Mortality High, Poor Adherence to Treatment for Rheumatic Heart Disease in Poorer Countries: REMEDY two-year follow up
An article focused on the two-year follow-up of the Global Rheumatic Heart Disease Registry (the REMEDY study) was recently published in Circulation – the peer-reviewed journal of the American Heart Association has identified that patients with rheumatic heart disease living in low- and lower-middle–income countries enrolled in the REMEDY study had a poor prognosis and were at an increased risk for high mortality and morbidity despite a young age, according to follow-up data and major clinical outcomes.
The study is of significance as it is the first known prospective multi-centre study of mortality and morbidity in rheumatic heart disease (RHD) patients from low and middle income countries (LMICs). The baseline characteristics of the 3343 patients recruited for the study has previously been reported.
Zühlke and colleagues analysed data on 3343 patients enrolled in REMEDY between January 2010 and November 2012 from 25 centres in 14 countries (12 African countries, Yemen and India). They had vital status on 2960 (88.5%) patients at 24 months.
The mortality rate was 116.3/1000 patient-years the first year and 65.4/1000 patient-years the second year for patients with a median age of 28.7 years. Over 2 years, 500 deaths (16.9%) occurred.
The authors found independent predictors of death to be:
- Severe valve disease (hazard ratio [HR] 2.36; 95% CI 1.80–3.11).
- Congestive heart failure (HR 2.16; 95% CI 1.70–2.72).
- NYHA class 3/4 (HR 1.67; 95% CI 1.32–2.10).
- Atrial fibrillation (HR 1.40; 95% CI 1.10–1.78).
- Older age (HR 1.02; 95% CI 1.10–1.02).
Additionally, they found older age and previous occurrence of stroke to independently predict stroke/transient ischemic attack or systemic embolism.
Patients in low- and lower-middle–income countries had higher age- and sex-adjusted mortality than patients in upper-middle–income countries. Valve surgeries were also found to be significantly more common in upper-middle–income countries.
The study identified poor adherence to both penicillin for secondary prophylaxis, and also poor adherence to anticoagulation medication. Almost half of the patient cohort were not taking penicillin, and despite a number of patients having atrial fibrillation, only 70% were taking oral anticoagulants. The World Health Organization recommends that all patients with severe rheumatic heart disease are maintained on penicillin for secondary prophylaxis. Anticoagulation is universally recommended for patients with valvular atrial fibrillation or those with mechanical heart valves (who do not have a contraindication).
Most patients with valve disease required intervention; however, only 10.3% with severe disease had had surgery or percutaneous procedures.
The study highlights the importance of access to essential surgery for patients with symptomatic rheumatic heart disease living in low- and middle-income countries. Additionally the study identifies a need to improve the uptake of secondary prophylaxis with penicillin and optimize anticoagulation for patients with rheumatic atrial fibrillation.
* Recently “Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study)” in European Heart Journal (7; 36(18):1115-22a) was selected as winner of the best publication award for the Early Career Award, Clinical Sciences category of the Faculty of Health Sciences of the University of Cape Town.