MANAGEMENT OF RHEUMATIC HEART DISEASE IN LOW-TO-MIDDLE-INCOME COUNTRY

Abstract

Rheumatic heart disease (RHD) remains a global health burden. In 2017, approximately 38–40.8 million cases of RHD were observed all around the world. The prevalence of RHD in non-endemic regions is 3.4 cases per 100,000, whereas in endemic regions, it is higher than 1,000 cases per 100,000. RHD is also responsible for the premature deaths of 0.15/100000 children and an annual case-fatality rate of 1.5% per year among the global population ages. In Indonesia, eighty-three out of 15,608 mine workers in Papua suffered from RHD. A cardiac center in Bandung observed that 108/4,682 (2.3%) of the patients were diagnosed with RHD. Meanwhile, the Cardiovascular Centre Harapan Kita, Jakarta, a national cardiovascular disease referral hospital in Indonesia, stated that 40.5% of 7112 valvular cases during 2016–2019 were RHD cases. Definitive management of RHD with significant mitral valve stenosis consist of percutaneous balloon mitral valvuloplasty (PBMV) and mitral valve surgery (MVS). The survival analysis of patient with rheumatic MS after PBMV compared to MVS in Indonesia revealed that those who underwent PBMV, 1.8% died within 24 months, while 3.5% of those who underwent mitral valve replacement died within 27 months. The occurrence of rehospitalization did not differ between the two groups, with acute decompensated heart failure being the leading cause. PBMV is the first choice for patients with rheumatic heart disease without contraindications because it provides faster relief compared to mitral valve replacement. In terms of cost, PBMV is more affordable and less invasive, which is more beneficial for patients with rheumatic heart disease in low- to middleincome countries. Thereafter, a cohort retrospective study was conducted to assess the improvement of exercise capacity after early phase II cardiac rehabilitation in patients who undergo rheumatic mitral valve surgery. The study revealed that 6MWD and VO2 peak increased significantly in these patients after the early phase II CR program (p = 0.001). On the other hand, the use of ACE inhibitors as anti-fibrotic treatment is now being considered to address the fibrotic process in rheumatic mitral stenosis valve as a non-intervention management. It has been demonstrated that ACE inhibitors can break the inflammatory cycle that leads to fibrosis in the valve. Thus, we developed a research protocol to determine the anti-fibrotic effects of ACEI and designed an RCT in which patients received ramipril (5 mg) for at least 3 months preoperatively. Ramipril 5mg could be a breakthrough in the management of rheumatic heart disease, improving patient outcomes and proving highly beneficial in low- to middle-income countries. In conclusion, rheumatic heart disease, specifically rheumatic mitral stenosis, is the most common valvular disorder that occurs and should be comprehensively addressed through primary prevention, secondary prevention, non-intervention management, intervention management, and rehabilitation. Each approach is valuable and helpful in providing advancements in the management of rheumatic mitral stenosis.