Heart disease warning

Cardiologist, Dr. Satupaitea Viali, has warned that Samoa is facing rising costs of rheumatic heart disease – one that is already using up a big part of the country’s $10 million overseas treatment budget.

In a report titled “Rheumatic heart disease in Samoa and the Pacific Nations” published in this month’s edition of the Journal of Primary Health Care, Dr. Viali said acute rheumatic fever (A.R.F.) and its long-term sequel, chronic rheumatic heart disease (R.H.D.), remain a massive problem around the world, especially in the developing world.

“Since 2003, the Government of Samoa has sent between 25 and 30 young people every year for R.H.D. surgery in New Zealand,” he said.

“This has an enormous impact on the overseas treatment budget of NZ$10 million per year. “The prevalence of R.H.D. imposes a significant burden on health care systems in the Pacific nations, which have very limited budgets.

“None of the Pacific nations can afford the escalating costs of R.H.D. surgery and, therefore, there should be a strong focus on primordial, primary and secondary prevention of A.R.F. and R.H.D.”

Recognition of symptoms of rheumatism is one of the main keys to diagnosing this disease and sets in motion a cascade of primary and secondary prevention, he said.

“R.H.D. has always been assumed to follow A.R.F,” he said.

“Unfortunately, it is now becoming increasingly apparent that the majority of R.H.D. cases have had minimal or no symptoms of A.R.F.

“Many patients who have never had A.R.F. symptoms are presenting to hospitals and clinics with arrhythmia and congestive heart failure from undiagnosed R.H.D.

“The sensitivity of auscultation for heart murmurs is also becoming lower because auscultation is not done well. “Identifying R.H.D. is much easier with echocardiography.

“The World Heart Federation (W.H.F.) R.H.D. Echocardiography Criteria was recently published in 2012 to assist in defining definite R.H.D. and borderline R.H.D.

“There are now published studies to show the superiority of echocardiographic screening.”

Dr. Viali said as part the national R.H.D. screening programme in Samoa from 2008 to 2012, medical personal screened 8,457 school children aged three to 16 years in primary schools in Upolu and Savaii using a portable echocardiography ultrasound machine. Preliminary results show a R.H.D. prevalence of 14 per 1000, he said.

This compares with a 2011 paper by Dr. Viali in the New Zealand Medical Journal, which reported that “Rheumatic fever is very common in Samoa.”

In that paper, the incidence of A.R.F. was reported as decreasing to 30 per 100,000 in 2005, 12.8 per 100,000 in 2007, 7.3 per 100,000 in 2008, and 9.5 per 100,000 in 2009.

The incidence of R.H.D. had decreased to 40.2 per 100,000 in 2007, 34 per 100,000 in 2008, and 31.8 per 100,000 in 2009. However while cases go down, expenses still go up, increasing the need to improve surveillance.

R.H.D. screening with echocardiogram at schools may be the best way to reduce the burden and suffering from R.H.D.

“Although there are some concerns regarding the screening of R.H.D. with echocardiography, the utilisation of echocardiographic screening in Samoa may prove cheaper and more effective in the long term, as more R.H.D. cases are identified much earlier.

“There will be a greater chance of preventing R.H.D. deterioration by the secondary prophylaxis programme, thus reducing the number of costly cardiac operations needed.

“It must be emphasised, however, that echocardiographic screening should not be carried out without a good secondary prophylaxis programme.”

Prophylaxis refers to preventative treatment. According to the report A.R.F. is an inflammatory disease that can develop after a sore throat or pharyngitis caused by Group A streptococcal infection, usually during childhood. “R.H.D. is the result of valvular damage caused by this inflammatory disease,” according to the report.

“It is manifested by inflammation causing thickening of the valves, leaking of the valves as a result of lengthening of the valve chords, failure of coaption of the valves, annulus dilatations, or stenosis of the valves from scarring and tethering of the valve leaflets or valve chords,” the report reads.

“R.H.D. remains a massive problem in Pacific nations, including Samoa, Tonga, Fiji, and others. “R.H.D. prevalence remains high in the indigenous populations of New Zealand (Maori) and Australia (Aborigines), and the Pacific nations’ migrant populations in New Zealand and Australia.

“R.H.D. remains a major cause of morbidity and premature death.” Dr. Viali said symptoms of A.R.F. include “carditis”, which is a heart murmur or heart failure, arthritis, chorea, subcutaneous nodule and a rash.

“Other supporting features include fever, high inflammatory markers and evidence of streptococcus infection, either by direct visual throat inspection, throat swab, or blood tests,” he said.

“There is no question that regular secondary prevention with intramuscular penicillin is very effective.

“Primary prevention can also work quite well if it is done well and is timely.

“If the health systems perform primary and secondary prevention well, the development and worsening of R.H.D. should be minimised and expensive cardiac surgery to repair or replace affected valves should not be needed.

“Primordial prevention is crucial to the fight against A.R.F. and R.H.D., but this area involves a multitude of determined and enthusiastic people working within and outside of health ministries to ‘chip away’ at all the issues to address in housing, socioeconomic status, schooling, culture, cultural behaviour and other areas.”