• Ganesan Karthikeyan, Mpiko Ntsekhe, Shofiqul Islam, Sumathy Rangarajan, Alvaro Avezum, Alexander Benz, Tantchou Tchoumi Jacques Cabral, Ma Changsheng, Philly Chillo, J Antonio Gonzalez-Hermosillo, Bernard Gitura, Albertino Damasceno, Antonio Miguel L Dans, Kairat Davletov, Alaa Elghamrawy, Ahmed ElSayed, Golden Tafadzwa Fana, Lillian Gondwe, Abraham Haileamlak, Azhar Mahmood Kayani, Peter Lwabi, Fathi Maklady, Onkabetse Julia Molefe-Baikai, John Musuku, Okechukwu Samuel Ogah, Maria Paniagua, Emmanuel Rusingiza, Sanjib Kumar Sharma, Liesl Zuhlke, Stuart Connolly, Salim Yusuf, and INVICTUS Investigators.
• Department of Cardiology, All India Institute of Medical Sciences, New Delhi.
• JAMA. 2024 Jul 9; 332 (2): 133140133-140.

ImportanceRheumatic 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.ObjectiveTo assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD.Design, Setting, And ParticipantsMulticenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs.Main Outcomes And MeasuresThe 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.ResultsBetween 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.Conclusions And RelevanceMortality 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.

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