Neglect exacerbating rheumatic heart disease

Primary healthcare systems in many low- and middle-income countries are not prioritising simple, effective measures to treat rheumatic heart disease, a preventable disease, says a new study lead by UCT's Professor Bongani Mayosi and published in the European Heart Journal.

A common disease in Africa and other poor regions, rheumatic heart disease is being neglected by health ministries and by the international community in general, says Mayosi.

Head of UCT's Department of Medicine and Groote Schuur Hospital, Mayosi lead the research on the Global Rheumatic Heart Disease Registry, known as the REMEDY study.

"Our findings reflect the utter neglect of rheumatic heart disease in affected countries," he said.

Rheumatic fever triggers

Rheumatic heart disease is triggered by rheumatic fever, which is preceded by a group A streptococcal throat infection.

It kills up to 1.4 million people a year, mainly in low- and middle-income countries where overcrowding, limited access to healthcare and poor housing and nutrition are exacerbating factors.

It affects the heart, joints and central nervous system. Untreated, it can cause scarring (fibrosis) of the heart valves, requiring expensive and inaccessible valve replacement or repair work. It can also cause an irregular heartbeat, heart failure and death.

However its treatment relies on simple measures. Regular antibiotics prevent rheumatic fever recurring and can stop the condition worsening in those with the disease, while oral anti-coagulants can help prevent strokes in patients with rheumatic heart disease and atrial fibrillation.

Antibiotics and contraception vital

The pilot phase of the REMEDY study, undertaken between 2010 and 2012, surveyed 3 343 rheumatic heart disease patients attending one of 25 hospitals in 12 African countries, or in Yemen and India. It found that the majority of rheumatic heart disease patients were young (median age of 28), mainly female (66%) and unemployed (77%).

Results showed that:

• only 55% of rheumatic heart disease patients were receiving antibiotics;
• oral anti-coagulants were prescribed in 70% of patients – but less than one-third received this medication at the right therapeutic level;
• 20% of pregnant patients were on the anti-coagulant warfarin, despite its damaging effects on foetuses;
• among the 1 825 women of child-bearing age only 4% were taking contraceptive measures, in spite of rheumatic heart disease increasing the risks during pregnancy and at birth. The disease is a major non-obstetric cause of maternal death in Africa.

Study a baseline for intervention

Study co-author Professor Salim Yusuf, executive director at the Population Health Research Institute, McMaster University, Canada, and incoming president of the World Heart Federation, said the World Health Organisation had called for a 25% reduction of mortality associated with rheumatic heart disease and other non-communicable disease by the year 2025.

This is known as the 25x25 target.

"The finding of this study not only set the baseline by which to judge progress but point to the need to close the gap in the use of evidence-based interventions if the 25x25 target is to be achieved," Yusuf added.

Mayosi said a full study of 30 000 patients with rheumatic heart disease would be launched in 166 endemic countries in 2015.

"The full REMEDY study, which will involve contributors from across the world, will serve as a platform for monitoring progress towards the 25x25 target and also trialing new and novel strategies, such as new oral anti-coagulants.

"By applying preventive measures, REMEDY seeks to end rheumatic heart disease in our own lifetime."