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Abstract：
Rheumatic heart disease (RHD) remains a public health issue in low- and middle-income countries (LMICs). However, there are few large studies enrolling individuals from multiple endemic countries.
To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD.
Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs.
The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality, heart failure (HF) hospitalization, stroke, recurrent rheumatic fever, and infective endocarditis. This study analyzed event rates by World Bank country income groups and determined the predictors of mortality using multivariable Cox models.
Between August 2016 and May 2022, a total of 13 696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12 967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41 478 patient-years), 1943 patients died (15% overall; 4.7% per patient-year). Most deaths were due to vascular causes (1312 [67.5%]), mainly HF or sudden cardiac death. The number of patients undergoing valve surgery (604 [4.4%]) and HF hospitalization (2% per year) was low. Strokes were infrequent (0.6% per year) and recurrent rheumatic fever was rare. Markers of severe valve disease, such as congestive HF (HR, 1.58 [95% CI, 1.50-1.87]; P < .001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P < .001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P < .001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P < .001) or valvuloplasty (HR, 0.24 [95% CI, 0.06-0.95]; P = .042) were associated with lower mortality. Higher country income level was associated with lower mortality after adjustment for patient-level factors.
Mortality in RHD is high and is correlated with the severity of valve disease. Valve surgery and valvuloplasty were associated with substantially lower mortality. Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation.
To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD.
Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs.
The primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality, heart failure (HF) hospitalization, stroke, recurrent rheumatic fever, and infective endocarditis. This study analyzed event rates by World Bank country income groups and determined the predictors of mortality using multivariable Cox models.
Between August 2016 and May 2022, a total of 13 696 patients were enrolled. The mean age was 43.2 years and 72% were women. Data on vital status were available for 12 967 participants (94.7%) at the end of follow-up. Over a median duration of 3.2 years (41 478 patient-years), 1943 patients died (15% overall; 4.7% per patient-year). Most deaths were due to vascular causes (1312 [67.5%]), mainly HF or sudden cardiac death. The number of patients undergoing valve surgery (604 [4.4%]) and HF hospitalization (2% per year) was low. Strokes were infrequent (0.6% per year) and recurrent rheumatic fever was rare. Markers of severe valve disease, such as congestive HF (HR, 1.58 [95% CI, 1.50-1.87]; P < .001), pulmonary hypertension (HR, 1.52 [95% CI, 1.37-1.69]; P < .001), and atrial fibrillation (HR, 1.30 [95% CI, 1.15-1.46]; P < .001) were associated with increased mortality. Treatment with surgery (HR, 0.23 [95% CI, 0.12-0.44]; P < .001) or valvuloplasty (HR, 0.24 [95% CI, 0.06-0.95]; P = .042) were associated with lower mortality. Higher country income level was associated with lower mortality after adjustment for patient-level factors.
Mortality in RHD is high and is correlated with the severity of valve disease. Valve surgery and valvuloplasty were associated with substantially lower mortality. Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation.
摘要：
风湿性心脏病（RHD）仍然是低收入和中等收入国家（LMICs）的公共卫生问题。然而,很少有大型研究招募来自多个流行国家的个体。
■评估临床RHD患者的主要患者重要临床结局的风险和预测因素。
■多中心，以医院为基础，前瞻性观察性研究，包括24个RHD地方性LMIC的138个站点。
■主要结局是全因死亡率。次要结果是病因特异性死亡率，心力衰竭（HF）住院治疗，中风,复发性风湿热，和感染性心内膜炎.这项研究分析了世界银行国家收入组的事件发生率，并使用多变量Cox模型确定了死亡率的预测因素。
■2016年8月至2022年5月，共纳入13696例患者。平均年龄为43.2岁，72%为女性。随访结束时，12967名参与者（94.7％）的生命状态数据可用。中位持续时间为3.2年（41478患者年），1943例患者死亡（总体占15％；每患者年占4.7％）。大多数死亡是由于血管原因（1312[67.5%]），主要是HF或心源性猝死。接受瓣膜手术（604[4.4%]）和HF住院（每年2%）的患者数量较低。中风很少见（每年0.6％），复发性风湿热很少见。严重瓣膜疾病的标志物,如充血性心力衰竭(HR，1.58[95%CI，1.50-1.87]；P<.001)，肺动脉高压（HR，1.52[95%CI，1.37-1.69]；P<.001)，和心房颤动（HR，1.30[95%CI，1.15-1.46]；P<.001）与死亡率增加相关。手术治疗（HR，0.23[95%CI，0.12-0.44]；P<.001）或瓣膜成形术（HR，0.24[95%CI，0.06-0.95]；P=0.042）与较低的死亡率相关。调整患者水平因素后，较高的国家收入水平与较低的死亡率相关。
■RHD患者的死亡率很高，并且与瓣膜疾病的严重程度相关。瓣膜手术和瓣膜成形术与显著降低的死亡率相关。研究结果表明，更需要改善获得手术和介入治疗的机会，除了目前的方法集中在抗生素预防和抗凝。
■评估临床RHD患者的主要患者重要临床结局的风险和预测因素。
■多中心，以医院为基础，前瞻性观察性研究，包括24个RHD地方性LMIC的138个站点。
■主要结局是全因死亡率。次要结果是病因特异性死亡率，心力衰竭（HF）住院治疗，中风,复发性风湿热，和感染性心内膜炎.这项研究分析了世界银行国家收入组的事件发生率，并使用多变量Cox模型确定了死亡率的预测因素。
■2016年8月至2022年5月，共纳入13696例患者。平均年龄为43.2岁，72%为女性。随访结束时，12967名参与者（94.7％）的生命状态数据可用。中位持续时间为3.2年（41478患者年），1943例患者死亡（总体占15％；每患者年占4.7％）。大多数死亡是由于血管原因（1312[67.5%]），主要是HF或心源性猝死。接受瓣膜手术（604[4.4%]）和HF住院（每年2%）的患者数量较低。中风很少见（每年0.6％），复发性风湿热很少见。严重瓣膜疾病的标志物,如充血性心力衰竭(HR，1.58[95%CI，1.50-1.87]；P<.001)，肺动脉高压（HR，1.52[95%CI，1.37-1.69]；P<.001)，和心房颤动（HR，1.30[95%CI，1.15-1.46]；P<.001）与死亡率增加相关。手术治疗（HR，0.23[95%CI，0.12-0.44]；P<.001）或瓣膜成形术（HR，0.24[95%CI，0.06-0.95]；P=0.042）与较低的死亡率相关。调整患者水平因素后，较高的国家收入水平与较低的死亡率相关。
■RHD患者的死亡率很高，并且与瓣膜疾病的严重程度相关。瓣膜手术和瓣膜成形术与显著降低的死亡率相关。研究结果表明，更需要改善获得手术和介入治疗的机会，除了目前的方法集中在抗生素预防和抗凝。
