Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Uganda Heart Institute, Kampala, Uganda.
Lancet Glob Health. 2024 Mar;12(3):e500-e508. doi: 10.1016/S2214-109X(23)00567-3.
Rheumatic heart disease is the largest contributor to cardiac-related mortality in children worldwide. Outcomes in endemic settings after its antecedent illness, acute rheumatic fever, are not well understood. We aimed to describe 3-5 year mortality, acute rheumatic fever recurrence, changes in carditis, and correlates of mortality after acute rheumatic fever.
We conducted a prospective cohort study of Ugandan patients aged 4-23 years who were diagnosed with definite acute rheumatic fever using the modified 2015 Jones criteria from July 1, 2017, to March 31, 2020, enrolled at three rheumatic heart disease registry sites in Uganda (in Mbarara, Mulago, or Lira), and followed up for at least 1 year after diagnosis. Patients with congenital heart disease were excluded. Patients underwent annual review, most recently in August, 2022. We calculated rates of mortality and acute rheumatic fever recurrence, tabulated changes in carditis, performed Kaplan-Meier survival analyses, and used Cox regression models to identify correlates of mortality.
Data were collected between Sept 1 and Sept 30, 2022. Of 182 patients diagnosed with definite acute rheumatic fever, 156 patients were included in the analysis. Of these 156 patients (77 [49%] male and 79 (51%) female; data on ethnicity not collected), 25 (16%) died, 21 (13%) had a cardiac-related death, and 17 (11%) had recurrent acute rheumatic fever over a median of 4·3 (IQR 3·0-4·8) years. 16 (24%) of the 25 deaths occurred within 1 year. Among 131 (84%) of 156 survivors, one had carditis progression by echo. Moderate-to-severe carditis (hazard ratio 12·7 [95% CI 3·9-40·9]) and prolonged PR interval (hazard ratio 4·4 [95% CI 1·7-11·2]) at acute rheumatic fever diagnosis were associated with increased cardiac-related mortality.
These are the first contemporary data from sub-Saharan Africa on medium-term acute rheumatic fever outcomes. Mortality rates exceeded those reported elsewhere. Most decedents already had chronic carditis at initial acute rheumatic fever diagnosis, suggesting previous undiagnosed episodes that had already compounded into rheumatic heart disease. Our data highlight the large burden of undetected acute rheumatic fever in these settings and the need for improved awareness of and diagnostics for acute rheumatic fever to allow earlier detection.
Strauss Award at Cincinnati Children's Hospital, American Heart Association, and Wellcome Trust.
风湿性心脏病是全球导致儿童心脏相关死亡的最大原因。在风湿热这一前驱疾病之后，在流行地区的结局尚不清楚。我们旨在描述风湿热后 3-5 年的死亡率、风湿热复发、心瓣膜炎变化以及与风湿热后死亡率相关的因素。
我们对 2017 年 7 月 1 日至 2020 年 3 月 31 日期间在乌干达三个风湿性心脏病登记处（姆巴拉拉、穆拉戈或利拉）确诊为明确风湿热的年龄在 4-23 岁的乌干达患者进行了前瞻性队列研究，这些患者符合经改良的 2015 年琼斯标准，且至少在诊断后 1 年进行了随访。患有先天性心脏病的患者被排除在外。患者接受了年度复查，最近一次复查是在 2022 年 8 月。我们计算了死亡率和风湿热复发率，列出了心瓣膜炎的变化，进行了 Kaplan-Meier 生存分析，并使用 Cox 回归模型确定了死亡率的相关因素。
数据收集于 2022 年 9 月 1 日至 9 月 30 日。在确诊为明确风湿热的 182 名患者中，有 156 名患者纳入了分析。这 156 名患者（77 名[49%]为男性，79 名[51%]为女性；未收集种族数据）中有 25 人死亡，21 人死于心脏相关疾病，17 人在中位时间为 4.3 年（IQR 3.0-4.8）后复发风湿热。25 例死亡中有 16 例（16%）发生在 1 年内。在 156 名幸存者中，有 131 名（84%）患者的超声心动图显示心瓣膜炎进展。风湿热诊断时存在中度至重度心瓣膜炎（风险比 12.7[95%CI 3.9-40.9]）和 PR 间期延长（风险比 4.4[95%CI 1.7-11.2]）与心脏相关死亡风险增加相关。
这是撒哈拉以南非洲地区关于风湿热中期结局的首批最新数据。死亡率高于其他地区报告的死亡率。大多数死者在初次风湿热时已经有慢性心瓣膜炎，这表明之前有未确诊的病例，这些病例已经发展成风湿性心脏病。我们的数据突出表明，在这些环境中存在大量未被发现的风湿热，需要提高对风湿热的认识和诊断水平，以便及早发现。
辛辛那提儿童医学中心的斯特劳斯奖、美国心脏协会和惠康信托基金会。
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