In developing countries, rheumatic heart disease (RHD) remains a great public health burden [1–3].This study set out to describe the echocardiographic characteristics of RHD, severity of valvular lesions and attendant complications at presentation in a tertiary hospital serving a predominantly rural population. It highlights a clinical argument for early detection and intervention in cases of RHD.

Methodology

At the Moi Teaching and Referral Hospital (MTRH), Eldoret Kenya, where a new cardiac service was rolled out in 2009, echo studies were analyzed retrospectively from January 2009 to June 2010. Of the 3850 echo studies 3196 were abnormal. Of these, 582 were confirmed to have rheumatic heart disease (RHD) based on the American Heart Association guidelines of 2008 [5].

Using STRATA statistical software package version-10.0, the findings were analyzed according to age, gender, indication for echo assessment, severity and complications.

Results

RHD was the second commonest lesion (18%), after hypertensive heart disease (31%). The overall mean ± SD age for RHD patients was 21.1 ± 12 years, peaking at 14–18 years of age.

Among the patients under 14 years of age (39% of patients), the commonest lesions were: Mitral regurgitation (MR) alone (52%), MR in combination with aortic insufficiency (AI) (32.6%), mitral stenosis (MS) in combination with MR or aortic regurgitation (AR) (11.1%).

Among the patients aged ≥15 years, the commonest lesions were MR in combination with AR (61.1%), MR alone (16%) and AR alone (28%).

Moderate to severe valvular disease comprised 90% of all RHD echos with findings of significant pulmonary hypertension in 85% of the patients, and only 40% being suitable for any surgery.

Discussion

Rheumatic fever and RHD are preventable [3, 4, 6–8] and its pathogenesis and valvular patterns have been well described [1, 2, 9–11]. However, in Africa, it continues to thrive in the context of poverty, and overcrowding [12].

Our hospital-based study may be an underestimate of the disease burden since patients who present to the hospital are mainly those who can access care. Community screening, as shown by Marijon et al. [13], may reveal the true disease magnitude to be up to 10 times higher.

Late presentation limits care options. We found that a large proportion of the fewer than 14-year olds (11.1%) needed surgery and all the adults would have needed surgery if they had presented early. Unfortunately, surgery is expensive and the available capacity is inadequate [14].

In our opinion, one way to prevent severe disease is by strengthening the primary health care system. This approach has been tried in Cuba and Costa Rica [15, 16] with concomitant reduction in the incidence and prevalence of RF/RHD. Public education should be addressed at the local national and international levels.

As the global health paradigm shifts toward non-communicable diseases [17], RHD should not be forgotten. Though it is not as prevalent in developed countries, it is terribly real to hundreds of patients and their care givers in developing nations.

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