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Background: Cardiovascular disease is the most common cause of morbidity and premature mortality in patients on chronic haemodialysis. There are limited data on cardiac abnormalities among these patients in sub-Saharan Africa, including Uganda. We determined the prevalence and patterns of echocardiographic (echo) abnormalities among patients with end-stage renal disease (ESRD) on haemodialysis at Mulago National Referral Hospital, Kampala, Uganda. Methods: Eighty patients with ESRD on chronic haemodialysis were enrolled in the study over a period of five months from November 2017 to March 2018. We collected data on demographic and baseline clinical characteristics by reviewing charts and conducting patient interviews. Participants had blood pressure measurements performed and blood samples taken for laboratory investigations. We then conducted a cardiac evaluation using standard transthoracic echo protocols. Bivariable and multivariable analysis was performed to study associations with left ventricular hypertrophy and diastolic dysfunction. Results: Fifty-three of the 80 patients (66%) were male, mean age was 49 ± 16 years and the median duration on dialysis was 9.5 months (interquartile range 4–24 months). Twenty-eight (35%) had to travel >50 km to access dialysis. Seventy-four patients (93%) had at least one cardiac echo abnormality and 30% had at least three abnormalities. Left ventricular hypertrophy (68%) and diastolic dysfunction (64%) were the most common abnormalities. There was a high prevalence of factors that have previously been associated with left ventricular hypertrophy and diastolic dysfunction including anaemia (79%), poorly controlled hypertension (79%) and dyslipidaemia (56%) but none of these was statistically significantly associated in this study. Conclusions: Our study confirmed a high prevalence of cardiac abnormalities among a young population of African patients with ESRD on chronic dialysis. We recommend that echocardiography be part of the routine care to help plan early intervention for those at high risk of cardiovascular events.

ObjectiveEstimates of the prevalence of rheumatic heart disease (RHD) in many endemic countries are limited to samples of children attending schools, which generate an incomplete picture of disease burden in communities. The present study conducted household-based RHD screening in a representative community in Gulu district, Uganda.MethodsMembers of households identified through a two-stage cluster-sampling approach between the ages of 5 years and 50 years were invited to undergo limited cardiac testing with a handheld echocardiogram to assess for the presence of RHD. Suspicious cases underwent confirmatory echocardiogram with a fully functional machine.ResultsOf the 2453 community members screened, 2.45% (95% CI 1.87% to 3.14%) showed echocardiographic evidence of RHD with 1.26% (95% CI 0.860% to 1.79%) having definite RHD. The overall prevalence of RHD among participants 20 years) of RHD was 2.34% (95% CI 1.49% to 3.49%). The majority of definite cases were mild (81%) and marked by mitral regurgitation and associated morphological valve changes (71%).ConclusionOur data reveal a high prevalence of undiagnosed RHD within an endemic community and fill a critical gap in RHD epidemiology in African adults.

Background Although rheumatic heart disease remains the leading cause of valve heart disease (VHD) in developing countries, other forms of valve disease have been over shadowed and not regarded as a public health problem. However, several facts suggest that the role of non-rheumatic VHD as a significant cardiovascular disease should be reconsidered. We aimed to assess the prevalence and characteristics of different forms of primary left sided valve diseases from a series of 15,009 echocardiographic studies. Methods This was a retrospective review of echocardiographic reports for studies performed between January 2012 and December 2013 (24 months) at Uganda Heart Institute. All patients with primary left-sided valve disease were classified into one of five major diagnostic categories and in each diagnostic category; patients were sub-classified into stages A-D of primary valve disease as defined by the American College of Cardiology. Results Three thousand five hundred eighty-two echocardiography reports qualified for final data analysis. The “sclerotic valve changes with normal valve function”, a Stage A sub-class of “degenerative valve disease” overwhelmingly overshadowed all the other diagnostic categories in this stage. “Rheumatic Heart Disease”, “Degenerative Valve Disease”, “Bicuspid Aortic Valve”, “Mitral Valve Prolapse” and “Endomyocardial Fibrosis” diagnostic categories accounted for 53.0%, 41.8%, 2.2%, 1.4% and 1.7% respectively in stages B-D of primary VHD. Rheumatic heart disease disproportionately affected the young, productive age groups. It was the major risk factor for infective endocarditis; and was the indication for valve surgery in 44 of 50 patients who had undergone valve replacement procedures. Conclusions We acknowledge that rheumatic heart disease remains a leading cause of progressive and severe primary left-sided valve disease among young adults in Uganda. But we bring to light the contemporary footprints of other forms of primary valve disease that require coordinated multidisciplinary approach to research, education and clinical management to ensure improved patient outcomes.

To assess the impact of a peer-support group on knowledge, quality of life, and social support for children with rheumatic heart disease (RHD).Children diagnosed with RHD and receiving 4-weekly injectable penicillin were invited to participate in a monthly support group for 6 months. Pre- and post-intervention assessments included a baseline RHD knowledge assessment, a measure of health related quality of life (HRQOL) (PedsQL42 participants attended ≥3 groups and were included in the analyses. Attending support groups resulted in increased total HRQOL scores (60.3v 70.2, p0.001), as well as the following HRQOL sub-scores (physical functioning 55.3v 68.6 (p0.001), social functioning 64.2v 75.8 (p0.001) and school functioning 59.2v 69.1 (p=0.001)). Significant increases in Friendship Scale scores (15.4v 19.7, p0.001) and RHD Knowledge scores were observed (3.6v 6.4, p0.001).Peer-support groups may be effective at normalizing decreased HRQOL scores and increasing RHD disease knowledge and social support.Peer-support groups implemented in conjunction with RHD screening can minimize the negative psychosocial effects associated with early RHD detection.

IMPORTANCE: Rheumatic heart disease (RHD), a sequela of rheumatic fever characterized by permanent heart valve damage, is the leading cause of cardiac surgery in Africa. However, its pathophysiologic characteristics and genetics are poorly understood. Understanding genetic susceptibility may aid in prevention, control, and interventions to eliminate RHD. OBJECTIVE: To identify common genetic loci associated with RHD susceptibility in Black African individuals. DESIGN, SETTING, AND PARTICIPANTS: This multicenter case-control genome-wide association study (GWAS), the Genetics of Rheumatic Heart Disease, examined more than 7 million genotyped and imputed single-nucleotide variations. The 4809 GWAS participants and 116 independent trio families were enrolled from 8 African countries between December 31, 2012, and March 31, 2018. All GWAS participants and trio probands were screened by use of echocardiography. Data analyses took place from May 15, 2017, until March 14, 2021. MAIN OUTCOMES AND MEASURES: Genetic associations with RHD. RESULTS: This study included 4809 African participants (2548 RHD cases and 2261 controls; 3301 women [69%]; mean [SD] age, 36.5 [16.3] years). The GWAS identified a single RHD risk locus, 11q24.1 (rs1219406 [odds ratio, 1.65; 95% CI, 1.48-1.82; P = 4.36 × 10(−8)]), which reached genome-wide significance in Black African individuals. Our meta-analysis of Black (n = 3179) and admixed (n = 1055) African individuals revealed several suggestive loci. The study also replicated a previously reported association in Pacific Islander individuals (rs11846409) at the immunoglobulin heavy chain locus, in the meta-analysis of Black and admixed African individuals (odds ratio, 1.16; 95% CI, 1.06-1.27; P = 1.19 × 10(−3)). The HLA (rs9272622) associations reported in Aboriginal Australian individuals could not be replicated. In support of the known polygenic architecture for RHD, overtransmission of a polygenic risk score from unaffected parents to affected probands was observed (polygenic transmission disequilibrium testing mean [SE], 0.27 [0.16] SDs; P = .04996), and the chip-based heritability was estimated to be high at 0.49 (SE = 0.12; P = 3.28 × 10(−5)) in Black African individuals. CONCLUSIONS AND RELEVANCE: This study revealed a novel candidate susceptibility locus exclusive to Black African individuals and an important heritable component to RHD susceptibility in African individuals.

Background: Task sharing of TTE may improve capacity for heart failure diagnosis and management in patients in remote, low-resource settings but the impact on diagnostic accuracy and patient outcomes has not been studied. Objectives: Determine feasibility and impact of non-expert training in transthoracic echocardiography (TTE) to improve the diagnosis and outcomes of patients with suspected heart failure in Uganda. Methods: This two-part study examined an innovative training program to develop TTE competency among non-experts and used a pre-post design to determine the impact of decentralized TTE. Four of 8 non-experts (50%) passed a three-part training course. The training comprised of distance learning through a web-based curriculum, a 2-day hands-on workshop with cardiologists, and independent practice with remote mentorship. Continuous measures were compared (pre- vs. post-TTE) using t-tests or Wilcoxon rank-sum tests as distributionally appropriate and categorical variables assessed through chi-square testing. Sensitivity and specificity were calculated according to standard methodology comparing diagnosis pre- and post-TTE during phase 2. Results: Performance in the post-training phase showed good agreement with expert categorization (κ = 0.80) with diagnostic concordance in 421 of 454 studies (92.7%). TTE changed the preliminary diagnosis in 81% of patients, showing low specificity of clinical decision-making alone (14.2%; 95% CI 10.1–19.2%). Dilated cardiomyopathy, hypertensive heart disease with preserved systolic function, and right heart failure were the most underdiagnosed conditions prior to TTE while hypertensive heart disease with decreased systolic function was the most over-diagnosed condition. Conclusions: In conclusion, non-expert providers can achieve a high level of proficiency for the categorization of heart failure using handheld TTE in low-resource settings and use of telemedicine and remote mentorship may improve performance and feasibility. The addition of TTE resulted in substantial improvement in etiological specificity. Further study is needed to understand implications of this strategy on healthcare utilization, long-term patient outcomes, and cost.

Background Group A Streptococcus (GAS) skin infections can lead to invasive sepsis, poststreptococcal glomerulonephritis, and potentially rheumatic heart disease (RHD). Within a study to identify predisposing factors of RHD in Ugandan schoolchildren, we determined the prevalence of skin infections and assessed the clinical features and antibiotic susceptibility of GAS skin infection. Methods Cross-sectional study conducted at 3 urban primary schools in Western and Northern Uganda in March 2017. A dermatologist rendered clinical diagnoses and obtained a skin swab specimen from lesions with signs of bacterial infection. Beta-hemolytic colonies underwent Lancefield grouping, species identification by polymerase chain reaction and antimicrobial susceptibility testing. Results From 3265 schoolchildren, we observed 32% with ≥1 fungal, 1.8% with ≥1 bacterial, 0.9% with ≥1 viral, and 0.2% with ≥1 ectoparasitic infection. Of 79, 25 (32%) specimens were GAS-positive, of which one-third demonstrated tetracycline resistance. Of 17 impetigo cases, 13 (76%) were located on the leg/foot and 3 (18%) on the head/neck. Prevalence of GAS skin infection was 0.8% (25 of 3265). In Northern Uganda, where subclinical definite RHD prevalence is 1.1%, GAS skin infection prevalence was 1.2% (4 of 343) and 0.9% (3 of 352). Conclusion This study identifies tetracycline-resistant GAS in Ugandan communities, suggests modified skin examination of exposed anatomic locations may be appropriate for population-based GAS skin infection studies, and underscores need for clear case definitions of GAS skin infection. Future studies are needed to evaluate the role of GAS skin infection in development of RHD in Ugandan communities.

Background Screening echocardiography (echo) detects subclinical rheumatic heart disease (RHD) which is categorised as definite or borderline. The natural history of subclinical RHD is not known. Follow up single centre studies have included a relatively small number of participants, and have shown variable progression rates. Aim To determine incidence of and factors associated with progression and regression among a cohort of children with baseline subclinical RHD across multiple countries and regions. Methods This is a retrospective cohort study of RHD evolution in children with subclinical RHD. Study sites were Australia, Fiji, Malawi, New Zealand, and Uganda. Progression or regression was determined from echos obtained at baseline and most recent follow-up. Factors associated with echo progression or regression were identified using multivariable logistic regression. Results 482 participants (131 with definite, 351 with borderline subclinical RHD) from 5 countries were included (mean age 11.5 years, range 5–19 years). Mean follow up was 3.4 yrs (range 0.4–9.5 yrs). Of 482 participating children, 204 (42%) regressed. Among 131 children with definite lesions, 48 (37%) regressed to borderline or normal, and 83 (63%) remained definite. Among 351 children with borderline lesions, 39 (11.1%) progressed, 156 (44.4%) remained borderline, and 156 (44.4%) regressed to normal. World Heart Federation defines subcategories based on characteristics of affected valves. By subcategory, children with definite C (pathological aortic regurgitation and 2 morphologic characteristics of the aortic valve) and borderline A (at least 2 morphologic features of the mitral valve without pathologic mitral regurgitation or stenosis) were less likely to regress, and borderline A was more likely to progress. In univariable analysis, good adherence (>80%) to penicillin prophylaxis (BPG) was associated with more regression among all patients (definite + borderline) (OR 1.9, CI 1, 3.5; p=0.04) but this association did not remain significant after adjustment. With multivariable analysis, borderlines prescribed BPG was the only factor related to progression from borderline to definite (OR 4.1, CI 1.8, 9.3, p Conclusion This is the largest reported subclinical RHD cohort followed to report outcomes. 42% of definite RHD regressed with subtype C more likely to regress. 11% of borderline RHD progressed. Borderline A was more likely to progress and less likely to regress. We have also identified that being prescribed BPG is associated with borderline progression. This is likely because children with more advanced borderline disease may be more likely to be prescribed BPG. This study highlights that RHD evolution is variable out to 3–4 years post echo detection. While borderline disease is likely, in some cases, to reflect the earliest change of RHD, how this should be monitored and whether it should be treated with BPG should be a priority for future prospective evaluation.

Aims Cardiac arrhythmia services are a neglected field of cardiology in Africa. To provide comprehensive contemporary information on the access and use of cardiac arrhythmia services in Africa. Methods and results Data on human resources, drug availability, cardiac implantable electronic devices (CIED), and ablation procedures were sought from member countries of Pan African Society of Cardiology. Data were received from 23 out of 31 countries. In most countries, healthcare services are primarily supported by household incomes. Vitamin K antagonists (VKAs), digoxin, and amiodarone were available in all countries, while the availability of other drugs varied widely. Non-VKA oral anticoagulants (NOACs) were unequally present in the African markets, while International Normalized Ratio monitoring was challenging. Four countries (18%) did not provide pacemaker implantations while, where available, the implantation and operator rates were 2.79 and 0.772 per million population, respectively. The countries with the highest pacemaker implantation rate/million population in descending order were Tunisia, Mauritius, South Africa, Algeria, and Morocco. Implantable cardioverter-defibrillator and cardiac resynchronization therapy (CRT) were performed in 15 (65%) and 12 (52%) countries, respectively. Reconditioned CIED were used in 5 (22%) countries. Electrophysiology was performed in 8 (35%) countries, but complex ablations only in countries from the Maghreb and South Africa. Marked variation in costs of CIED that severely mismatched the gross domestic product per capita was observed in Africa. From the first report, three countries have started performing simple ablations. Conclusion The access to arrhythmia treatments varied widely in Africa where hundreds of millions of people remain at risk of dying from heart block. Increased economic and human resources as well as infrastructures are the critical targets for improving arrhythmia services in Africa.

Background: The 2012 World Heart Federation Criteria are the current gold standard for the diagnosis of latent rheumatic heart disease (RHD). Because data and experience using these criteria have grown, there is opportunity to simplify and develop outcome prediction tools. We aimed to develop a simple echocardiographic score applicable for RHD screening with potential to predict disease progression. Methods: This study included 3 cohorts used for score derivation (n=9501), score validation (n=7312), and assessment of outcomes prediction (n=227). In the derivation cohort, variables independently associated with definite RHD were assigned point values proportional to their regression coefficients. The sum of these values was stratified into low (0–6), intermediate (7–9), and high (≥10) risk. Results: Five components were selected for score development, including mitral valve anterior leaflet thickening, excessive leaflet tip motion, and regurgitation jet length ≥2 cm, and aortic valve focal thickening and any regurgitation. The score showed optimal discrimination and calibration for RHD diagnosis in the derivation and validation cohorts (C statistic, 0.998 and 0.994, respectively), with good discrimination for predicting disease progression (C statistic, 0.811). Progression-free survival rate in the low-risk children at 1-, 2-, and 3-year follow-up was 100%, 100%, and 93%, respectively, compared with 90%, 60%, and 47% in high-risk group. The point-based score was strongly associated with disease progression (hazard ratio, 1.270; 95% CI, 1.188–1.358; P Conclusions: This simplified score, based on components of the World Heart Federation criteria, is highly accurate to recognize definite RHD and provides the first tool for risk stratification, assigning children with latent RHD to low, intermediate, or high risk based on echocardiographic features at diagnosis.

BackgroundCentral to rheumatic fever (RF) diagnosis is evidence of streptococcal exposure, specifically antistreptolysin O (ASO) and antideoxyribonuclease B (ADB) antibodies. It is unknown if these antibody titers should be adjusted to the background exposure rates of GAS or if published standards should be used. Here, we establish the normal values of ASO and ADB in Uganda and examine RF case detection using published vs. population-specific thresholds.MethodsParticipants (age 0-50 years) were recruited. ASO was measured in-country by nephelometric technique. ADB samples were sent to Australia (PathWest) for ADB determination by enzyme inhibition assay, andthe 80% upper limit values by age were established. The published standard values for ASO (200IU/ml) and ADB (375IU/ml) were compared to the Ugandan 80% upper limit of normal values (ULN) for RF case detection in children 5-15 years.FindingsOf the 428 participants, 16 were excluded from analysis (9 sore throat, 1 skin sores, 5 fever, 4 echocardiograms showing occult RHD), and 183 of the remaining were children 5-15 years. The median ASO titer in this age group was 220 IU/ml, with the 80th percentile value of 389 IU/ml. The median ADB titer in this age group was 375 IU/ml, with the 80th percentile value of 568 IU/ml. Application of new Ugandan cutoffs to 528 children enrolled in our prospective RF study, reduced the number of definite RF cases to 120/528 (22·7%), as compared to 173/528 (32·8%) using published normal values.InterpretationThe 80th percentile ULN for ASO and ADB are higher in Uganda than in other countries. Applying these higher values to RF diagnosis in Uganda results in higher diagnostic specificity, but some unknown loss in sensitivity. Implications of over-diagnosis and missed cases will be explored through a longitudinal follow-up study of children in the RF research program.FundingThis work was supported by American Heart Association Grant #17SFRN33670607 / Andrea Beaton / 2017 and DELTAS Africa Initiative.Research in contextEvidence before this studyWe searched PubMed for data on normal values of streptococcal antibody titers within diverse populations between database inception and January 1, 2019, using the search terms (rheumatic fever) OR (streptococcal antibodies). Nine studies were identified, but only one was from sub-Saharan Africa (2018, Ethiopia) and it was limited by vague exclusion criteria and lack of data on anti-DNase B. Given the high burden of rheumatic heart disease in sub-Saharan Africa, further data is needed to determine normal streptococcal antibody titers in this population and to assess the clinical impact of different cutoffs for RF diagnosis.Added value of this studyOur study utilized a rigorous approach to exclude patients with history of recent possible streptococcal exposure including skin and throat infection and employed echocardiography to exclude patients with pre-existing rheumatic heart disease. Additionally, this study was conducted in parallel to a larger epidemiological cohort study of rheumatic fever in Uganda, allowing us, for the first time, to prospectively determine how utilization of different streptococcal antibody titer cutoffs affect diagnosis of rheumatic fever.Implications of all the available evidenceRheumatic fever remains a challenging diagnosis based on a clinical decision rule with imperfect sensitivity and specificity. Improved understanding of streptococcal antibody titers in rheumatic heart disease endemic populations may improve diagnostic performance. Our study also points to the need for development of a rheumatic fever diagnostic test, in order to provide a more definitive assessment of risk.

Background: There are few contemporary data on the mortality and morbidity associated with rheumatic heart disease or information on their predictors. We report the 2-year follow-up of individuals with rheumatic heart disease from 14 low- and middle-income countries in Africa and Asia. Methods: Between January 2010 and November 2012, we enrolled 3343 patients from 25 centers in 14 countries and followed them for 2 years to assess mortality, congestive heart failure, stroke or transient ischemic attack, recurrent acute rheumatic fever, and infective endocarditis. Results: Vital status at 24 months was known for 2960 (88.5%) patients. Two-thirds were female. Although patients were young (median age, 28 years; interquartile range, 18–40), the 2-year case fatality rate was high (500 deaths, 16.9%). Mortality rate was 116.3/1000 patient-years in the first year and 65.4/1000 patient-years in the second year. Median age at death was 28.7 years. Independent predictors of death were severe valve disease (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.80–3.11), congestive heart failure (HR, 2.16; 95% CI, 1.70–2.72), New York Heart Association functional class III/IV (HR, 1.67; 95% CI, 1.32–2.10), atrial fibrillation (HR, 1.40; 95% CI, 1.10–1.78), and older age (HR, 1.02; 95% CI, 1.01–1.02 per year increase) at enrollment. Postprimary education (HR, 0.67; 95% CI, 0.54–0.85) and female sex (HR, 0.65; 95% CI, 0.52–0.80) were associated with lower risk of death. Two hundred and four (6.9%) patients had new congestive heart failure (incidence, 38.42/1000 patient-years), 46 (1.6%) had a stroke or transient ischemic attack (8.45/1000 patient-years), 19 (0.6%) had recurrent acute rheumatic fever (3.49/1000 patient-years), and 20 (0.7%) had infective endocarditis (3.65/1000 patient-years). Previous stroke and older age were independent predictors of stroke/transient ischemic attack or systemic embolism. Patients from low- and lower-middle–income countries had significantly higher age- and sex-adjusted mortality than patients from upper-middle–income countries. Valve surgery was significantly more common in upper-middle–income than in lower-middle– or low-income countries. Conclusions: Patients with clinical rheumatic heart disease have high mortality and morbidity despite being young; those from low- and lower-middle–income countries had a poorer prognosis associated with advanced disease and low education. Programs focused on early detection and the treatment of clinical rheumatic heart disease are required to improve outcomes.

Background Rheumatic heart disease (RHD) and HIV are prevalent diseases in sub-Saharan Africa, but little is known about their potential interrelationships. The objective of this study was to assess the prevalence of protective natural autoantibodies among patients with RHD in Uganda, and to determine whether the levels of these autoantibodies are affected by HIV status. Methods Participants were grouped according to RHD and HIV status. The three control groups (RHD − HIV −, RHD − HIV +, RHD + HIV −) were age-matched to the RHD + HIV + participants. All participants underwent HIV testing and echocardiography to evaluate for RHD. Natural autoantibody levels reactive with phosphorylcholine (PC) and malondialdehyde (MDA) were measured. Findings We enrolled 220 participants; 21 with both RHD and HIV. Ages ranged from 10 to 60 years, with female predominance (144/220, 65%). After adjusting for age and gender, HIV infection and RHD were each associated with low IgM anti-PC (HIV: p, Highlights • Little is known about rheumatic heart disease (RHD) in people with HIV. • Natural autoantibodies have roles in other autoimmune and inflammatory diseases. • HIV and RHD are associated with alterations in levels of natural autoantibodies. • These alterations may impact disease pathogenesis and risk for atherosclerosis. Natural arising autoantibodies to oxidation-associated epitopes such as phosphorylcholine and malondialdehyde have been shown to modulate the initiation and progression of a range of immune-mediated inflammatory diseases including atherosclerosis and systemic lupus erythematous (SLE). This cross-sectional study examined natural autoantibodies among people with rheumatic heart disease (RHD) and HIV. It provides initial support for the hypothesis that these natural autoantibodies may be altered by HIV infection in ways that increase risk for atherosclerosis and autoimmune diseases such as RHD.

Objectives Few African countries have the resources to provide optimal cardiac surgery care. We explored needs at cardiac surgery centers in Namibia, Zambia, and Uganda. Our objectives were (1) to determine the key variables to be included in a cardiac surgery needs assessment tool and (2) to highlight the current initiatives, challenges and opportunities, and future goals for cardiac surgery in these 3 countries. Methods We conducted in-depth interviews with stakeholders in each country as well as surveys of surgical facilities. We synthesized our findings using a health systems conceptual framework. Each program's current capacity was compared with a standardized definition of "adequate" surgical capacity. On the basis of these findings, we developed a formal needs assessment questionnaire for use in resource-constrained countries. Results Although each of these countries has adequate facilities and surgical expertise, they still lack key support staff and material resources. Training and mentorship programs are being built, and the sites participate in cardiovascular research. Yet a comprehensive, multidisciplinary approach—including palliative care and rehabilitation—is lacking, and patients in remote areas are not being served. These observations allowed us to define the variables in our needs assessment tool. Conclusions Our study demonstrates the great potential that exists to expand cardiac surgery in Africa and highlights some of the major resource bottlenecks that may hinder the scale-up of surgical programs. Our needs assessment questionnaire will assist ministries of health in building sustainable cardiac surgery programs using innovative Afro-centric solutions.

BackgroundThe burden of pre-existing cardiovascular disease and the contribution to adverse pregnancy outcomes are not robustly quantified, particularly in low-income countries. We aimed to determine both the prevalence of maternal heart disease through active case finding and its attributable risk to adverse pregnancy outcomes.MethodsWe conducted a 24-month prospective longitudinal investigation in three Ugandan health centres, using echocardiography for active case finding during antenatal care. Women with and without heart disease were followed to 6 weeks post partum to determine pregnancy outcomes. Prevalence of heart disease was calculated. Per cent attributable risk estimates were generated for maternal, fetal and neonatal mortality.ResultsScreening echocardiography was performed in 3506 women. The prevalence of heart disease was 17 per 1000 women (95% CI 13 to 21); 15 per 1000 was rheumatic heart disease. Only 3.4% of women (2/58) had prior diagnosis. Cardiovascular complications occurred in 51% of women with heart disease, most commonly heart failure. Per cent attributable risk of heart disease on maternal mortality was 88.6% in the exposed population and 10.8% in the overall population. Population attributable risk of heart disease on fetal death was 1.1% and 6.0% for neonatal mortalityConclusionsOccult maternal heart disease may be responsible for a substantial proportion of adverse pregnancy outcomes in low-resource settings. Rheumatic heart disease is, by far, the most common condition, urging global prioritisation of this neglected cardiovascular disease.

Background There is mounting evidence to support the influence of inflammation and oxidative stress in the pathogenesis of atrial fibrillation (AF) and heart failure (HF). The efficacy of coenzymeQ10 (CoQ10), an antioxidant used as an adjunct treatment in patients with AF and HF, remains less well established. Methods Consecutive patients with HF were randomized and divided into 2 groups: the CoQ10 group (combined administration of common drugs and CoQ10) and the control group (administration of common drugs). Ambulatory electrocardiogram Holter monitoring (24 hours), Doppler echocardiography, and evaluation of inflammatory cytokines were performed before treatment and 6 and 12 months after treatment. Results One hundred two patients (72 male and 30 female patients), with ages ranging from 45 to 82 years (mean age, 62.3 years), were examined. There was significant reduction in the level of malondialdehyde (3.9 ± 0.7 vs 2.5 ± 0.6 ng/mL; 3.9 ± 0.7 vs 2.3 ± 0.5 ng/mL, P < 0.05) in the CoQ10 group, whereas there was no significant difference (3.3 ± 0.8 vs 2.9 ± 0.8 ng/mL; 3.3 ± 0.8 vs 2.9 ± 0.5 ng/mL) in the control group after 6 and 12 months. Three patients (6.3%) in the CoQ10 group and 12 patients (22.2%) in the control group had episodes of AF after 12 months’ treatment ( P = 0.02). Four patients with AF in the control group went through the third Holter recording. Conclusions CoenzymeQ10 as adjuvant treatment in patients with HF may attenuate the incidence of AF. The mechanisms of the effect perhaps have relation with the reduced levels of malondialdehyde.

Background— Rheumatic heart disease (RHD) is a leading cause of premature death and disability in low-income countries; however, few receive optimal benzathine penicillin G (BPG) therapy to prevent disease progression. We aimed to comprehensively describe the treatment cascade for RHD in Uganda to identify appropriate targets for intervention. Methods and Results— Using data from the Uganda RHD Registry (n=1504), we identified the proportion of patients in the following care categories: (1) diagnosed and alive as of June 1, 2016; (2) retained in care; (3) appropriately prescribed BPG; and (4) optimally adherent to BPG (>80% of prescribed doses). We used logistic regression to investigate factors associated with retention and optimal adherence. Overall, median (interquartile range) age was 23 (15–38) years, 69% were women, and 82% had clinical RHD. Median follow-up time was 2.4 (0.9–4.0) years. Retention in care was the most significant barrier to achieving optimal BPG adherence with only 56.9% (95% confidence interval, 54.1%–59.7%) of living subjects having attended clinic in the prior 56 weeks. Among those retained in care, however, we observed high rates of BPG prescription (91.6%; 95% confidence interval, 89.1%–93.5%) and optimal adherence (91.4%; 95% confidence interval, 88.7–93.5). Younger age, latent disease status, and access to care at a regional center were the strongest independent predictors of retention and optimal adherence. Conclusions— Our study suggests that improving retention in care—possibly by decentralizing RHD services—would have the greatest impact on uptake of antibiotic prophylaxis among patients with RHD in Uganda.

In this case study, we describe an ongoing approach to develop sustainable acute and chronic cardiovascular care infrastructure in Uganda that involves patient and provider participation. Leveraging strong infrastructure for HIV/AIDS care delivery, University Hospitals Harrington Heart and Vascular Institute and Case Western Reserve University have partnered with U.S. and Ugandan collaborators to improve cardiovascular capabilities. The collaboration has solicited innovative solutions from patients and providers focusing on education and advanced training, penicillin supply, diagnostic strategy (e.g., hand-held ultrasound), maternal health, and community awareness. Key outcomes of this approach have been the completion of formal training of the first interventional cardiologists and heart failure specialists in the country, establishment of 4 integrated regional centers of excellence in rheumatic heart disease care with a national rheumatic heart disease registry, a penicillin distribution and adherence support program focused on retention in care, access to imaging technology, and in-country capabilities to treat advanced rheumatic heart valve disease.

Aims To provide comprehensive information on the access and use of cardiac implantable electronic devices (CIED) and catheter ablation procedures in Africa. Methods and results The Pan-African Society of Cardiology (PASCAR) collected data on invasive management of cardiac arrhythmias from 2011 to 2016 from 31 African countries. A specific template was completed by physicians, and additional information obtained from industry. Information on health care systems, demographics, economics, procedure rates, and specific training programs was collected. Considerable heterogeneity in the access to arrhythmia care was observed across Africa. Eight of the 31 countries surveyed (26%) did not perform pacemaker implantations. The median pacemaker implantation rate was 2.66 per million population per country (range: 0.14–233 per million population). Implantable cardioverter-defibrillator and cardiac resynchronization therapy were performed in 12/31 (39%) and 15/31 (48%) countries respectively, mostly by visiting teams. Electrophysiological studies, including complex catheter ablations were performed in all countries from Maghreb, but only one sub-Saharan African country (South Africa). Marked variation in cost (up to 1000-fold) was observed across countries with an inverse correlation between implant rates and the procedure fees standardized to the gross domestic product per capita. Lack of economic resources and facilities, high cost of procedures, deficiency of trained physicians, and non-existent fellowship programs were the main drivers of under-utilization of interventional cardiac arrhythmia care. Conclusion There is limited access to CIED and ablation procedures in Africa. A quarter of countries did not have pacemaker implantation services, and catheter ablations were only available in one country in sub-Saharan Africa.

BackgroundEchocardiographic screening represents an opportunity for reduction in the global burden of rheumatic heart disease. A focussed single-view screening protocol could allow for the rapid training of healthcare providers and screening of patients.ObjectiveThe aim of this study was to determine the sensitivity and specificity of a focussed single-view hand-held echocardiographic protocol for the diagnosis of rheumatic heart disease in children.MethodsA total of nine readers were divided into three reading groups; each interpreted 200 hand-held echocardiography studies retrospectively as screen-positive, if mitral regurgitation ⩾1.5 cm and/or any aortic insufficiency were observed, or screen-negative from a pooled study library. The performance of experts receiving focussed hand-held protocols, non-experts receiving focussed hand-held protocols, and experts receiving complete hand-held protocols were determined in comparison with consensus interpretations on fully functional echocardiography machines.ResultsIn all, 587 studies including 76 on definite rheumatic heart disease, 122 on borderline rheumatic heart disease, and 389 on normal cases were available for analysis. The focussed single-view protocol had a sensitivity of 81.1%, specificity of 75.5%, negative predictive value of 88.5%, and a positive predictive value of 63.2%; expert readers had higher specificity (86.1 versus 64.8%, pConclusionOur data support a focussed screening protocol limited to parasternal long-axis images. This holds promise in making echocardiographic screening more practical in regions where rheumatic heart disease remains endemic.

Background: Screening echocardiography has emerged as a potentially powerful tool for early diagnosis of rheumatic heart disease (RHD). The utility of screening echocardiography hinges on the rate of RHD progression and the ability of penicillin prophylaxis to improve outcome. We report the longitudinal outcomes of a cohort of children with latent RHD and identify risk factors for unfavorable outcomes. Methods: This was a prospective natural history study conducted under the Ugandan RHD registry. Children with latent RHD and ≥1 year of follow-up were included. All echocardiograms were re-reviewed by experts (2012 World Heart Federation criteria) for inclusion and evidence of change. Bi- and multivariable logistic regression, Kaplan-Meier analysis, and Cox proportional hazards models, as well, were developed to search for risk factors for unfavorable outcome and compare progression-free survival between those treated and not treated with penicillin. Propensity and other matching methods with sensitivity analysis were implemented for the evaluation of the penicillin effect. Results: Blinded review confirmed 227 cases of latent RHD: 164 borderline and 63 definite (42 mild, 21 moderate/severe). Median age at diagnosis was 12 years and median follow-up was 2.3 years (interquartile range, 2.0–2.9). Penicillin prophylaxis was prescribed in 49.3% with overall adherence of 84.7%. Of children with moderate-to-severe definite RHD, 47.6% had echocardiographic progression (including 2 deaths), and 9.5% had echocardiographic regression. Children with mild definite and borderline RHD showed 26% and 9.8% echocardiographic progression and 45.2% and 46.3% echocardiographic improvement, respectively. Of those with mild definite RHD or borderline RHD, more advanced disease category, younger age, and morphological mitral valve features were risk factors for an unfavorable outcome. Conclusions: Latent RHD is a heterogeneous diagnosis with variable disease outcomes. Children with moderate to severe latent RHD have poor outcomes. Children with both borderline and mild definite RHD are at substantial risk of progression. Although long-term outcome remains unclear, the initial change in latent RHD may be evident during the first 1 to 2 years following diagnosis. Natural history data are inherently limited, and a randomized clinical trial is needed to definitively determine the impact of penicillin prophylaxis on the trajectory of latent RHD.

Background Beta-hemolytic streptococci carrier rates in children living in low-income countries are high ranging from 10 to 50%. Although most of these children are asymptomatic, they are a reservoir and pose a risk of transmission. The aim of this study was to determine the prevalence of group a streptococcus pharyngeal carriage and clinical manifestations in school going children in Wakiso district, Uganda. Methods A cross sectional study targeting children age 5–15 years in primary schools in one sub-county of Wakiso district was carried out. Three hundred and sixty-six children from five primary schools were enrolled and evaluated for group a streptococcus (GAS) carriage. A semi-structured questionnaire was used to collect data that included social demographics, school environment and clinical findings. For every enrolled child a throat swab was taken and cultured for GAS and blood was drawn for anti-streptolysin-O titres. Analysis of data was done using STATA. Results The prevalence of GAS carriage was 16%. The children with GAS positive cultures were mainly females. The factor associated with GAS carriage was the school location, with peri-urban schools more likely to have children with GAS compared to rural schools; AOR 2.48 (95% CI: 1.01 – 6.11), P = 0.049. There was no significant difference between the characteristic of children with GAS positive verses GAS negative throat swab cultures. Conclusion There is a high prevalence of GAS pharyngeal carriage among children aged 5–15 years attending primary schools in Wakiso District, Uganda. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2353-5) contains supplementary material, which is available to authorized users.

BACKGROUND: The Wilkins score and commissural calcification scores predict outcomes after percutaneous balloon mitral valvuloplasty. However, many cardiologists are inadequately trained in their application—both in the United States where the incidence of rheumatic heart disease (RHD) has fallen but also in RHD endemic countries where training infrastructure is weak. OBJECTIVES: The objectives were (1) to develop a computer based educational module teaching two scoring systems for rheumatic mitral stenosis, and (2) to validate the module among cardiology fellows in the United States and Uganda. STUDY DESIGN-SETTING-PATIENTS: We developed a module organized into 3 sets of 10 echocardiograms each. The module was completed by 13 cardiology fellows from two academic centers in the United States and one in Uganda. Subject answers were compared with a score assigned by two experts in echocardiography. OUTCOME MEASURES: The primary outcome was change in subjects’ accuracy from set 1 to set 3, measured by mean absolute deviation from expert scores. Secondary outcomes included change in interoperator variability and individual subject bias from set 1 to set 3. FINDINGS AND INTERPRETATION: The mean absolute deviations from expert scores in sets 1 and 3 were 2.09 and 1.82 for the Wilkins score (possible score range 0–16) and 1.13 and 0.94 for the commissural calcification score (possible score range 0–4). The change from set 1 to set 3 was statistically significant only for one of the Wilkins component scores (leaflet calcification, p

Background : The estimated rate of sudden cardiac death (SCD) in Western countries ranges from 300 000 to 400 000 annually, which represents 0.36 to 1.28 per 1 000 inhabitants in Europe and the United States. The burden of SCD in Africa is unknown. Our aim is to assess the epidemiology of SCD in Africa. Methods : The Pan-Africa SCD study is a prospective, multicentre, community-based registry monitoring all cases of cardiac arrest occurring in victims over 15 years old. We will use the definition of SCD as 'witnessed natural death occurring within one hour of the onset of symptoms' or 'unwitnessed natural death within 24 hours of the onset of symptoms'. After approval from institutional boards, we will record demographic, clinical, electrocardiographic and biological variables of SCD victims (including survivors of cardiac arrest) in several African cities. All deaths occurring in residents of districts of interest will be checked for past medical history, circumstances of death, and autopsy report (if possible). We will also analyse the employment of resuscitation attempts during the time frame of sudden cardiac arrest (SCA) in various patient populations throughout African countries. Conclusion : This study will provide comprehensive, contemporary data on the epidemiology of SCD in Africa and will help in the development of strategies to prevent and manage cardiac arrest in this region of the world.

Background Rheumatic heart disease (RHD) remains endemic in most of the developing world. Echocardiography has proved highly sensitive for early detection of RHD, but it remains too costly for most low-income settings. Handheld ultrasound machines used to perform handheld echocardiography (HAND) are both less expensive and more portable, possibly making them ideal screening tools. HAND has never been tested for the early diagnosis of RHD. The aim of this study was to evaluate the performance of focused HAND compared with focused standard portable echocardiography for the diagnosis of subclinical RHD. Methods HAND and standard portable echocardiography were performed on 125 Ugandan children, 41 with borderline or definite RHD, and 84 healthy controls. Images were blindly reviewed according to the 2012 World Heart Federation guidelines. Results HAND was highly sensitive (90.2%) and specific (92.9%) for distinguishing between normal patients and those with RHD, but it performed best with definite RHD. HAND overestimated mitral valve morphologic valve abnormalities, being only 66.7% specific for anterior leaflet thickness > 3 mm and 79.0% specific for restricted leaflet motion. False-negative results ( n = 4) were due primarily to underestimation of mitral regurgitation length. Conclusions In this population, HAND was highly sensitive and specific for early detection of RHD. HAND functions best as a screening tool with confirmation of positive screening results by fully functional echocardiography machines. Technical advances may enable one-step RHD screening using HAND. The performance of HAND should be studied across diverse populations and in field tests before recommending it for widespread screening.

Background: Severe valve disease, which requires intervention, remains strongly associated with mortality in patients with rheumatic heart disease. Percutaneous mitral commissurotomy (PMC) is the procedure of choice for the treatment of patients with isolated or predominantly rheumatic mitral stenosis. This procedure has been performed under sedation to avoid the potential effects of general anesthesia on intracardiac pressure measurements. However, there are limited data on sedation during PMC, especially using easily available medications in low- and middle-income countries. Objectives: This study was designed to evaluate the efficacy and hemodynamic effects of conscious sedation during PMC in patients with significant mitral stenosis. Methods: This study prospectively enrolled 23 patients who underwent PMC with the Inoue balloon technique for hemodynamically significant mitral stenosis. For conscious sedation, midazolam 25 mg/kg and fentanyl 1 mg/kg were administered, and 5 min after the infusion, the level of sedation was evaluated by Ramsay sedation scale. A range of invasive hemodynamic measurements, including cardiac output and pulmonary artery pressures, were recorded before and immediately after sedation. Results: The mean age was 44.9 ± 10.8 years, and 19 patients (83%) were women. After sedation, the majority of patients were in categories 2 and 3 of the Ramsay sedation scale (cooperative, orientated, tranquil, and responding to commands). Oxygen saturation dropped from an average of 98.5% to 96.0% without supplementary oxygen. Left ventricular systolic pressure and central aortic pressures decreased after sedation. However, none of the other parameters changed significantly after sedation, including pulmonary artery pressures, pulmonary vascular resistance, and cardiac index. Conclusions: This simple model of conscious sedation was able to promote anxiolysis, analgesia, and comfort for the procedure without serious hemodynamic effects, which can be a reasonable choice in developing countries. Highlights Percutaneous valve intervention is the main treatment for severe rheumatic MS. Effective interventions with affordable cost are essential to manage valve disease in developing countries. Conscious sedation using easily available medication promotes comfort without hemodynamic effects. Fundamento: A doença valvar grave, que requer intervenção, permanece fortemente associada à mortalidade em pacientes com cardiopatia reumática. A comissurotomia mitral percutânea (CPM) é o procedimento de escolha para o tratamento de pacientes com estenose mitral isolada ou predominantemente reumática. Este procedimento foi realizado sob sedação para evitar os potenciais efeitos da anestesia geral nas medidas da pressão intracardíaca. No entanto, há dados limitados sobre sedação durante a CMP, especialmente usando medicamentos facilmente disponíveis em países de baixa e média renda. Objetivos: Este estudo foi desenhado para avaliar a eficácia e os efeitos hemodinâmicos da sedação consciente durante a CPM em pacientes com estenose mitral significativa. Métodos: Este estudo envolveu prospectivamente 23 pacientes submetidos à CMP com a técnica do balão de Inoue para estenose mitral hemodinamicamente significativa. Para sedação consciente, foram administrados midazolam 25 mg/kg e fentanil 1 mg/kg, e 5 min após a infusão, o nível de sedação foi avaliado pela escala de sedação de Ramsay. Uma série de medidas hemodinâmicas invasivas, incluindo débito cardíaco e pressões da artéria pulmonar, foram registradas antes e imediatamente após a sedação. Resultados: A média de idade foi de 44,9 ± 10,8 anos e 19 pacientes (83%) eram mulheres. Após a sedação, a maioria dos pacientes estava nas categorias 2 e 3 da escala de sedação de Ramsay (cooperativa, orientada, tranquila e respondendo a comandos). A saturação de oxigênio caiu de uma média de 98,5% para 96,0% sem oxigênio suplementar. A pressão sistólica do ventrículo esquerdo e a pressão aórtica central diminuíram após a sedação. No entanto, nenhum dos outros parâmetros mudou significativamente após a sedação, incluindo pressões da artéria pulmonar, resistência vascular pulmonar e índice cardíaco. Conclusões: Este modelo simples de sedação consciente foi capaz de promover ansiólise, analgesia e conforto para o procedimento sem graves efeitos hemodinâmicos, o que pode ser uma escolha razoável em países em desenvolvimento. Destaques A intervenção valvar percutânea é o principal tratamento para EM reumática grave. Intervenções eficazes com custo acessível são essenciais para o manejo da doença valvar em países em desenvolvimento. A sedação consciente com medicamentos de fácil acesso promove conforto sem efeitos hemodinâmicos.

Introduction : Rheumatic heart disease (RHD) frequently occurs following recurrent episodes of acute rheumatic fever (ARF). Benzathine penicillin (benzapen) is the most effective method for secondary prophylaxis against ARF whose efficacy largely depends on adherence to treatment. Various factors determine adherence to therapy but there are no data regarding current use of benzapen in patients with RHD attending Mulago Hospital. The study aims were (1) to determine the levels of adherence with benzapen prophylaxis among rheumatic heart disease patients in Mulago Hospital, and (2) establish the patient factors associated with adherence and, (3) establish the reasons for missing monthly benzathine penicillin injections. Methods : This was a longitudinal observational study carried out in Mulago Hospital cardiac clinics over a period of 10 months; 95 consecutive patients who satisfied the inclusion criteria were recruited over a period of four months and followed up for six months. Data on demographic characteristics and disease status were collected by means of a standardised questionnaire and a card to document the injections of benzapen received. Results : Most participants were female 75 (78.9%). The age range was five to 55 years, with a mean of 28.1 years (SD 12.2) and median of 28 years. The highest education level was primary school for most patients (44, 46.3%) with eight (8.4%) of the patients being illiterate. Most were either NYHA stage II (39, 41.1%) or III (32, 33.7%). Benzathine penicillin adherence: 44 (54%) adhered to the monthly benzapen prophylaxis, with adherence rates ≥ 80%; 38 (46%) patients were classified as non-adherent to the monthly benzapen, with rates less than 80%. The mean adherence level was 70.12% (SD 29.25) and the median level was 83.30%, with a range of 0-100%; 27 (33%) patients had extremely poor adherence levels of ≤ 60%. Factors associated with adherence: higher education status, residing near health facility favoured high adherence, while painful injection was a major reason among poor performers. Conclusion : The level of non-adherence was significantly high (46%). Residence in a town/city and having at least a secondary level of education was associated with better adherence, while the painful nature of the benzapen injections and lack of transport money to travel to the health centre were the main reasons for non-adherence among RHD patients in Mulago.

Background : Complications of rheumatic heart disease are associated with severe morbidity and mortality in developing countries where the disease prevalence remains high. Due to lack of screening services, many patients present late, with severe valve disease. In Uganda, the disease and its complications are still not well studied. Objective : To profile and describe cardiovascular complications in newly diagnosed rheumatic heart disease patients attending the Mulago National Referral Hospital in Uganda. Methods : This was a cross-sectional study where consecutive, newly diagnosed rheumatic heart disease patients were assessed and followed up for complications, such as heart failure, pulmonary hypertension, atrial fibrillation, recurrence of acute rheumatic fever, and stroke. Results : A total of 309 (115 males and 196 females) definite rheumatic heart disease patients aged 15-60 years were enrolled in the study and analysed. Complications occurred in 49% (152/309) of the newly diagnosed rheumatic heart disease cases, with heart failure (46.9%) the most common complication, followed by pulmonary arterial hypertension (32.7%), atrial fibrillation (13.9%), recurrence of acute rheumatic fever (11.4%), infective endocarditis (4.5%) and stroke (1.3%). Atrial fibrillation and acute rheumatic fever were the most common complications associated with heart failure. Conclusion : In this study we found that about 50% of newly diagnosed rheumatic heart disease patients in Uganda presented with complications. Heart failure and pulmonary arterial hypertension were the most commonly observed complications.

Introduction : Rheumatic 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. Methods : One 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. Results : Seventy-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 (g 49 mm). Conclusion : A 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.

Introduction: Since the establishment of the Uganda Rheumatic Heart Registry, over 900 patients have been enrolled. We sought to stratify the patients in the registry according to disease severity and optimal management strategy.Methods: We reviewed data of 618 patients who had enrolled in the Registry between March 2010 and February 2013. The 67 patients who had died were excluded leaving 551 patients who were recruited. The optimum management strategy was determined according to the 2012 European Society of Cardiology guidelines on the management of valvular heart disease.Results: Out of the 551 patient’s records evaluated, 398 (72.3%) required invasive intervention, with 332(60.3%) patients requiring surgery and 66 (12.0%) requiring percutaneous mitral commissurotomy (PMC). This leaves only 27.7% of patients who required only medical management. Currently, majority of the patients (498, 90.4%) in the registry are on medical treatment. Of the 60.3% requiring surgical intervention, only 8.0% (44 patients) underwent valvular surgery and 5(1.0%) patients of the 66 (12.0%) underwent PMC successfully.Conclusion: There is a high proportion of patients with severe disease that require surgical treatment yet they cannot access this therapy due to absence of local expertise.Keywords: Rheumatic Heart Disease, surgical intervention, percutaneuos intervention

Summary Objective To assess the cost-effectiveness of an ambulance service within a comprehensive hospital/community-based program aimed at improving access and quality of reproductive health in poor-resources settings. Methods Obstetrical cases referred to the hospital with the ambulance during a 3-month period were prospectively recorded. Clinical indications were used to determine the effectiveness of the referral; the direct costs of the service were calculated. Overall effectiveness was then measured against WHO thresholds. Results Ninety-two obstetrical referrals were recorded. Eleven (12%) were considered effective, corresponding to 611.7 years saved. Cost per year saved was 15.82 US dollars which about half of WHO’s 30 US dollar benchmark defining very attractive interventions. Sensitivity analyses on the costs of the ambulance and the rate of effective referrals emphasized the robustness of the result. Conclusions The cost-effectiveness profile of an ambulance service within a series of interventions aimed at improving reproductive health in remote settings is very attractive. Objetivo: Evaluar la costo-efectividad de un servicio de ambulancias dentro de un programa integral hospitalario y comunitario con el objetivo de mejorar el acceso y la calidad de la salud reproductiva en emplazamientos pobres. Metodos: Se registraron de forma prospectiva todos los casos obstetricos referidos al hospital en una ambulancia durante un periodo de 3 meses. Se utilizaron las indicaciones clinicas para determinar la efectividad de la derivacion; se calcularon los costes directos del servicio. La efectividad total se midio frente a los puntos de corte de la OMS. Resultados: Se registraron 92 derivaciones obstetricas. 11 (12%) fueron considerados como efectivos, lo que corresponde a 611.7 anos salvados. El coste por ano salvado era de 15.82 dolares americanos lo cual es alrededor de la mitad de los 30 dolares americanos que la OMS define como punto de referencia para intervenciones muy atractivas. Los analisis de sensibilidad sobre el coste de la ambulancia y la tasa de efectividad de las derivaciones enfatizaba la robustez del resultado. Conclusiones: El perfil de coste-efectividad de un servicio de ambulancia dentro de una serie de intervenciones cuyo objetivo es mejorar la salud reproductiva en emplazamientos remotos es muy atractivo.

Background Rheumatic heart disease (RHD) is a leading cause of premature mortality in low- and middle-income countries (LMICs). Women of reproductive age are a unique and vulnerable group of RHD patients, due to increased risk of cardiovascular complications and death during pregnancy. Yet, less than 5% of women of childbearing age with RHD in LMICs use contraceptives, and one in five pregnant women with RHD take warfarin despite known teratogenicity. It is unclear whether this suboptimal contraception and anticoagulant use during pregnancy is due to lack of health system resources, limited health literacy, or social pressure to bear children. Methods We conducted a mixed methods study of 75 women living with RHD in Uganda. Questionnaires were administered to 50 patients. Transcripts from three focus groups with 25 participants were analyzed using qualitative description methodology. Results Several themes emerged from the focus groups, including pregnancy as a calculated risk; misconceptions about side-effects of contraceptives and anticoagulation; reproductive decision-making control by male partners, in-laws, or physicians; abandonment of patients by male partners; and considerable stigma against heart disease patients for both their reproductive and financial limitations (often worse than that directed against HIV patients). All questionnaire respondents were told by physicians that their hearts were not strong enough to support a pregnancy. Only 14% used contraception while taking warfarin. All participants felt that society would look poorly on a woman who cannot have children due to a heart condition. Conclusions To our knowledge, this is the first qualitative study of female RHD patients and their attitudes toward cardiovascular disorders and reproduction. Our results suggest that health programs targeting heart disease in LMICs must pay special attention to the needs of women of childbearing age. There are opportunities for improved family/societal education programs and community engagement, leading to better outcomes and patient empowerment.

Objectives Rheumatic heart disease (RHD) remains a major driver of cardiovascular morbidity and mortality in low-resource settings. Registry-based care for RHD has been advocated as a powerful tool to improve clinical care and track quality metrics. Data collected through an RHD registry may also reveal epidemiological and geospatial trends, as well as insight into care utilisation. Uganda established a central RHD registry at the country’s only tertiary cardiac centre in 2010. In 2014 RHD care and registry enrolment expanded to the Western region and in 2015 to the North. Here, we examine the geographical distribution of RHD cases in Uganda and the impact of registry expansion. Methods A retrospective search of the Ugandan national RHD registry was preformed to capture all cases of acute rheumatic fever or clinical RHD from January 2010 through July 2016. A geospatial analysis revealed that the density of detected cases (cases/100 000 district residents) reflected proximity to an RHD registry enrolment centre. Regionalisation improved the number of cases detected in the regions of expansion and improved retention of patients in care. Results and conclusions RHD appears to have uniform distribution throughout Uganda with geographical clustering surrounding RHD registry enrolment centres reflecting access to care, rather than differences in prevalence. Higher rates of case detection and improved retention in care with regionalisation highlight the urgent need for decentralisation of cardiovascular services. Future studies should examine sustainable models for cardiovascular care delivery, including task shifting of clinical care and echocardiography and use of telemedicine.

Introduccion y objetivos Estudios recientes han demostrado que la estimulacion auricular rapida causa un remodelado electrico auricular. Sin embargo, no se ha aclarado el efecto del nervio vago en el remodelado electrico auricular. Metodos Se dividio un total de 24 perros en tres grupos. En el grupo control, se estudio la inducibilidad de fibrilacion auricular (FA) durante la estimulacion vagal (EV1). En el grupo de estimulacion electrica (EE), se determino el periodo refractario efectivo auricular (PREA) antes y despues de la estimulacion en la vena pulmonar superior izquierda (VPSI). En el grupo de EV+EE, tras la estimulacion vagal (EV2), se aplico EE rapida en la VPSI. Se determino el PREA antes de la EV2 y despues de la EE. Se determinaron las densidades de IKACh en las celulas de VPSI y de miocardio auricular mediante la tecnica de patch clamp en los tres grupos. Resultados La duracion de la FA inducida en el grupo de EE fue superior a la de los grupos de control y de EV+EE. En el grupo de EE, el PREA presento un acortamiento marcado y la dispersion del PREA (dPREA) aumento de forma significativa (p Conclusiones La disminucion del PREA puede ser fundamental, pero no es de por si causa de la induccion colinergica de la FA. La estimulacion rapida en la VPSI aumento la IKACh. Sin embargo, la EV antes de la EE rapida protege en parte a las auriculas contra el remodelado electrico.

Recent studies have shown that rapid atrial pacing causes atrial electrical remodeling. However, the influence of the vagus nerve on atrial electrical remodeling is not clear.This study involved 24 dogs divided into three groups. In the control group, the inducibility of atrial fibrillation (AF) during vagal stimulation (VS(1)) was investigated. In the pacing group, the atrial effective refractory period (AERP) was determined before and after pacing in the left superior pulmonary vein (LSPV). In the vagal stimulation (VS) plus pacing group, the LSPV was subjected to rapid electrical pacing after vagal stimulation (VS(2)), and the AERP was measured both before VS(2) and after pacing. The I(KACh) density was measured in LSPV and atrial myocardial cells in the three groups using the patch-clamp technique.The duration of induced AF was greater in the pacing group than in the control or VS-plus-pacing group. In the pacing group, the AERP was markedly shortened and the AERP dispersion (dAERP) was significantly increased (P.05). However, there was no significant change in AERP in the VS-plus-pacing group, though the dAERP increased significantly (P.05). The I(KACh) density was increased in LSPV and atrial myocardial cells after pacing. However, there was no significant change in I(KACh) density after VS(2) plus pacing.Although shortening of the AERP may play a fundamental role, it is not in itself responsible for cholinergically induced AF. Rapid pacing in the LSPV increased the I(KACh). However, VS before rapid pacing partly protected the atria against electrical remodeling.

Atrial fibrillation (AF) is a common complication of myocardial infarction (MI). Angiotensin II receptor antagonists prevent the promotion and propagation of AF. However, the activation of the acetylcholine-regulated K(+) current (I(K,ACh)) in the atrium after MI and the effect of valsartan on I(K,ACh) are less understood.Twenty-four adult rabbits were randomly divided into three groups: sham-operated, MI and MI plus valsartan administration (MI+valsartan). The sham-operated group received a median sternotomy without left ventricular coronary artery ligation. Both the MI group and the MI+valsartan group received a median sternotomy followed by ligation of the midpoint of the left ventricular coronary artery. The MI+valsartan group was administered oral valsartan for 12 weeks. After 12 weeks, the initiation of AF was measured by vagal stimulation followed by quick excision of the heart. I(K,ACh) in the left atrial myocardium was measured by the patch clamp technique.AF was induced in four animals in the MI group, two in the sham-operated and two in the MI+valsartan groups, with the total AF duration expectedly longer in the MI group than in the sham-operated and MI+valsartan groups (38 s versus 9 s and 9 s, respectively). Furthermore, the mean (+/- SEM) density of I(K,ACh) increased significantly more in the left atrial myocardia of the MI group than in the sham-operated and the MI+valsartan groups (-13+/-0.42 pA/pF versus -9+/-0.38 pA/pF and -10+/-0.37 pA/pF, respectively at -100 mV; and 4.1+/-0.28 pA/pF versus 3.1+/-0.27 pA/pF and 3.3+/-0.27 pA/pF, respectively at 20 mV; P0.05). However, there was no statistically significant difference in I(K,ACh) between the sham-operated group and the MI+valsartan group.AF is associated with increased I(K,ACh) after MI. Inhibition of increased IK,ACh may be the mechanism by which valsartan prevents AF following MI.