Despite declines in deaths from rheumatic heart disease (RHD) in Africa over the past 30 years, it remains a major cause of cardiovascular morbidity and mortality on the continent. We present an ...investment case for interventions to prevent and manage RHD in the African Union (AU).
We created a cohort state-transition model to estimate key outcomes in the disease process, including cases of pharyngitis from group A streptococcus, episodes of acute rheumatic fever (ARF), cases of RHD, heart failure, and deaths. With this model, we estimated the impact of scaling up interventions using estimates of effect sizes from published studies. We estimated the cost to scale up coverage of interventions and summarised the benefits by monetising health gains estimated in the model using a full income approach. Costs and benefits were compared using the benefit–cost ratio and the net benefits with discounted costs and benefits.
Operationally achievable levels of scale-up of interventions along the disease spectrum, including primary prevention, secondary prevention, platforms for management of heart failure, and heart valve surgery could avert 74 000 (UI 50 000–104 000) deaths from RHD and ARF from 2021 to 2030 in the AU, reaching a 30·7% (21·6–39·0) reduction in the age-standardised death rate from RHD in 2030, compared with no increase in coverage of interventions. The estimated benefit–cost ratio for plausible scale-up of secondary prevention and secondary and tertiary care interventions was 4·7 (2·9–6·3) with a net benefit of $2·8 billion (1·6–3·9; 2019 US$) through 2030. The estimated benefit–cost ratio for primary prevention scale-up was low to 2030 (0·2, <0·1–0·4), increasing with delayed benefits accrued to 2090. The benefit–cost dynamics of primary prevention were sensitive to the costs of different delivery approaches, uncertain epidemiological parameters regarding group A streptococcal pharyngitis and ARF, assumptions about long-term demographic and economic trends, and discounting.
Increased coverage of interventions to control and manage RHD could accelerate progress towards eradication in AU member states. Gaps in local epidemiological data and particular components of the disease process create uncertainty around the level of benefits. In the short term, costs of secondary prevention and secondary and tertiary care for RHD are lower than for primary prevention, and benefits accrue earlier.
World Heart Federation, Leona M and Harry B Helmsley Charitable Trust, and American Heart Association.
Objectives This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda. Background ...Heart failure contributes significantly to noncommunicable disease burden in sub-Saharan Africa. Specialized care is provided primarily at referral hospitals by physicians, limiting patients' access. Simplifying clinical strategies can facilitate decentralization of quality care to the district hospital level and improve care delivery. Methods Heart failure services were established within integrated advanced noncommunicable disease clinics in 2 rural district hospitals in Rwanda. Nurses, supervised by physicians, were trained to use simplified diagnostic and treatment algorithms including echocardiography with diagnoses confirmed by a cardiologist. Data on 192 heart failure patients treated between November 2006 and March 2011 were reviewed from an electronic medical record. Results In our study population, the median age was 35 years, 70% were women, 63% were subsistence farmers, and 6% smoked tobacco. At entry, 47% had New York Heart Association class III or IV functional status. Of children age <18 years (n = 54), rheumatic heart disease (48%), congenital heart disease (39%), and dilated cardiomyopathy (9%) were the leading diagnoses. Among adults (n = 138), dilated cardiomyopathy (54%), rheumatic heart disease (25%), and hypertensive heart disease (8%) were most common. During follow-up, 62% were retained in care, whereas 9% died and 29% were lost to follow-up. Conclusions In rural Rwanda, the causes of heart failure are almost exclusively nonischemic even though patients often present with advanced symptoms. Training nurses, supervised by physicians, in simplified protocols and basic echocardiography is 1 approach to integrated, decentralized care for this vulnerable population.
Abstract Background The use of tranexamic acid (TEA) can significantly reduce the need for allogenic blood transfusions in elective primary joint arthroplasty. Revision total hip arthroplasty ...requires increased utilization of post-operative blood transfusions for acute blood loss anemia compared to elective primary hip replacement. There is limited literature to support the routine use of TEA in revision THA. Methods We performed a retrospective review of 161 consecutive patients who underwent revision total hip arthroplasty from 2012-14 at a single institution by two fellowship-trained surgeons. We compared the transfusion requirements and the post-operative hemoglobin drop of the TEA Group (109 patients, 114 hips) versus the No TEA group (52 patients, 56 hips). Our standard protocol for administering TEA is 1000mg IV at incision, and the same dose repeated two hours later. The No TEA group did not receive the medication because of previous hospital contraindication criteria. Results The transfusion rate was significantly less for the TEA group (7%) compared to the No TEA group (34%) (p < 0.0001). The mean hemoglobin delta was also significantly less for the TEA group (2.0 ± 1.3 g/dL) compared to the No TEA group (3.5 ± 1.4 g/dL, p < 0.0001). No adverse thromboembolic events occurred in the patients who received TEA. Conclusion The routine use of TEA during revision total hip arthroplasty demonstrated a significant reduction in allogenic blood transfusion rates. The post-operative hemoglobin drop was also significantly less with the use of TEA. We recommend the routine use of TEA during revision THA.
Short-Term Serial Sampling of Natriuretic Peptides in Patients Presenting With Chest Pain Gene Kwan, Susan R. Isakson, Jennifer Beede, Paul Clopton, Alan S. Maisel, Robert L. Fitzgerald Although ...single levels of natriuretic peptides in patients admitted for acute coronary syndromes (ACS) have important prognostic value, it is unclear if serial measurements have diagnostic and prognostic value. We followed 276 patients who presented with chest pain. We sampled brain natriuretic peptide (BNP) and amino-terminal (NT) proBNP up to 5 times within 24 h and again at discharge. Adverse events included emergency department visits for chest pain, cardiac readmission, and death. Natriuretic peptides were diagnostic for congestive heart failure (CHF) and new-onset CHF but less so for ACS. Baseline elevated BNP and NT-proBNP concentrations were predictive of adverse events. Serial sampling did not improve the prognostic value of natriuretic peptides.
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