age, comorbidities, and valve disease severity as the country transitioned from a developing to developed status. Despite a rise in mitral valve interventions, clinical outcomes deteriorated over 20 years, highlighting the need for modified treatment approaches to improve patient outcomes.

Temporal Trends of Age-Adjusted Mortality Rates for Rheumatic Heart Disease in Brazil From 2000 to 2021

Background Rheumatic heart disease (RHD) is a chronic cardiovascular condition stemming from an infectious origin, posing a substantial health burden, particularly in economically disadvantaged regions. It starts with acute rheumatic fever (ARF), a complication following group A Streptococcus infection, leading to heart valve damage and, over time, structural heart abnormalities. RHD contributes to premature deaths, especially in low-middle-income countries. Although the incidence and prevalence have generally reduced globally due to antibiotics and improved healthcare, it remains a significant public health concern in Brazil, echoing its prevalence in many developing nations around the world. RHD stands as a poignant testament to the intersection of socio-economic disparities and healthcare challenges within Brazil's diverse population. In Brazil, despite advancements in healthcare, RHD continues to impact communities, highlighting the urgent need for enhanced prevention strategies, access to quality healthcare services, and heightened awareness to combat this preventable, yet persistent, cardiac condition. Understanding the epidemiological landscape and socio-cultural factors influencing RHD in Brazil is crucial for developing targeted interventions aimed at mitigating its burden on individuals, families, and the healthcare system at large. Thus, our study focuses on analyzing age-related mortality rates linked to ARF and chronic RHD (ARHD) in Brazil from 2000 to 2021, particularly examining gender disparities. Materials and methods This retrospective cohort study employed a descriptive time-series approach, utilizing comprehensive nationwide data from Brazil spanning from 2000 to 2021 to assess trends in diverse age groups, among both sexes, enabling a detailed analysis of temporal patterns. Mortality data, extracted and categorized meticulously, were subjected to Joinpoint statistical analyses enabling comparative assessments, with average annual percent change (AAPC) and annual percent change (APC) serving as key metrics to quantify and interpret trends over the analyzed period. Results The acute RHD (ARHD)-related mortality declined over the analyzed years supported by AAPC, with higher mortality reduction in females. The age-adjusted mortality rate for "males and females" decreased from 78 to 67 deaths/100,000 from 2000 to 2021. Female mortality dropped from 85 to 69/100,000, and male mortality decreased from 73 to 63/100,000 over the same period. For ARHD, male age groups (20-29, 60-69, 70-79, 80+) showed declining mortality, while the 30-59 age group exhibited an upward. Females AAMR for chronic RHD (CRHD) decreased across all age groups, with significant reductions in the 80 years and above age group from 2000-2002 (APC: -11.94*) and steadily from 2002 onwards (APC: -1.33). Conclusions Our study revealed an overall decline in mortality rates for both acute and CRHD across both sexes. Females consistently exhibited higher mortality rates and a more pronounced reduction compared to males in both acute and CRHD. In ARHD, males experience the highest mortality in the 50-59 age group, while females have a peak in the 40-49 age group. The 60-69 age group had the highest mortality in CRHD for both sexes. Conversely, the 20-29 age group displayed the lowest mortality in CRHD, and the 80-89 age group had the lowest mortality in ARHD.

The role of echocardiographic screening in reducing the burden of rheumatic heart disease in Latin America

The objectives of this article are to reflect on the rationale behind the use of echocardiographic screening for rheumatic heart disease and to provide key recommendations about steps needed to implement and improve echocardiographic screening programs in Latin America. Rheumatic heart disease remains a public health problem affecting mainly low-income and lower-middle-income countries and populations. Latin America is an area with economic inequalities, and the epidemiology of rheumatic heart disease remains largely unknown. Echocardiographic screening is useful for updating the epidemiology and providing early diagnosis of the disease. We discuss different approaches used in successful echocardiographic screening programs worldwide and in Latin America. We then identify the key elements needed to establish successful echocardiographic screening programs in Latin America, including increased awareness and involvement from multiple sectors (e.g. the community, health care professionals, scientific organizations and public health entities), identification of areas in need, development of a plan and structure that include different screening approaches, and how to ensure appropriate follow up for those who screen positive.

Adoption of minimally invasive mitral valve surgery: single-centre implementation experience in Vietnam

The adoption of minimally invasive mitral valve surgery (MIMVS) has become a prominent trend in mitral valve procedures. This article emphasizes that the success of the MIMVS program relies not only on effective teamwork but also on comprehensive hospital support and a clearly defined training strategy. Additionally, targeted marketing initiatives that highlight the value of the heart valve centre are crucial for sustaining the program's success and attracting a consistent patient flow. The implementation of these strategies requires diligent execution, consistent maintenance, and continuous improvement to ensure the triumph of the MIMVS program. This article aims to share our experience in implementing MIMVS at our centre, providing valuable insights for centres that have yet to adopt this approach or have low adoption rates. While acknowledging that sharing our centre's experience cannot guarantee success in all centres, customizing the implementation by selecting appropriate features and access points is vital. Each centre may encounter unique challenges, and tailoring the strategy to address specific needs will enhance the effectiveness of the MIMVS program.

Pregnancy risk and contraception among reproductive-age women with rheumatic heart disease attending care at a tertiary cardiac center in Tanzania: a hospital-based cross-sectional study

BACKGROUND

Rheumatic heart disease (RHD) remains prevalent in the developing world and reproductive-age women are disproportionately affected. It is among the common est cardiac diseases during pregnancy and is associated with poor pregnancy outcomes. Despite its importance among reproductive-age women, there are no local studies that characterize the clinical characteristics, risk of poor pregnancy outcomes and contraception which represents one effective way to prevent unplanned pregnancies in this population.

METHODS

This was a hospital-based descriptive cross-sectional study. Non-pregnant reproductive-age women with echocardiographically diagnosed RHD were consecutively recruited from in- and out-patients units of the Jakaya Kikwete Cardiac Institute (JKCI). A clinical research form was used to gather socio-demographic, clinical characteristics, contraception status and echocardiographic information. The maternal/pregnancy risk class was determined using the modified World Health Organization (WHO) classification of maternal risk.

RESULTS

Two hundred thirty-eight women of reproductive age with RHD were recruited. The median age (range) was 36 years (15-49). Two-thirds were dyspneic on moderate exertion and 17.2% had New York Heart Association class IV heart failure. A quarter had atrial fibrillation/flutter. On echocardiography, mitral regurgitation was the most common valvular lesion (68.1%), followed by mitral stenosis (66.8%), and 12.2% of participants had reduced left ventricular ejection fraction. Two-thirds (66%) had a high pregnancy risk (class IV) based on the modified WHO classification system. The proportion of participants using contraception was 7.1% and common methods were: bilateral tubal ligation 5 of 17 (29.4%) and hormonal implant (4 of 17). The most common reason for the choice of a method was safety, 10 out of 17 (58.8%).

CONCLUSION

The majority of women of reproductive age with RHD in our hospital cohort are at the highest pregnancy risk based on the modified WHO classification and a very small proportion of them are on contraception. These results call for action among clinicians to offer counselling to these patients, educating them on their risk and offering appropriate contraception advice while waiting for definitive interventions.

The Global Burden of Valvular Heart Disease: From Clinical Epidemiology to Management

Valvular heart disease is a leading cause of cardiovascular morbidity and mortality and a major contributor of symptoms and functional disability. Knowledge of valvular heart disease epidemiology and a deep comprehension of the geographical and temporal trends are crucial for clinical advances and the formulation of effective health policy for primary and secondary prevention. This review mainly focuses on the epidemiology of primary (organic, related to the valve itself) valvular disease and its management, especially emphasizing the importance of heart valve centers in ensuring the best care of patients through a multidisciplinary team.

Prevalence of rheumatic heart disease in adults from the Brazilian Amazon Basin

BACKGROUND

Rheumatic heart disease (RHD) continues to be a burden in low- and middle-income countries and prevalence estimates are lacking from South America. We aimed to determine the prevalence of RHD in the Brazilian Amazon Basin.

METHODS

We examined a random sample of adults (≥18 years) from the general population, who underwent echocardiographic image acquisition by a medical doctor. All images were analyzed according to (i) the 2012 World Heart Federation criteria and (ii) a simplified algorithm for RHD from a previously validated risk score (categories: low-, medium-, high-risk) which involved assessment of the mitral valve (leaflet thickening and excessive motion, regurgitation jet length) and aortic valve (thickening and any regurgitation).

RESULTS

A total of 488 adults were screened (mean age 40 ± 15 years, 38% men). The prevalence of RHD was 39/1000 adults (n = 17 definite and n = 2 borderline). Fourteen (74%) had pathological mitral regurgitation, four (21%) mitral stenosis, 0 (0%) pathological aortic regurgitation and six (32%) both mitral and aortic valve disease. None had a prior diagnosis of RHD, 10 (53%) had positive cardiac auscultation and two (11%) reported a history of rheumatic fever. The simplified algorithm identified four (21%) adults as low-risk, six (32%) as intermediate, and nine (47%) as high-risk.

CONCLUSIONS

The prevalence of RHD was 39/1000 in adults from the Brazilian Amazon Basin, indicating the need for screening programs in remote areas. A simplified model was only able to categorize every second case of RHD as high-risk. External validation of simplified screening models to increase feasibility in clinical practice are encouraged.

Rheumatic heart disease: The role of global cardiac surgery

Rheumatic heart disease (RHD) remains a neglected disease of poverty. While nearly eradicated in high-income countries due to timely detection and treatment of acute rheumatic fever, RHD remains highly prevalent in low- and middle-income countries (LMICs) and among indigenous and disenfranchised populations in high-income countries. As a result, over 30 million people in the world have RHD, of which approximately 300,000 die each year despite this being a preventable and treatable disease. In LMICs, such as in Latin America, sub-Saharan Africa, and Southeast Asia, access to cardiac surgical care for RHD remains limited, impacting countries' population health and resulting economic growth. Humanitarian missions play a role in this context but can only make a difference in the long term if they succeed in training and establishing autonomous local surgical teams. This is particularly difficult because these populations are typically young and largely noncompliant to therapy, especially anticoagulation required by mechanical valve prostheses, while bioprostheses have unacceptably high degeneration rates, and valve repair requires considerable experience. Devoted and sustained leadership and local government and public health cooperation and support with the clinical medical and surgical sectors are absolutely essential. In this review, we describe historical developments in the global response to RHD with a focus on regional, international, and political commitments to address the global burden of RHD. We discuss the surgical and clinical considerations to properly manage surgical RHD patients and describe the logistical needs to strengthen cardiac centers caring for RHD patients worldwide.