Distance from tertiary care, pericardial effusion, and nutritional status predict all-cause mortality among Malawian children with rheumatic heart disease.

BACKGROUND

This study of Malawian children with rheumatic heart disease (RHD) sought to detect demographic, clinical, and echocardiographic risk factors for mortality.

METHODS

Pediatric patients with RHD were recruited from March to October, 2018 from clinic rosters and inpatient consults in Lilongwe and Blantyre, Malawi. An echocardiogram was performed upon study enrollment. Cox regression analyses were performed to assess for factors associated with mortality over nearly 2 years of follow-up.

RESULTS

Of 118 patients, nearly two-thirds were female (64.4%) and median age was 12 (IQR 10-14). Just under half (47.0%) lived >40km from a tertiary care center. There was a high prevalence of severe mitral regurgitation (65.3%), and pericardial effusion was present in 18.6%. Nearly a quarter (23.7%) died during follow-up. In univariable Cox regression, living >40km from tertiary care, living in a remote area, moderate or severe malnutrition, taking a beta blocker, severe mitral stenosis, any severe valve disease, severe left atrial enlargement, and presence of a pericardial effusion were statistically significant risk factors for mortality (p<0.05). In the adjusted model, living >40km from tertiary care (HR 2.66, CI 1.06-6.07, p=0.037), malnutrition (mild HR 3.92, CI 1.03-14.91, p=0.045); moderate HR 7.41, CI 1.92-28.54, p=0.004; severe HR 4.91, CI 1.44-16.71, p=0.011), beta blocker use (HR 4.62, CI 1.63-13.10, p=0.004), and presence of a pericardial effusion (HR 6.96, CI 3.00-16.13, p<0.001) remained independent risk factors for mortality.

CONCLUSIONS

This study of Malawian children emphasizes the dire prognosis of RHD in under-resourced settings and provides potential area of focus for targeted intervention.