CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 3, April 2013
84
AFRICA
occurs in ARF is due to myocarditis or severe valve damage.
Essop
et al.
30
suggested that the heart failure observed during
ARF is probably secondary to volume overload from the valve
lesion, not primary myocardial dysfunction. Our data suggest
that myocardial dysfunction contributes to the heart failure seen,
as patients with ARF had decreased left ventricular ejection
fraction (mean 44%). Whether the myocardial dysfunction is
attributable to acute myocarditis or secondary to acute on chronic
volume overload remains unknown. In the future, myocardial
biopsy might provide this answer and help direct therapy.
Silwa and collegues
5
report a different experience with
recurrent ARF. In their study, there were no cases of ARF at
the time of the initial RHD diagnosis. This difference is likely
attributable to the notifiable nature of ARF in South Africa.
Among countries in sub-Saharan Africa, active surveillance for
new ARF cases is unique to South Africa.
As we are reporting only new diagnoses, no patient in our
cohort was receiving benzathine penicillin. Benzathine penicillin
prophylaxis reduces recurrence of ARF to less than 20% in
those who achieve at least 80% adherence.
8
Two to three weekly
benzathine penicillin injections are now thought to offer better
protection than the older recommendation of injections every
four weeks.
31,32
Atrial fibrillation was found in almost 14% of our patients,
and was the third most common complication. Worldwide, atrial
fibrillation is the most common sustained arrhythmia and is
associated with complications such as heart failure, stroke and
other embolic phenomena.
33
In our cohort, atrial fibrillation had
the strongest association with heart failure; 81.4% of our patients
with atrial fibrillation had heart failure. This was not surprising
given that the average left atrial diameter was 5.5 cm in the cases
with atrial fibrillation. Previous studies have showed that patients
with dilated atria over 5.0 cm are less likely to remain in sinus
rhythm even after attempted cardioversion or ablation.
34
Patients
with atrial fibrillation are also at increased risk of cardio-embolic
phenomena, secondary to stasis of blood and clot formation.
35,36
In the present study, four patients presented with stroke, all
of whom had concurrent atrial fibrillation. No patients were
on anticoagulant medication at presentation. The best strategy
for medical management of this population in the developing
world is debatable. Fearing side effects, clinicians often hesitate
to prescribe anticoagulation in settings where reliable dosing
and monitoring of INR levels is difficult. Yet, this can have
dire consequences for the patient.
37,38
Evidence is clear from
developed nations that patients with atrial fibrillation have
decreased stroke when properly anticoagulated.
39,40
It is our
practice to concomitantly begin low-molecular weight heparin
and coumadin at the time of anti-arrythmia initiation (for either
rate or rhythm control).
41
The main limitation to this study was that it was conducted
at the national referral hospital where severe cases are typically
referred for treatment. This may have under-represented the
number of patients with milder forms of the disease, who are
seen at lower levels of the healthcare system.
Conclusion
We describe the first report of RHD presentation in Uganda. We
have compiled a profile of symptoms and complications in 309
patients, including symptoms and complications at the time of
presentation. Almost all (88%) patients were symptomatic, and
half had already developed complications from RHD. Patients
presented late in the disease course, suggesting there may be
opportunity for earlier intervention.
In 2012, the World Heart Federation published the first
evidence-based guidelines for echocardiographic screening in
RHD.
42
Implementation of a screening programme using these
guidelines may be an effective way to detected cases early, when
patients have the most to gain from secondary prophylaxis.
We also noted that recurrence of acute rheumatic fever was
high in our study. This underscores the urgent need to improve
patients’ and healthcare providers’ knowledge of the diagnosis
and treatment of streptococcal infections, as well as delivery and
adherence to secondary prophylaxis. It is clear that there is much
work to be done to prevent RHD and to ensure patients who
develop RHD are diagnosed before symptoms and complications
develop. Raising awareness of the burden of RHD, as well as
the development of local guidelines for screening, diagnosis and
management could begin to lessen the devastation of this all
too-common disease.
We thank the staff of the Division of Cardiology, Makerere University and
the Uganda Heart Institute for their support of the study. The study (grant
number R24TW008861) was supported by the office of the United States
Global Aids Coordinator, National Institutes of Health and Health Resources
and Services Administration, and the Millennium Science Initiative. The
funders had no role in the study design, data collection and analysis, decision
to publish or preparation of the manuscript.
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