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期刊来源：JAMA

原文链接：https://doi.org/10.1001/jama.2024.8258

摘要内容如下：

重要性

风湿性心脏病（RHD）仍然是低收入和中等收入国家（LMIC）的公共卫生问题。然而，很少有大型研究纳入来自多个流行国家的个体。

目的

评估临床风心病患者的主要患者-重要临床结果的风险和预测因素。

设计、设置和参与者

多中心、以医院为基础的前瞻性观察研究，包括24个RHD流行LMIC的138个地点。

主要成果和措施

主要转归是全因死亡率。次要转归为病因特异性死亡率、心力衰竭（HF）住院、卒中、复发性风湿热和感染性心内膜炎。本研究分析了世界银行国家收入组的事件发生率，并使用多变量Cox模型确定了死亡率的预测因素。

结果

在2016年8月至2022年5月期间，共招募了13696名患者。平均年龄为43.2岁，72%为女性。随访结束时，12967名参与者（94.7%）的生命状态数据可用。在3.2年（41478患者-年）的中位时间内，1943名患者死亡（总体死亡率为15%；每患者年4.7%）。大多数死亡是由于血管原因（1312[67.5%]），主要是心衰或心源性猝死。接受瓣膜手术（604例[4.4%]）和心衰住院（每年2%）的患者数量较低。中风并不常见（每年0.6%），复发的风湿热也很罕见。严重瓣膜疾病的标志物，如充血性HF（HR，1.58[95%CI，1.50-1.87]；P<0.001），肺动脉高压（HR，1.52[95%CI，1.37-1.69]；P<0.001）和心房颤动（HR，1.30[95%CI，1.15-1.46]；P<.001）与死亡率增加相关。手术治疗（HR，0.23[95%CI，0.12-0.44]；P<0.001）或瓣膜成形术（HR，0.24[95%CI，0.06-0.95]；P=.042）与较低的死亡率相关。在调整患者水平因素后，较高的国家收入水平与较低的死亡率相关。

结论和相关性

风湿性心脏病的死亡率很高，并且与瓣膜疾病的严重程度相关。瓣膜手术和瓣膜成形术与显著降低的死亡率相关。研究结果表明，除了目前集中于抗生素预防和抗凝治疗的方法外，更需要改善外科和介入治疗的可及性。

英文原文如下：

Abstracts

Importance  Rheumatic 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.

Objective  To assess the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD.

Design, Setting, and Participants  Multicenter, hospital-based, prospective observational study including 138 sites in 24 RHD-endemic LMICs.

Main Outcomes and Measures  The 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.

Results  Between 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 Relevance  Mortality 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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