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Ten-year follow up of a cohort with rheumatic heart disease (RHD)
J R Carapetis1, C J Kilburn, K T MacDonald
1Menzies School of Health Research, Darwin, NT.
Insights
Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) disproportionately affect Aboriginal Australians. Recurrences of ARF and initial mild valve damage are linked to poor RHD outcomes, necessitating improved control programs.
Area of Science:
- Cardiology
- Public Health
- Epidemiology
Background:
- Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are prevalent in Aboriginal Australians in the Northern Territory.
- Understanding the long-term outcomes of ARF and RHD in this population is critical.
Purpose of the Study:
- To follow-up a cohort of Aboriginal children diagnosed with RHD.
- To better understand ARF and RHD outcomes and identify areas for intervention.
Main Methods:
- A cohort of 33 children diagnosed with RHD between 1980-1984 was followed.
- 25 survivors were followed for a mean of 10.6 years.
- Outcomes, including mortality, surgery, and disease progression, were assessed.
Main Results:
- Two deaths occurred, both due to RHD.
- Six patients underwent valve replacement surgery.
- RHD severity progression correlated with ARF recurrences (RR 3.6) and initial mild valve lesions (RD 0.58).
- Valve lesions evolved, with a higher incidence of aortic and multiple valve involvement.
Conclusions:
- Poor RHD outcomes are common in Aboriginal Australians, linked to ARF recurrences and early severe valve lesions.
- A coordinated ARF and RHD control program is essential.
- Strategies should focus on patient registration, secondary prophylaxis adherence, improved clinical care, and education.
Background:
Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) occur at among the highest rates in the world in Aboriginal Australians of the Northern Territory.
Aims:
To follow-up a previously-described cohort of Aboriginal children with RHD, in order to understand better the outcome of ARF and RHD in this population, and to identify areas where the impact of these diseases might be lessened
Methods And Results:
Of a cohort of 33 children seen between 1980 and 1984, 27 survived until July, 1984. Twenty-five of the survivors were followed up for a mean of 10.6 years to a mean age of 24.1 years. The two deaths during follow-up were both due to RHD. Six people underwent valve replacement surgery; all were clinically healthy when last seen. Complications included two thromboembolic events and two episodes of endocarditis. Deterioration of RHD severity was associated with ARF recurrences (relative risk 3.6; 95% CI 1.7-7.6), and resolution of RHD was associated with having only mild valve lesions initially (risk difference 0.58; 95% CI 0.30 to 0.86). During follow-up, valve lesions tended either to resolve or to become more complex and severe, with a higher proportion of aortic valve lesions and multiple valve lesions. Of seven children with suspected past ARF, excluded from the original cohort because of normal cardiac findings at the time, three developed RHD, including one who died due to RHD and two with moderate or severe valve lesions.
Conclusions:
In Aboriginal Australians, poor outcomes of RHD are common, and are associated with ARF recurrences and early onset of more severe valve lesions. A coordinated ARF and RHD control programme is needed in this region, using a centralised register of patients, and concentrating on strategies to improve adherence to secondary prophylaxis regimens, better clinical care (including newer surgical techniques) and education of patients, families, and health staff.