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

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

AFRICA

Presenting features of newly diagnosed rheumatic heart

disease patients in Mulago Hospital: a pilot study

WANZHU ZHANG, CHARLES MONDO, EMMY OKELLO, CHARLES MUSOKE, BARBARA KAKANDE,

WILSON NYAKOOJO, JAMES KAYIMA, JURGEN FREERS

Abstract

Introduction:

Rheumatic heart disease (RHD) continues to

cause gross distortions of the heart and the associated compli-

cations of heart failure and thromboembolic phenomena in

this age of numerous high-efficacy drugs and therapeutic

interventions. Due to the lack of contemporary local data,

there is no national strategy for the control and eradication

of the disease in Uganda. This study aimed to describe the

presenting clinical features of newly diagnosed patients with

RHD, with particular reference to the frequency of serious

complications (atrial fibrillation, systemic embolism, heart

failure and pulmonary hypertension) in the study group.

Methods:

One hundred and thirty consecutive patients who

satisfied the inclusion criteria were recruited over a period of

eight months from June 2011 to January 2012 at the Mulago

Hospital, Uganda. Data on demographic characteristics,

disease severity and presence of complications were collected

by means of a standardised questionnaire.

Results:

Seventy-one per cent of the patients were female with

a median age of 33 years. The peak age of the study group

was 20 to 39 years, with the commonest presenting symptoms

being palpitations, fatigue, chest pain and dyspnoea. The

majority of the patients presented with moderate-to-severe

valvular disease. Pure mitral regurgitation was the common-

est valvular disease (40.2%), followed by mitral regurgitation

plus aortic regurgitation (29%). Mitral regurgitation plus

aortic regurgitation plus mitral stenosis was found in 11%

of patients. There was only one case involving the tricuspid

valve. The pulmonary valves were not affected in all patients;

45.9% of patients presented in severe heart failure in NYHA

class III/IV, 53.3% had pulmonary hypertension, 13.9% had

atrial fibrillation and 8.2% had infective endocarditis. All

patients presented with dilated atria (

49 mm).

Conclusion:

A significant proportion of RHD patients present

to hospital with severe disease associated with severe compli-

cations of advanced heart failure, pulmonary hypertension,

infective endocarditis and atrial fibrillation. There is a need

to improve awareness of the disease among the population,

and clinical suspicion in primary health workers, so that

early referral to specialist management can be done before

severe damage to the heart ensues.

Keywords:

rheumatic heart disease, clinical presentation, newly

diagnosed

Submitted 24/4/12, accepted 23/10/12

Cardiovasc J Afr

2013;

: 28–33

www.cvja.co.za

DOI: 10.5830/CVJA-2012-076

Rheumatic heart disease (RHD) is the most common acquired

cardiovascular disease in children and young adults and remains

a major public health problem in developing countries.

1-3

Africa has the largest number of children with the disease; in

sub-Saharan Africa, over a million children are estimated to

suffer from this debilitating and often fatal condition.

Rheumatic heart disease is the result of damage to the heart

valves, which occurs after repeated episodes of acute rheumatic

fever (ARF). The valves become stretched and scarred and do

not move normally, resulting in regurgitation and/or stenosis. If

RHD is not diagnosed and managed early, it may result in heart

failure and premature death.

Several factors determine the type of lesion and severity of

the disease among affected individuals. Genetic susceptibility

and environmental factors (low socio-economic status) are the

key determinants of disease pathogenesis.

1-4

The extent to which

environmental factors impact on the pathogenesis of the disease

varies from population to population and is largely influenced

by people’s perception of the disease.

Hence it is important to

identify the common factors within the population that present

with RHD. There are no studies in more than 35 years in Uganda

to document the characteristics of patients affected by RHD.

The symptoms of RHD depend on the valve lesion and its

severity.

Symptoms of RHD may not show for many years

until valvular disease becomes severe. In general terms, initial

symptoms of RHD are the symptoms of early heart failure:

breathlessness on exertion, feeling tired and general weakness.

As heart failure progresses, other symptoms may develop,

including orthopnoea, paroxysmal nocturnal dsypnoea, and

peripheral oedema. Palpitations may occur if atrial fibrillation

is present (particularly in mitral stenosis). This arrhythmia

is associated with increased thromboembolic risk, including

stroke. People with aortic valve disease may experience angina

and syncope in addition to heart failure symptoms. Clinical

examination includes assessment of severity and complications,

including signs of heart failure, the presence of atrial fibrillation

and any new murmurs.

Early diagnosis of RHD is important as secondary prophylaxis

can be started as soon as possible to help prevent the progression

Department of Medicine, Division of Cardiology, College of

Health Sciences, Makerere University, Kampala, Uganda

CHARLES MONDO, MB ChB, MMed, PhD, charlesmondo2011@

gmail.com

CHARLES MUSOKE, MB ChB

JAMES KAYIMA, MB ChB, MMed

JURGEN FREERS, MB ChB, MMed, MD

Uganda Heart Institute and Department of Medicine, College

of Health Sciences, Makerere University, Kampala, Uganda

WANZHU ZHANG, MB ChB

EMMY OKELLO, MB ChB, MMed

BARBARA KAKANDE, MB ChB, MMed

Uganda Heart Institute, Mulago Hospital, Kampala, Uganda

WILSON NYAKOOJO, MD, PhD