Rheumatic heart disease is significantly under-treated in Africa and India
Rheumatic heart disease (RHD) is significantly under-treated in Africa and India according to the preliminary findings of a new global study presented today at the World Congress of Cardiology.
Across the African and Indian regions included in the study it was revealed that patients are not receiving the surgery they need, secondary prevention with penicillin - to prevent further attacks of rheumatic fever - is being under-utilized and many patients are unaware of their target anti-coagulation levels.
Specifically, only 41 per cent of patients enrolled in the study had received surgery. As the pilot results included a large tertiary academic centre, this does not reflect the dire lack of surgery available at the majority of enrolling centers. In fact, more than 85 per cent of the enrolling centres do not have surgery available on a regular basis for RHD patients.
Nearly one-quarter of all patients (22 per cent) were in atrial fibrillation and of these patients, only 65 per cent were receiving necessary anti-coagulant therapy. Moreover, 71 per cent of these patients did not know their target international normalized ratio (INR) - an indicator of blood clotting time - 14 per cent had no INR reading in the six months prior to enrolling in the study and 78 per cent were not at their INR target.
The study results further showed that only 36 per cent of patients with moderate or severe disease and only 20 per cent of those that have undergone valve replacement surgery are receiving secondary prophylaxis with penicillin.
“Across Africa and India it is widely known by cardiologists that many patients with RHD do not have access to the healthcare treatment they need. These results unfortunately show that even those that are being treated are not receiving the care they need, for a variety of reasons,” said Dr. Liesl Züklhe, Paediatric Cardiologist, Red Cross Children’s Hospital, University of Cape Town, South Africa. “These preliminary results are the first step in really understanding the extent of the problems that the RHD community are facing. We urgently need to accumulate robust data and investigate the barriers of care that exist in order to control this disease. Hopefully this will reinforce the need for political commitment and action to fight this disease.”
Rheumatic heart disease is the most serious complication of rheumatic fever. Acute rheumatic fever follows 0.3% of cases of group A beta-hemolytic streptococcal pharyngitis in children. As many as 39% of patients with acute rheumatic fever may develop varying degrees of pancarditis with associated valve insufficiency, heart failure, pericarditis, and even death. With chronic rheumatic heart disease, patients develop valve stenosis with varying degrees of regurgitation, atrial dilation, arrhythmias, and ventricular dysfunction. Chronic rheumatic heart disease remains the leading cause of mitral valve stenosis and valve replacement in adults in the United States.
Acute rheumatic fever and rheumatic heart disease are thought to result from an autoimmune response, but the exact pathogenesis remains unclear. Although rheumatic heart disease was the leading cause of death 100 years ago in people aged 5-20 years in the United States, incidence of this disease has decreased in developed countries, and the mortality rate has dropped to just above 0% since the 1960s. Worldwide, rheumatic heart disease remains a major health problem. Chronic rheumatic heart disease is estimated to occur in 5-30 million children and young adults; 90,000 individuals die from this disease each year. The mortality rate from this disease remains 1-10%. A comprehensive resource provided by the World Health Organization (WHO) addresses the diagnosis and treatment.
These data represent the first findings from the RHD global registry (REMEDY), which is currently ongoing in almost 30 centres in Africa, Middle East and India. Five hundred and seventy-nine patients from 10 sites in Africa and India were enrolled in the REMEDY study during the first 10-month pilot period as part of a global effort to better understand the situation today.
Rheumatic Heart Disease Treatment
Although having rheumatic fever leaves a child more susceptible to heart damage, it does not always permanently damage the heart. However, when the inflammation caused by rheumatic fever leaves one or more of the heart valves scarred, the result is rheumatic heart disease. The mitral valve and the aortic valve are usually the ones damaged by the disease. Years later, the mitral valve may become narrowed, a condition known as mitral stenosis.
Treatment of acute rheumatic fever includes antibiotics to treat the strep infection and additional medications to ease the inflammation of the heart and other symptoms. Usually aspirin is given in large doses until the joint inflammation goes away; rarely, steroids are needed. Once the acute illness has gone away, patients need to take penicillin, or an equivalent antibiotic, for many years to prevent recurrences. This is a very important treatment because the risk of heart valve damage increases if rheumatic fever recurs.
Most often the valve leak caused by the disease is mild and does not need treatment. If the leak is severe enough to strain and enlarge the heart, surgery may be needed to eliminate the leak. This surgery may involve repair of the damaged valve. Sometimes the valve is too badly damaged to repair, in which case it must be replaced by an artificial valve.
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The list of treatments mentioned in various sources for Rheumatic heart disease includes the following list. Always seek professional medical advice about any treatment or change in treatment plans.
Preventive antibiotics - to prevent bacterial heart conditions
Preventive antibiotics before surgery
Preventive antibiotics before dental procedures
Preventive antibiotics for tooth extraction
Preventive antibiotics for an injury
About RHD
RHD is a chronic heart condition caused by rheumatic fever that can be prevented and controlled. Rheumatic fever is caused by a preceding group A streptococcal (strep) throat infection. Treating strep throat with antibiotics can prevent rheumatic fever. Moreover, regular antibiotics (usually by injections every three to four weeks) can prevent patients with rheumatic fever from contracting further strep infections and causing progression of valve damage.
RHD is a substantial global health problem that can result in irreversible heart damage and death. It occurs predominately in developing countries and is also common in poorer populations in middle-income countries (e.g. Brazil, India) and some indigenous populations in wealthy countries (Australia, New Zealand). RHD will continue to be a global problem unless current prevention initiatives are expanded and sustained.
Previous estimates state that more than 15 million people have RHD and that 350,000 people die each year while many more are left disabled.
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About the World Congress of Cardiology
The World Congress of Cardiology Scientific Sessions (WCC) is the official congress of the World Heart Federation and is held every two years. Through the Congress the World Heart Federation offers an international stage for the latest developments in science and public outreach in the field of cardiovascular health. The WCC places emphasis on the complementary nature of science and public outreach and strives to spread the message that through individual, community and patient-care interventions, the growing epidemic of cardiovascular diseases can be prevented. For more information, please visit: http://www.worldcardiocongress.org; keep up with the conversation on Twitter using the hashtag #WCC2012Dubai
About the World Heart Federation
The World Heart Federation is dedicated to leading the global fight against heart disease and stroke with a focus on low- and middle-income countries via a united community of more than 200 member organizations. With its members, the World Heart Federation works to build global commitment to addressing cardiovascular health at the policy level, generates and exchanges ideas, shares best practice, advances scientific knowledge and promotes knowledge transfer to tackle cardiovascular disease – the world’s number one killer. It is a growing membership organization that brings together the strength of medical societies and heart foundations from more than 100 countries. Through our collective efforts we can help people all over the world to lead longer and better heart-healthy lives.
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Charanjit Jagait
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41-796-253-296
World Heart Federation