Summary
Background
There are few African data available on rheumatic heart disease (RHD).
Aim
To provide data on the clinical characteristics and treatment of patients with RHD hospitalized in sub-Saharan Africa.
Methods
The VALVAFRIC study is a multicentre hospital-based retrospective registry of patients with RHD hospitalized in African cardiology departments from 2004 to 2008.
Results
Among 3441 patients with at least one mild RHD lesion seen on echocardiography in 5 years in 12 cardiology departments from seven countries, 1385 had severe lesions (502 men; 803 women; mean age 29.3 ± 15.6 years). The ratio of severe to any RHD valvular lesion was higher in countries with the lowest gross domestic product (GDP). Mitral valve regurgitation was seen in 52.8% of cases, aortic regurgitation in 32.1%, mitral stenosis in 13.4% and aortic stenosis in 1.8%. Combined valvular lesions were observed in 13% of cases. Heart failure was present in 40% of patients. Major left ventricular dilatation was observed in 13.6% of patients, ectasic left atrial dilatation in 13.8%, dilatation of the right cardiac chambers in 19.8% and pulmonary hypertension in 28.7%. Patients with no formal schooling (41.5%) were older and had a higher New York Heart Association (NYHA) class and a lower ejection fraction (EF). Among patients aged < 20 years (mean age 14.5 ± 3.8 years), those who were schooled had a lower NYHA class (2.86 ± 0.92 vs 3.42 ± 0.93; P < 0.01) and a higher EF (60.3 ± 11.7 vs. 54.8 ± 12.8; P < 0.05) than those who were not. RHD-related delays or school failures were affected by NYHA class, EF and the number of children in the household. Although 1200 of 1334 patients required valve repair or replacement, only 27 had surgery. In-hospital outcomes included death (16%), heart failure (62%), arrhythmias (22%), endocarditis (4%) and thromboembolic events (4%). Subsequently, 176 patients were readmitted (13.6%).
Conclusions
Patients with RHD hospitalized in sub-Saharan Africa are young, socially disadvantaged, with a high mortality rate and extremely low access to surgery. Poverty, as quantified by GDP and educational level, affects RHD-related severity, NYHA class and left ventricular dysfunction.
Résumé
Contexte
Les données africaines sur les valvulopathies rhumatismales (VR) sont peu nombreuses.
Objectif
Préciser les caractéristiques cliniques et le traitement des patients avec VR en Afrique subsaharienne.
Méthodes
L’étude VALVAFRIC est un registre rétrospectif multicentrique des patients hospitalisés pour VR.
Résultats
Parmi 3441 patients avec VR observés en échocardiographie en 5 ans dans 12 services de cardiologie de 7 pays, 1385 (502 H, 803 F, âge moyen 29,3 ± 15,6 ans) ont une atteinte sévère, plus fréquente dans les pays à produit intérieur brut (PIB) les plus bas. Une régurgitation mitrale est observée dans 52,8 % des cas, une régurgitation aortique dans 32,1 %, une sténose mitrale dans 13,4 %, une sténose aortique dans 1,8 %, des lésions valvulaires combinées dans 13 %, une insuffisance cardiaque dans 40 %, une dilatation ventriculaire gauche majeure dans 13,6 %, une dilatation auriculaire gauche ectasique dans 13,8 %, une dilatation des cavités droites dans 19,8 % et une hypertension artérielle pulmonaire dans 28,7 %. Les patients sans aucune scolarisation (41,5 %) sont plus âgés, ont une classe NYHA plus élevée et une fraction d’éjection plus basse. Parmi ceux de moins de 20 ans les scolarisés ont une classe NYHA classe inférieure (2,86 ± 0,92 vs 3,42 ± 0,93 ; p < 0,01) et une FE supérieure (60,3 ± 11,7 vs 54,8 ± 12,8 ; p < 0,05) à ceux sans scolarisation. Les retards et échecs scolaires liés à une VR sont impactés par la classe NYHA, la FE et le nombre d’enfants dans la fratrie. Une plastie ou un remplacement valvulaire est nécessaire chez 1200 malades sur 1334. Seuls 27 ont été opérés. Les complications hospitalières comprennent décès (16 %), insuffisances cardiaques (62 %), 129 arythmies (22 %), endocardites (4 %), complications thrombo-emboliques (4 %). Au cours de l’étude, 176 patients sont re-admis (13,6 %).
Conclusions
Les malades hospitalisés pour VR en Afrique subsaharienne sont jeunes, socialement défavorisés, avec un accès très limité à la chirurgie et une mortalité élevée. La pauvreté, quantifiée par le PIB ou le degré de scolarisation, est corrélée à la sévérité des VR, la classe NYHA et la dysfonction VG.
Background
Although theoretically preventable for several decades, rheumatic heart disease (RHD) remains one of the leading causes of non-communicable diseases in developing and low-income countries. The prevalence of RHD is estimated worldwide at 15.6 million people, affecting mostly socially and economically disadvantaged populations, and accounting for up to 233,000 deaths per year . RHD still ranks among the major cardiovascular healthcare challenges in sub-Saharan Africa. The RHD prevalence has been estimated mainly from surveys of school-going children, and varies from 2.7/1000 in Kenya to 14.3/1000 in Congo . While mortality rates of chronic valvular RHD have been estimated at 1.5% of patients per year , this may be largely underestimated in sub-Saharan Africa . Indeed, despite the magnitude of the problem, systematically collected African data on disease characteristics, treatments and subsequent prognosis are scarce. Recently, the Global Rheumatic Heart Disease Registry (REMEDY) provided data from 12 African countries, including Ethiopia, Kenya, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Sudan, Uganda and Zambia . The present VALVAFRIC study, a retrospective hospital-based registry of patients with rheumatic valve disease, aimed to gather clinical, echocardiographic, treatment and prognostic data, as well as information about RHD-associated socioeconomic factors, from patients with severe RHD in Western and Central sub-Saharan Africa.
Methods
Study design
The VALVAFRIC study is a multicentre international hospital-based retrospective registry of patients with RHD hospitalized in African cardiology departments from 2004 to 2008. Patients were included from 12 referral cardiac centres in eight African countries [Cameroon, Ivory Coast, Gabon, Guinea (Conakry), Mali, Nigeria, Senegal and Togo]. The study was initiated during the annual meeting of the Working Group on Tropical Cardiology of the French Society of Cardiology, which is intended to promote collaborative works by academic cardiology teams from sub-Saharan Africa and France. The study was intentionally designed to be entirely performed using logistics and data obtained by the African participating centres, without any methodological or financial support from the French Society of Cardiology.
The participating cardiology departments had to fulfil the following requirements: availability of an archive department to store medical records; availability of Doppler-coupled ultrasound echocardiography; and availability of a trained cardiologist to perform two-dimensional (2D) Doppler ultrasound examinations. Among the 12 centres from the eight countries initially intended to take part in the study, one (Gabon) failed to fulfil the criteria for participation because of the lack of a suitable echocardiography laboratory archive department.
The study rationale was to provide data on disease characteristics, treatment and, when available, prognosis of RHD in sub-Saharan African referral centres for cardiovascular diseases. All referral centres in the countries participated in the study, except the one that failed to fulfil the inclusion criteria (Gabon). Referral centres involved in the study are listed in the Supplementary data, Online Table (online only supplement) . A 5-year retrospective analysis of patients hospitalized in these departments for any cardiac disease was performed, using patients’ hospital files, medical notes and echocardiographic examinations. Clinical presentation of patients, type and severity of valvular lesions, past and/or ongoing complications, key treatments and readmissions were noted. Patients were checked for educational level (none, Koranic, primary, secondary/high school, university), occupation (unemployed or housewife, craftsman or merchant, clerk, employee or manager), habitation (concrete block house or mud, cardboard or straw hut) and educational, social and professional adverse consequences of their heart disease (delays and school failure, prolonged periods off work, termination of employment).
Patients
We included patients aged at least 3 years, regardless of sex, with a suspicion of heart disease on the basis of clinical examination, and in whom the diagnosis of at least one valvular heart disease was clearly established by 2D Doppler-coupled echocardiography. All patients listed on the echocardiography registries’ files between January 2004 and December 2008 were included. The European Society of Cardiology and American Heart Association/American College of Cardiology guidelines were used for assessment of severity of valve lesions, left ventricular (LV) systolic dysfunction (LV ejection fraction [EF] ≤ 54%) and LV dilatation (LV ≥ 50 mm in children and ≥ 55 mm in adults) .
Patients without evidence of echocardiography-ascertained valvular disease were excluded. Also, patients with other causes of valvular damage, such as infective endocarditis, congenital, post-traumatic, dystrophic and degenerative lesions, cardiomyopathy and ischaemic or inflammatory diseases were excluded.
Data collection
Demographic and socioeconomic data, past history of cardiac complications, clinical and echocardiographic findings were recorded on case report forms at research sites and transmitted to the coordination site of the main investigator (S.K.). Data were collected using a standardized form ( Supplementary data, Online Figs. A and B; online only supplement ). Patients were classified into two groups in terms of the severity of valvular lesions, LV function and clinical impairment: patients with at least one valvular lesion suggestive of RHD, even mild; and patients with severe valvular lesions.
Heart failure was diagnosed in patients using clinical criteria, and classified using the New York Heart Association (NYHA) classification .
Ultrasound examination
The degree of expertise of the physicians who performed the ultrasound examinations (consultants, senior registrars) was not specified, but all examinations were performed by trained cardiologists. There were no echocardiography-trained technicians in any of the echocardiography laboratories involved in the study. According to simplified criteria recommended by current guidelines , the diagnosis of RHD was based on the presence of one or more of the following patterns: mitral valve [commissural fusion; typical marked thickening of the leaflet margins, cusps, chordae tendinae; thickening and shortening of chordal structures; restricted leaflet motion, excessive leaflet tip motion during systole, prolapse; funnel shape or buttonhole shape in case of mitral stenosis; annular and valvular calcifications; significant mitral regurgitation (jet length ≥ 2 cm in two planes, high velocity with mosaic pattern, pansystolic)]; aortic valve [irregular or focal thickening; coaptation defect; restricted leaflet motion; prolapse, calcification; significant aortic regurgitation (jet length ≥ 1 cm in two planes, high velocity with mosaic pattern, pandiastolic)]; multivalvular involvement in the same patient.
Statistical analysis
Continuous variables are expressed as means and standard deviations and categorical variables as frequencies and percentages; these were computed using the SPSS statistical software package (version 13.0; IBM, Armonk, NY, USA) and Epi Info™ (version 3.5.1; Centers for Disease Control and Prevention, Atlanta, GA, USA). Means comparisons were made using Student’s t -test. Percentages were compared using Pearson’s Chi 2 test. A probability of P < 0.05 was considered to be statistically significant.
Results
Patients
Among a total of 27,882 patients examined with 2D echocardiography between January 2004 and December 2008 in the 12 cardiology centres involved in the study, 3441 (12.3%) presented with a suspicion or at least one mild valvular lesion suggestive of RHD. There were 1388 men or young boys (40.3%) with a mean age of 28.3 ± 16.5 years, and 2053 women or young girls (59.7%) with a mean age of 31.1 ± 17.7 years. The age and sex distributions of patients are listed on Fig. 1 .
Among 2056 patients with mild RHD lesions, only 358 (17.4%) were hospitalized (including for non-cardiac diseases) and fulfilled the inclusion criteria. The lack of suitable medical records available for the remaining patients with mild RHD precluded their subsequent analysis.
Significant or severe rheumatic valvular lesions were observed in 1385 of included patients (40.2%), including 502 men or young boys and 803 women or young girls, with a mean age of 29.3 ± 15.6 years. This subgroup was analysed in the study. Patients were included in Cameroon ( n = 301), Guinea ( n = 358), Ivory Coast ( n = 80), Mali ( n = 118), Nigeria ( n = 51), Senegal ( n = 462) and Togo ( n = 15). Political instability during the study period resulted in inclusions of small numbers in Nigeria and Ivory Coast, where total numbers of patients with at least one mild RHD lesion were not obtained. Apart from Togo, where only 15 patients were included, the ratio of severe to at least one mild RHD lesion was higher in the countries with the lowest gross domestic product (GDP) ( Table 1 ).
| Patients with any lesion, at least mild ( n ) | Patients with severe RHD lesions ( n ) | Patients with severe RHD lesions (%) | Gross domestic product per inhabitant (USD) | |
|---|---|---|---|---|
| Cameroon | 1623 | 301 | 18.5 | 1328 |
| Ivory Coast | – | 80 | – | 1528 |
| Guinea | 477 | 358 | 75 | 523 |
| Mali | 120 | 118 | 98 | 715 |
| Nigeria | – | 51 | – | 3005 |
| Senegal | 980 | 462 | 47.5 | 1046 |
| Togo | 241 | 15 | 6.2 | 634 |
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