Rheumatic Heart Disease Gets Fresh Look From European Doctors

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While rheumatoid arthritis makes the most headlines in the field of rheumatology a recent push has been made to bring more attention to patients with rheumatic heart disease.

While rheumatoid arthritis makes the most headlines in the field of rheumatology a recent push has been made to bring more attention to patients with rheumatic heart disease.

The results of the Global Rheumatic Heart Disease Registry, also known as the REMEDY study, were recently published in the European Heart Journal.

According to a news release that accompanied publication of the study results, there are more than 1.4 million deaths as a result of rheumatic heart disease every year. Fatalities are often caused by rheumatic fever, which typically comes after patients are diagnosed with group A streptococcal throat.

While antibiotics can be taken to prevent strep throat or rheumatic fever from progressing to the point of death, the statement notes that most of the people who die from the disease are in “low and middle-income countries” and may not have access to needed medications and treatment. As with other heart conditions, medications like warfarin can help prevent patients from having strokes whether they have rheumatic heart disease or atrial fibrillation.

The REMEDY study included more than 3000 patients in 25 hospitals throughout 12 countries in Africa as well as India and Yemen between January 2010 and November 2012. The results of the study found that only 55% of patients with rheumatic heart disease received antibiotics, including penicillin.

More than 65% of patients in the study were female and 75% were unemployed. As the study progressed the authors noted 64% of participants had “moderate to severe disease of the heart valves.” More than 30% were diagnosed with congestive heart failure, while 29% were diagnosed with pulmonary hypertension, and 22% were diagnosed with atrial fibrillation. Other less common diagnoses included 7% with stroke, 4% with infective endocarditis, and 3% reporting “major bleeding.”

The news release also noted that those patients who lived in poorer countries were less likely to have surgery performed that could help improve their health.

For patients who were receiving anti-coagulants the study noted that 70% were receiving the drugs when they should have but only a fraction were receiving them at the right levels. Also, the authors reported that 20% of participants who were pregnant at the time of the study received warfarin, “despite its known damaging effects on the foetus.”

Another area of concern for the study authors regarding pregnancy involved the use of contraceptives. They said only 4% of patients were protecting themselves from getting pregnant despite the risks that come with rheumatic heart disease patients giving birth. “It is one of the major, non-obstetric causes of maternal death in Africa,” the statement said.

Study authors had strong words for the findings in their study and the implications it could have on the future of the populations they looked at.

“Our findings reflect the utter neglect of rheumatic heart disease in affected countries,” said Mongani Mayosi, a professor of medicine and the head of the Department of Medicine at Groote Schuur Hospital and University of Cape Town, South Africa. “Most of the interventions that are not applied, such as lack of penicillin use in half of the cases and a virtual absence of contraceptive use in almost all women during their reproductive period, are available and cheap in the countries concerned, and their application will provide the greatest benefit.”

Mayosi, who served as the leader of the research team, said small steps can make a big difference in the treatment of the condition.

“It is vital that these countries prioritise improving the use of penicillin prophylaxis, improving the appropriate use of oral anticoagulation therapy with warfarin, and providing contraceptive and other reproductive health services to women affected by rheumatic heart disease.” He added, “At present, the primary healthcare systems are not prioritizing these simple, but effective measures.

“Rheumatic heart disease is a disease of poverty, neglected by the health ministries in affected countries and by the international community in general.”

According to Salim Yusuf, a professor of medicine and Executive Director of the Population Health Research Institute at McMaster University, the World Health Organization “has called upon countries of the world to reduce mortality associated with rheumatic heart disease and other non-communicable diseases by 25% by the year 2025.” This is being called the 25x25 target.

With the recent data, Yusuf, who is also the incoming President of the World Heart Federation, said, “The findings of this study not only set the baseline by which to judge progress, but also point to the need to close the gap in the use of evidence-based interventions if the 25x25 target will be achieved for rheumatic heart disease.”

Mayosi said the REMEDY study is just one step in the process. The next goal is to study the same results in 30,000 people in 166 countries around the world. “The full REMEDY study, which will involve contributors from all inhabited continents of the world, will serve as a platform not only for monitoring progress to the achievement of the 25x25 target, but also for trialling new and novel strategies, such as new oral anti-coagulants, for reducing morbidity and mortality in rheumatic heart disease. REMEDY seeks to end rheumatic heart disease in our own lifetime through the application of preventive measures.”

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Elizabeth Cerceo, MD | Credit: ACP
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