CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 3, April 2013
AFRICA
83
C-reactive protein levels were 526.7 mg/l (normal range 0.00–
200.0) and 97.4I U/ml (normal range 0.0–5.0), respectively. In
addition to the carditis, joint pain and chorea were the only extra-
cardiac manifestations of acute rheumatic fever observed. All
cases of recurrence of ARF presented in heart failure.
Discussion
Rheumatic heart disease remains a common cause of heart failure
in developing countries and ranks among systemic hypertension
and idiopathic dilated cardiomyopathy as the leading causes of
heart failure in these nations.
19,20
Rheumatic heart disease is one
of the most common cardiac diagnoses seen in Uganda.
21
Among
our cohort of patients newly presenting with RHD, almost 90%
reported cardiovascular symptoms and almost 50% had already
developed related complications.
This is the first study to profile the presentation of rheumatic
heart disease in Uganda and highlights the tendency for late
disease presentation and high rates of associated complications.
Demographic information obtained from this study agrees
with previous studies that RHD is a disease of low socio-
economic status and low educational level, as the majority of
the respondents had either primary-level or no education.
22,23
Our
data continue to highlight that RHD is a disease of poverty, low
productivity, poor quality of life and early mortality.
19,20
In our cohort, mitral regurgitation was the commonest valve
lesion, with the majority presenting in heart failure, and about
half presenting with severe mitral valve regurgitation, with
average LVEDD, LVESD and LVEF of 65 mm, 50 mm and
54%, respectively This is severe valve disease and recent studies
have showed that an average LVESD of 50 mm or more is
associated with rapid decline in cardiac function.
24
In addition,
it has been shown that delayed surgery is associated with a poor
postoperative prognosis.
24,25
Furthermore, Sliwa
et al
. in a study of the clinical
characteristics of newly diagnosed RHD as seen in the Heart
of Soweto study, South Africa,
5
found the prevalence of newly
diagnosed RHD to be 36% among patients diagnosed with any
valvular heart disease, out of an overall total of 4 005 cases.
Mitral regurgitation was the commonest valve lesion. Only 25%
of cases had average LVDD
>
55 mm, lower than that in our
study where 52% of cases with mitral regurgitation had average
LVEDD
>
55 mm. This indicates that the cases in their study
probably presented or were picked out earlier.
Cardiovascular symptoms typically manifest when valvular
regurgitation or stenosis (regardless of valve) becomes severe.
26
This was demonstrated in our population, where 52% of patients
had severe mitral regurgitation with average LVESD
>
55 mm,
and 80% of these patients reported symptoms.
Among our cohort, the complication rate at presentation was
almost 50%. This is slightly higher than reported by Sani
et al
.,
who studied the prevalence and pattern of RHD in the Nigerian
savanah. In their echocardiography-based study, 32% had left
ventricular dysfunction, among other complications, at the time
of initial diagnosis.
6
This is slightly lower than our reported rate
of 49%.
In our population, pulmonary hypertension was the second
most common complication, affecting almost one-third of
patients at the time of presentation. Males and females were
affected equally. Pulmonary hypertension commonly develops as
a complication of mitral and aortic valve disease.
27
Development
of pulmonary hypertension decreases quality of life and shortens
life expectancy.
27,28
Recurrent ARF was found in 11% of patients at the time
of the initial diagnosis. Most of these cases did not fulfill the
classical Jones criteria.
14,29
Joint pains, chorea and evidence of
Group A streptococcal infection, as shown by raised ASO titres
were the only criteria met. These findings support the use of the
2003 WHO modification of the Jones criteria
29
for the diagnosis
of recurrence of ARF in established RHD.
The tendency of patients to present during an episode of
recurrent ARF has been previously described. Ravisha and
colleagues reported data on 550 cases of newly diagnosed RHD
in India.
19
In their study, almost 40% of newly diagnosed patients
were presenting with recurrence of ARF, and the rate of heart
failure in these patients was 36%. We report that 100% of those
presenting with ARF met the criteria for heart failure, which is
most likely what brought them to our attention.
It is not completely understood whether the heart failure that
TABLE 3.VALVE LESIONS VERSUS COMPLICATIONS
Total
n
(%)
Mitral
stenosis
n
(%)
Mitral
regurgi-
tation
n
(%)
Aortic
stenosis
n
(%)
Aortic
Regurgi-
tation
n
(%)
Total cases
309 (100)
104
(33.6)
280 (90.6) 8 (2.6)
128
(41.4)
Age, median (IQR)
30 (20)
33 (15)
30 (14)
30 (14) 29 (19)
Gender
Male
113 (36.6) 31 (27.4) 102 (90.3) 4 (3.5) 45 (39.8)
Female
196 (63.5 73 (37.2) 178 (90.8) 4 (2.0) 83 (42.4)
Complications
Heart failure
145 (46.9) 54 (37.2) 131 (90.3) 1 (0.7) 58 (40.0)
ARF
35 (11.4) 9 (25.7) 33 (94.3)
0 10 (28.6)
Stroke
4 (1.3)
2 (50)
4 (100)
0
2 (50)
Infective endocarditis
14 (4.5)
5 (35.7) 13 (92.9)
0
6 (42.8)
Atrial fibrillation
43 (13.9) 25 (58.1) 35 (81.4)
0 14 (32.6)
Dimensions
Mean LVEDD (mm)
58
±
17 48
±
9 65
±
13 50
±
9 58
±
14
LVEDD
>
55 mm 265 (85.7) 9 (8.7) 219 (78.2) 3 (37.5) 56 (43.8)
Mean LVESD (mm)
40
±
11 33
±
11 50
±
13 37
±
18 44
±
15
LVESD
>
45 mm 148 (47.8) 5 (4.8) 193 (68.9) 3 (37.5) 29 (22.5)
Mean LAD (mm)
53
63
55
45
47
Mean LVEF (%)
59.7
67
54
59.5
56.3
Systolic dysfunction 101.9 (33)
9 (9)
126 (45)
3 (12)
38 (30)
Severity of valve lesion
(%)
mild:
moderate:
severe
23:28:49 20:28:52 24:53:23 13:41:46
TABLE 4. BIVARIATEANALYSIS OF HEART FAILURE PREDICTORS
Congestive heart failure
p
-value
Yes,
n
(%)
No,
n
(%)
Male
56 (49.6)
57 (50.4 )
Female
89 (45.4)
107 (54.6)
0.225
Systolic blood pressure, mean
±
SD 117
±
1.76 124
±
1.82 0.006
Diastolic blood pressure, median (IQR)
70 (60–82) 71 (63–84)
0.614
Other complications of RHD
Acute rheumatic fever
25 (71.4)
10 (28.6)
0.002
Stroke
1 (50)
2 (50)
0.906
Infective endocarditis
11 (78.6)
3 (21.4)
0.015
Atrial fibrillation
35 (81.4)
8 (18.6)
<
0.05
