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Pediatric rheumatic carditis in Italy and Rwanda: The same disease, different socio-economic settings
Marianna Fabi1, Margherita Calicchia1, Daniela Palleri1
1Department of Pediatrics, University of Bologna, S. Orsola Hospital, Bologna, Italy.
Insights
Patients in Rwanda experienced more severe rheumatic heart disease, leading to higher rates of valve surgery and worse outcomes compared to Italy. This highlights disparities in diagnosis, treatment, and prophylaxis adherence impacting rheumatic carditis progression.
Area of Science:
- Cardiology
- Public Health
- Epidemiology
Background:
- Acute Rheumatic Fever (ARF) and Rheumatic Heart Disease (RHD) are significant causes of acquired heart disease globally.
- RHD disproportionately affects Low-Income Countries, while also being prevalent in High-Income Countries.
Purpose of the Study:
- To compare the echocardiographic presentation and progression of rheumatic carditis in Italy and Rwanda.
- To identify factors contributing to differences in disease severity and outcomes between the two countries.
Main Methods:
- A retrospective study of patients diagnosed with rheumatic carditis in Italian (IT) and Rwandan (RW) hospitals.
- Echocardiography at diagnosis and follow-up visits, with data collection on patient characteristics, prophylaxis, and complications.
Main Results:
- Rwandan patients (n=135) were older at diagnosis and had lower adherence to prophylaxis compared to Italian patients (n=79).
- More severe and mixed valve lesions were prevalent in Rwanda (96% mitral regurgitation) versus Italy (70%).
- Complete resolution of valve lesions occurred in 38% of IT patients vs. 2% of RW patients; cardiac surgery was needed in 31% of RW vs. 5% of IT patients. Cardiovascular complications and deaths were only seen in RW.
Conclusions:
- Severe cardiac involvement, higher rates of valve surgery, complications, and mortality in Rwanda are linked to delayed diagnosis and treatment.
- Scarce adherence to secondary prophylaxis and social determinants of health likely contribute to poorer outcomes in Rwanda.
- Addressing disparities in healthcare access and management is crucial for improving RHD outcomes globally.
Background:
Acute Rheumatic Fever and Rheumatic Heart Disease are the leading cause of acquired heart disease in Low-Income Countries, and a common cause in High-Income Countries. We compared rheumatic carditis, its echocardiographic presentation at diagnosis and its progression in Italy and Rwanda.
Methods:
Retrospective study including all consecutive patients diagnosed with rheumatic carditis in an Italian (IT) and two Rwandan Hospitals (RW). Echocardiography was performed at diagnosis and three follow-up visits. Baseline characteristics, history of primary and secondary prophylaxis and cardiovascular complications data were collected.
Results:
Seventy-nine and 135 patients were enrolled in IT and RW, respectively. Mitral regurgitation was the most common lesion (IT: 70%, RW: 96%) in both cohorts; mixed valve lesions and severe lesions were more prevalent in RW. Age at diagnosis (IT: 8.4 ± 2.9 yrs.; RW: 11.1 ± 2.7 yrs.; P < 0.001), adherence to secondary prophylaxis (IT: 99%; RW: 48%; P < 0.001) and history of primary prophylaxis (IT: 65%; RW: 6%; P < 0.001) were different. During the follow-up, native valve lesions completely resolved in 38% of IT and in 2% of RW patients (P < 0.001). By contrast, cardiac surgery was performed in 31% of RW and 5% of IT patients (P < 0.001). Cardiovascular complications and death were only observed in RW.
Conclusions:
The more severe cardiac involvement, the higher rate of valve surgery, CV complications and deaths in RW, could be due to delayed diagnosis and treatment, scarce adherence to secondary prophylaxis and differences in social determinants of health.
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