Cardiovascular Journal of Africa: Vol 28 No 4 (July/August 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017 248 AFRICA
Clinical presentation and outcomes of patients with acute
rheumatic fever and rheumatic heart disease seen at a
tertiary hospital setting in Port Elizabeth, South Africa
Zongezile Masonwabe Makrexeni, Lungile Pepeta
Abstract
Background: The incidence of acute rheumatic fever (ARF)
and rheumatic heart disease (RHD) has waned in Western
countries, however that is not the situation in developing
nations.
Methods: Records were reviewed of patients from the Eastern
Cape municipal districts who presented to the Paediatric
Cardiology Unit with ARF and RHD from January 2008 to
August 2015.
Results: Total of 56 patients with ARF/RHD was reviewed.
The majority of patients (n = 52) presented for the first time
with RHD. Four patients presented with ARF and two had
recurrent ARF. Six patients presented with a combination
of RHD and congenital heart disease. Twenty-three patients
were operated on for chronic rheumatic valve disease, with
good outcomes.
Conclusion: The true burden of ARF/RHD is unknown in
the Eastern Cape. Prospective studies are needed to accurately
determine the prevalence of RHD in this province.
Keywords: acute rheumatic fever, rheumatic heart disease,
left ventricular dysfunction, rheumatic valve surgery, disease
outcomes, prevention
Submitted 27/5/16, accepted 4/4/17
Published online 20/4/17
Cardiovasc J Afr 2017; 28: 248–250
DOI: 10.5830/CVJA-2017-019
Acute rheumatic fever (ARF) is apost-infectious, non-suppurative
sequela of pharyngeal infection with Streptococcus pyogenes or
a group A beta-haemolytic streptococcus.1 More than one-third
of affected children develop carditis, followed by progressive
and permanent valvular lesions.2 Devastating complications
of rheumatic heart disease (RHD) include severe valvular
regurgitation, heart failure, strokes and infective endocarditis,
usually affecting both younger school-going children and
economically active, child-bearing members of society.3
Industrialisedcountrieshavereportedthevirtualdisappearance
of RHD.4 The burden of RHD in developed countries declined
drastically at the end of the 20th century, largely due to reduced
overcrowding and improved sanitation and living conditions.5
By contrast, in developing countries, RHD remains a public
health issue and is the principal cause of acquired heart disease
in children and young adults.6-8 It is estimated that there are over
15 million cases of RHD worldwide, with 282 000 new cases and
233 000 deaths annually.
There was a noticeable decline in cases of ARF/RHD among
children under the age of 14 years in a tertiary care hospital in
South Africa over a period of 17 years, from 63 cases in 1993
to three cases in 2010.3 It was postulated that the decline was
probably due to improved access to medical care for the general
population, and the introduction in 1994 of free healthcare to
children under the age of six years.
This decline was also demonstrated by Smit and co-workers
in 2015 in an echocardiography-based prevalence study of
RHD in another tertiary care setting in South Africa, 9 where
the prevalence rate was 4.9/1 000 learners in grades 10 to 12.
This was much lower than the 12.2/1 000 clinical prevalence
rate reported by McClaren et al. in a similar South African
population in 1972. 10 Smit et al . postulated that socio-economic
and rural development in South Africa have initiated this decline
in RHD prevalence in South Africa.9
Although RHD remains a public health issue in developing
countries, it appears that in South Africa there has been a
decrease in the prevalence of RHD since 1994, compared with
earlier studies. However, we need more inclusive, multicentre,
prospective studies to confirm the overall prevalence of RHD
in South Africa. We therefore conducted a retrospective cohort
study to document the clinical presentation and outcomes of
patients with ARF/RHD who presented at a tertiary paediatric
cardiology referral centre in the Eastern Cape Province, South
Africa.
Methods
This was a retrospective review of records of paediatric patients
presenting with ARF and RHD at Dora Nginza Hospital,
Eastern Cape, South Africa, from January 2008 to August
2015 (seven years and eight months). The study was conducted
following ethics clearance from the Health Research Ethics and
Biosafety committee of Walter Sisulu University and permission
from the chief executive officer of Dora Nginza Hospital.
Demographic data such as age, gender, origin and clinical
presentation of either ARF or RHD, and disease severity and
surgical interventions were recorded. The diagnosis of ARF and
RHD was based on clinical and echocardiographic evidence of
RHD, using the newly revised Jones criteria of the World Heart
Federation of 2012.11 In addition, an antistreptolysin O titre
Paediatric Cardiology Unit, Walter Sisulu University, Port
Elizabeth, South Africa
Zongezile Masonwabe Makrexeni, MB ChB, FCPaed,
Faculty of Health Sciences, Nelson Mandela Metropolitan
University, Port Elizabeth, South Africa
Lungile Pepeta, DCH, MB ChB, FCPaeds, Cert. Cardiology, MMed,
FSCAI