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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

www.cvja.co.za

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,

mmmaso30@gmail.com

Faculty of Health Sciences, Nelson Mandela Metropolitan

University, Port Elizabeth, South Africa

Lungile Pepeta, DCH, MB ChB, FCPaeds, Cert. Cardiology, MMed,

FSCAI