Presenting features of newly diagnosed rheumatic heart disease patients in Mulago Hospital : a pilot study : cardiovascular topics

Abstract

IntroductionRheumatic heart disease (RHD) continues to cause gross distortions of the heart and the associated complications of heart failure and thromboembolic phenomena in this age of numerous high-efficacy drugs and therapeutic interventions. Due to the lack of contemporary local data, there is no national strategy for the control and eradication of the disease in Uganda. This study aimed to describe the presenting clinical features of newly diagnosed patients with RHD, with particular reference to the frequency of serious complications (atrial fibrillation, systemic embolism, heart failure and pulmonary hypertension) in the study group.MethodsOne hundred and thirty consecutive patients who satisfied the inclusion criteria were recruited over a period of eight months from June 2011 to January 2012 at the Mulago Hospital, Uganda. Data on demographic characteristics, disease severity and presence of complications were collected by means of a standardised questionnaire.ResultsSeventy-one per cent of the patients were female with a median age of 33 years. The peak age of the study group was 20 to 39 years, with the commonest presenting symptoms being palpitations, fatigue, chest pain and dyspnoea. The majority of the patients presented with moderate-to-severe valvular disease. Pure mitral regurgitation was the commonest valvular disease (40.2%), followed by mitral regurgitation plus aortic regurgitation (29%). Mitral regurgitation plus aortic regurgitation plus mitral stenosis was found in 11% of patients. There was only one case involving the tricuspid valve. The pulmonary valves were not affected in all patients; 45.9% of patients presented in severe heart failure in NYHA class III/IV, 53.3% had pulmonary hypertension, 13.9% had atrial fibrillation and 8.2% had infective endocarditis. All patients presented with dilated atria (> 49 mm).ConclusionA significant proportion of RHD patients present to hospital with severe disease associated with severe complications of advanced heart failure, pulmonary hypertension, infective endocarditis and atrial fibrillation. There is a need to improve awareness of the disease among the population, and clinical suspicion in primary health workers, so that early referral to specialist management can be done before severe damage to the heart ensues.

Impact of heart disease on maternal, fetal and neonatal outcomes in a low-resource setting

“…Second, patients are most often unaware of cardiovascular disease until the advanced stages. A recent study showed 85% of Ugandan patients with newly diagnosed rheumatic heart disease (RHD), the most common cardiovascular diagnosis in low-resource areas, presented only when advanced valvular damage had occurred and complications had developed 6. Echocardiography is the most sensitive and specific tool for diagnosis of cardiovascular disease, however, it is rarely available outside of large cities in sub-Saharan Africa 7…”

The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries

“…Echocardiographic screening studies have uncovered that 1.5–5.6% of children in low-resource areas demonstrate evidence of latent RHD,28 but almost none of them remembers a history of ARF 29. Even among adults presenting with advanced RHD to a tertiary care centre in Uganda, none recalled a childhood history consistent with ARF 30. No one fully understands why presentation rates of ARF remain relatively low in many areas where RHD is endemic.…”

Did we overcome rheumatic heart disease or is it still a public disease burden?

“…Recurrent acute rheumatic fever (ARF) attacks are associated with severity of valvular injury [4,5]. However, many patients with RHD can present with advanced valvular disease findings without history of significant ARF attacks [6][7][8]. RHD is the only chronic sequelae of acute rheumatic fever that results in lifelong.…”