Cardiovascular Journal of Africa: Vol 24 No 2 (March 2013)

CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 2, March 2013

AFRICA

Discussion

In this small, tertiary hospital-based study, we described the

presenting features and complications of newly diagnosed

RHD patients in a Ugandan population. All participants were

indigenous blacks and 72.3% of the study participants were

female, which concurs with the Soweto study where 68% were

female.

It contrasts with the Pakistan study were only 46%

were female.

More males had formal education than females.

Lack of formal employment was more prevalent in females than

males. The rates of living in temporary housing were similar in

both genders.

Although this study did not evaluate the association between

socio-economic status and RHD presentation, the finding that

low levels of formal education, high levels of unemployment and

poor housing conditions underscored their role in determining

disease incidence.

On the other hand, the nature of the heart

disease will have an impact on an individual’s education and

employment opportunities. Hence, there might be a vicious circle

between socio-economic status and RHD in the population. This

reminds us that control of the disease needs a dual effort from

both the economic sector and health service systems.

The higher prevalence of disease in females than males

correlated with their illiteracy and unemployment status.

However, this could have been attributed to factors such as

genetic predisposition, hormonal factors and poor health-seeking

behaviours among males. This needs to be studied further.

Fatigue and palpitations were the most common presenting

symptoms, followed by difficulty in breathing and chest pain.

Given that fatigue and palpitations are non-specific symptoms

of many physiological and pathological conditions, including

early heart failure,

it is proposed that health workers do not

overlook these symptoms. Improvement in disease awareness at

the community level is needed in order to diagnose the disease as

early as possible. The finding that over 40% of patients presented

in NYHA class III/IV indicates the poor quality of life, delayed

diagnosis and low level of knowledge of the disease in the

population, among both patients and health workers.

17,18

We found that the most common lesions seen in patients with

newly diagnosed RHD were pure MR, followed by MR + AR.

Tricuspid valve involvement was extremely rare. Regurgitation

was more common than stenotic lesions. Stenotic lesions were

understandably rare in children and adolescents, as time is

required for fibrosis and re-organisation to develop. Multiple

valvular lesions were mainly seen in young adults. This finding is

very important. For example, the finding that the most common

multi-valve lesion was MR + AR, and it was most prevalent

in the age group 20–39 years supports available evidence

that repeated attacks of ARF in RHD patients are responsible

for disease progression, thus underscoring the importance of

prophylaxis against repeated ARF.

Most valvular lesions in the patients were in the moderate-

to-severe form, which is consistent with previously reported

data from different countries.

17-20

Beaton and colleagues

have previously reported 4.9 cases of mild RHD per 1 000

asymptomatic school children in Uganda.

This finding,

combined with the finding that predominant disease in the

hospital was moderate to severe, again reinforces the importance

of screening and regular echocardiographic checks for high-risk

populations. Early intervention with prophylaxis would protect

other valves from infection and also control the progression of

the affected valve(s).

There were 6.9% of patients who had pure MS, and 6.9% had

MS + AR. The majority of these patients were in the age group

20–39 years. These patients could benefit from percutanous

mitral valvoplasty, which has been available at the Uganda Heart

Institute since December 2012. Optimal benefit depends on

early presentation before calcification and development of other

complications,

such as gross atrial dilatation, atrial fibrillation

and severe CCF, further emphasising the need for early disease

detection.

Almost half (43.1%) of the patients presented in NYHA

class III/IV heart failure, but 20.8% of patients had a calculated

ejection fraction (EF) of less than 55%. The lowest mean EF in

AR cases was related to the finding that AR was associated with

the most dilated left ventricles, understandably due to volume

overload and compensatory left ventricular (LV) wall stretch

(Table 3). All disease categories presented with significant

dilatation of the left atrium (LA). This frequency of LA

dilatation could partly explain the high prevalence of pulmonary

hypertension (PHT). Atrial fibrillation was more frequent in MS

and MR.

The presence of these complications heavily influences the

method and outcome of treatment, including surgery where

possible.

Patients with gross distortions of the heart, notably

grossly dilated atria will require chamber resection during valve

replacement.

This makes the operation more expensive but

also increases the risk of postoperative complications. Patients

with atrial fibrillation will need warfarin for prophylaxis against

thromboembolism. This however is associated with a high risk of

bleeding due to difficulty in INR monitoring and control, as most

patients are too poor to afford the cost of the test.

The data from this study showed a predominant proportion

of young adults with advanced forms of RHD, which is in

agreement with findings from other studies in Africa.

14,18

also noticed a 6.2% of recurrent ARF among our study group,

which was similar to that described in the Fiji study,

however

none of the study population could recall a clear history of past

ARF. This reaffirms the importance of meticulous secondary

prophylaxis. That the majority of patients were in the age group

20–39 years reflects the adolescent nature of ARF/RHD. The

presentation by the majority with moderate-to-severe disease

confirms the poor/low diagnostic rate of ARF in this population.

The findings of this study indicate that the majority of

patients with RHD present with palpitations, fatigue, dyspnoea

and chest pain. Given that these are not specific symptoms for

RHD, it is important for general practitioners and other lower-

cardre health professionals who see the majority of these patients

to suspect RHD and refer these patients for specialist evaluation

using echocardiography. This would facilitate early confirmatory

diagnosis of cases and hence aid in early intervention, so

preventing complications.

Our study had a number of limitations. First, this study

population reflects those who were fortunate enough (or sick

enough) to seek specialist care at the hospital and was always

likely to describe those with more advanced forms of RHD.

Second, unfortunately, there are no gold-standard diagnostic

criteria for RHD. We applied a clinically orientated approach

based on published criteria and acknowledge that there may

be inherent biases in our classification of cases. For example,

according to the NIH/WHO RHD echo-diagnosing criteria,