Mortality and Morbidity in Adults With Rheumatic Heart Disease.

Key Points: Questions: What is the risk of major clinical outcomes in patients with rheumatic heart disease (RHD) and what are the risk predictors in endemic countries? Findings: In this prospective observational study including 13 696 patients enrolled from 24 low- and middle-income countries, nearly 15% of patients died at 3 years, mostly due to heart failure or sudden death. Corrective valve surgery or valvuloplasty was independently associated with a reduced risk of death. However, although most patients were symptomatic, only about 5% underwent valve surgery in 3 years. Meaning: Improved availability and access to surgical and interventional care for patients with RHD in endemic countries are needed. Importance: Rheumatic heart disease (RHD) remains a public health issue in low- and middle-income countries (LMICs). However, there are few large studies enrolling individuals from multiple endemic countries. Objective: To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD. Design, Setting, and Participants: Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs. Main Outcomes and Measures: The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality, heart failure (HF) hospitalization, stroke, recurrent rheumatic fever, and infective endocarditis. This study analyzed event rates by World Bank country income groups and determined the predictors of mortality using multivariable Cox models. Results: Between August 2016 and May 2022, a total of 13 696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12 967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41 478 patient-years), 1943 patients died (15% overall; 4.7% per patient-year). Most deaths were due to vascular causes (1312 [67.5%]), mainly HF or sudden cardiac death. The number of patients undergoing valve surgery (604 [4.4%]) and HF hospitalization (2% per year) was low. Strokes were infrequent (0.6% per year) and recurrent rheumatic fever was rare. Markers of severe valve disease, such as congestive HF (HR, 1.58 [95% CI, 1.50-1.87]; P <.001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P <.001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P <.001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P <.001) or valvuloplasty (HR, 0.24 [95% CI, 0.06-0.95]; P =.042) were associated with lower mortality. Higher country income level was associated with lower mortality after adjustment for patient-level factors. Conclusions and Relevance: Mortality in RHD is high and is correlated with the severity of valve disease. Valve surgery and valvuloplasty were associated with substantially lower mortality. Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation. This prospective observational study investigates mortality rates and predictive risk factors for rheumatic heart disease in 24 endemic low- and middle-income countries and evaluates interventions like corrective valve surgery and valvuloplasty. [ABSTRACT FROM AUTHOR]