Is It Possible for a Heart Transplant Patient to Get Rheumatic Heart Disease Again
Introduction
Rheumatic heart illness (RHD) remains a illness of international importance, yet little has been published about affliction progression in a contemporary cohort. Much of our understanding of the natural history of the illness stems from seminal studies conducted over 50 years ago.ane , 2 , 3 While disease pathophysiology may accept inverse trivial since that time, the introduction of benzathine penicillin G (BPG) prophylaxis, too as the availability of cardiac valve surgery in some settings, has changed the prognosis of established RHD considerably. An understanding of the current trajectory of RHD is important so that the potential touch on of new interventions can be realistically estimated.
RHD is a disease of poverty, and the associations with overcrowding and lower socioeconomic status are well documented.4 , 5 While it is now predominantly a illness of developing countries, the Ethnic population of Australia continues to experience rates of astute rheumatic fever (ARF) and RHD that are amid the highest in the earth.six In the Northern Territory (NT) of Australia, there is an active RHD command program, and a computerized register was established in 1997. This register includes clinical information almost private patients' diagnosis, treatment, and clinical class, and provides the opportunity to evaluate local disease epidemiology in some detail. A number of audits have been undertaken using NT register data,6 , 7 , eight but none to date have analyzed the progression of RHD from diagnosis to the occurrence of several important clinical events, including heart failure, surgical intervention, death, or disease remission.
In order to evaluate the potential wellness and economic bear upon of new interventions, a model of disease progression is required. As RHD is a chronic illness that tin can progress or regress over time, a multi‐state model is well suited to this process (equally opposed to a uncomplicated decision tree). The progression from diagnosis to heart failure, and the need for plush surgery, is of primary interest for economical modeling. Quantifying the probability of progression over fourth dimension through standard Kaplan–Meier estimates (used in survival analysis) will exist inaccurate due to the competing risk of expiry,ix which is higher in RHD patients compared to the general Indigenous population.8 A multi‐state model overcomes this limitation considering middle failure and death can be divers as mutually exclusive health states. Additionally, wellness states can also exist included to represent the severity of RHD (ie, balmy, moderate, or astringent with and without surgery), allowing the natural history of disease to exist expressed every bit time spent in these wellness states, as divers by land transition probabilities. Thus, the expected modify in wellness states from an intervention that alters the natural history of disease can be estimated at an individual level by a modify in the transition probabilities, or at an aggregated accomplice level by a modify in the initial distribution of RHD severity at diagnosis.
Nosotros therefore aimed to create a multi‐state model for RHD progression using series clinical information from a real cohort of Australian RHD patients. This model can so exist used to evaluate the price‐effectiveness of a proposed school‐based echocardiographic screening program in the contemporary Australian context.
Methods
Model Type
Multi‐state models provide a flexible framework that allows united states to model a disease process by defining several health states of involvement and describing the probability of transitioning from 1 state to some other over time.10 , 11 , 12 If transition out of a health state is possible, the state is said to be transient. If transition is non possible, that land is said to exist arresting (for example, death). A multi‐country model is a particularly good model for RHD: a chronic process where patients may transition back and forth between different clinical states over time.
Our model is subject area to the Markovian assumption that the transition process is "memoryless," meaning that the probability of transitioning from one state to another is not affected by time spent in previous wellness states. This is somewhat artificial, given that prior history often affects future prognosis. Despite this limitation, nosotros chose a multi‐country model because it permits a more useful and valid analysis of RHD progression than a simple survival analysis, which can just evaluate 1 issue (eg, time to surgery, or time to decease), and does not take into consideration competing risks where 1 event precludes the event of interest occurring (eg, death preventing surgery).9 , 10
Information Source
The NT RHD register includes information nearly patient demographics, clinical details, and investigations of all individuals diagnosed with ARF or RHD in the NT. Data are entered by register staff at diagnosis, and at each subsequent clinical review, based on clinician notes and/or laboratory or echocardiography reports. Hospital and master intendance databases are regularly searched by register staff to ensure clinical information is equally complete equally possible. De‐identified information were extracted from the RHD register and assessed for inconsistencies and completeness. A wavier of consent was sought for the apply of existing data and the report was approved past the Human Research Ethics Committee of the Menzies School of Health Research.
Written report Cohort
Our report was based on a cohort of Indigenous persons identified from the NT RHD register. We selected NT residents aged 5 to 24 years diagnosed with RHD betwixt Jan i, 1999 and December 31, 2012, which was the date at which data were censored. We did not extract information about patients who had a diagnosis of ARF without RHD.
Health States
Patients on the NT RHD register are categorized as having mild, moderate, or astringent RHD (Priority level 3, ii, and 1, respectively), as outlined in the Australian RHD guidelines.13 We used this classification to describe illness severity (Table 1). Patients' priority levels are allocated by physicians, and are updated with each clinical see. It was causeless that patients remained in the same priority level each month between clinical encounters. Patients who crave surgery are automatically assigned a "Astringent" priority level (Priority 1) in the register; however, nosotros modeled surgery every bit an explicit health state (Priority 1a). In cases where surgery was required at diagnosis, we modeled the assignment of the "Severe" priority level followed by a delay of less than 1 week before transition to the "Astringent–Surgery" state. This change was required only at diagnosis to confine the initial states of RHD to mild, moderate, and severe.
| Classification | Description | Health State Type |
|---|---|---|
| Priority i (Severe) | Severe valvular disease or moderate–severe valvular lesion with symptoms of cardiac failure | Transient |
| Priority 1a (Severe–surgery)b | Mechanical or tissue prosthetic valves replacements, valve repairs (including balloon valvuloplasty) | Transient |
| Priority two (Moderate) | Any moderate valve lesion in the absence of symptoms, and with normal left ventricular function | Transient |
| Priority 3 (Mild) | Little‐to‐mild valvular disease | Transient |
| Priority 4 (Inactive) | Ceased prophylaxis | Transient |
| Priority five | Deceased (any cause) | Arresting |
According to the Australian RHD guidelines, a patient may transition to the "Inactive" country if they take completed a minimum of 10 years antibiotic prophylaxis afterwards their virtually contempo episode of ARF, and if in that location are minimal valvular changes on echocardiogram at the time of final review. Possible transitions betwixt RHD states are illustrated in Figure ane.
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Effigy 1. Potential health state transitions of patients on the
Our assay did non include 2 factors that could potentially bear upon the course of disease. Secondary prophylaxis information have only been entered into the register since 2007, and were therefore considered also incomplete to be useful. Recurrences of ARF were also hard to capture, equally they relied on a previous diagnosis of ARF, and some of our cohort had never had a previously recorded episode of ARF.
Data Quality Assessment and Exclusions
The engagement of RHD diagnosis was defined every bit the date of diagnosis recorded on the annals unless there were clinical reviews before the recorded diagnosis engagement, in which case the date of first review was used as a surrogate. If a priority level had non been assigned within 1 twelvemonth of a recorded RHD diagnosis, individual clinical records were reviewed and, where possible, a priority level was allocated based on available clinical information (including clinician notes and echocardiogram reports) contained in the register. Cases were excluded if there was insufficient clinical information to permit resource allotment of a priority level at diagnosis.
Statistical Methods
All data analysis was performed in R (version 3.1.0, 2015). Age at diagnosis was categorized into four groups (5–ix, 10–14, 15–19, and 20–24 years) for comparing with existing studies, and all data were summarized equally frequency distributions. Chi‐foursquare tests (or Fisher's exact exam where indicated) were performed to assess differences in RHD severity at diagnosis, valve surgery, and bloodshed between sexual practice, and the age at diagnosis. Additionally, RHD severity at diagnosis was compared betwixt sexes within 2 subgroups; children (5–xiv years) and immature adults (15–24 years).
The probabilities of being in a particular RHD health state at the end of each month following diagnosis were obtained from the Aalen‐Johansen transition estimates calculated past the "msSurv" package (version 1.one‐2, 2012), with respective 95% CI calculated from 200 bootstrap samples. Plots were constructed using the "ggplot2" package (version ane.0.1, 2015).
Results
Data Set
Information about 618 Ethnic persons anile 5 to 24 years inclusive, diagnosed with RHD betwixt January 1999 and Dec 2012, was extracted from the NT RHD annals (Effigy ii). A detailed review of 272 records (44.0%) was required due to incomplete or inconsistent data. A priority level had not been allocated inside 1 year of RHD diagnosis for 164 patients. Of these, sufficient clinical data was available to allow priority level allocation in 144 cases, but xx were excluded due to inadequate information, including iii deaths, which was the but data entry indicate for these patients.
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Figure 2. Option of
Ninety‐five patients had clinical reviews recorded more than than ane yr before their RHD diagnosis appointment; 7 of these were excluded due to an actual diagnosis date before 1999, and the remainder had their diagnosis date revised to correspond with the date of first clinical review. Other reasons for review included the following: surgery date before diagnosis appointment (n=2), interstate residence (n=3), and inconsistent sequences of records (for example, multiple priority transitions in <six months; n=8).
After exclusions, 591 records were available for analysis with a median follow‐up fourth dimension of 7.5 years postdiagnosis (interquartile range 4.3–x.3).
Clinical Information Obtained From NT Register
RHD incidence and severity
Clinical information regarding 591 cases of RHD is presented in Table 2. There were more females than males, which was consequent within each age category (information not shown), and the highest number of RHD cases was reported in 10‐ to 14‐twelvemonth‐olds.
| Clinical Indicator | Sex | Age Category | All | ||||
|---|---|---|---|---|---|---|---|
| Male person | Female | 5‐ to 9‐Year‐olds | ten‐ to xiv‐Year‐olds | 15‐ to xix‐Year‐olds | 20‐ to 24‐Yr‐olds | Total | |
| n (%) | n (%) | n (%) | n (%) | north (%) | n (%) | n (%) | |
| Number of RHD diagnoses | 226 | 365 | 140 | 219 | 136 | 96 | 591 |
| RHD severity at diagnosis | |||||||
| Severe | 31 (13.7) | 65 (17.8) | 21 (xv.0) | 28 (12.8) | 26 (xix.1) | 21 (21.nine) | 96 (16.2) |
| Moderate | 59 (26.one) | 102 (27.9) | 42 (30.0) | 56 (25.six) | 36 (26.5) | 27 (28.1) | 161 (27.ii) |
| Mild | 136 (sixty.2) | 198 (54.2) | 77 (55.0) | 135 (61.six) | 74 (54.iv) | 48 (50.0) | 334 (56.5) |
| Number of patients having ≥1 surgeries | 44 (19.5) | 53 (fourteen.5) | 25 (17.ix) | 32 (14.6) | 28 (20.6) | 12 (12.5) | 97 (16.iv) |
| Number of deaths | 8 (three.five) | 10 (2.7) | 2 (1.4) | 4 (one.8) | 7 (5.ane) | 5 (five.2) | 18 (3.0) |
At diagnosis, 96 (xvi.2%) patients had severe RHD, and over the 14‐year written report period 176 patients (29.8%) were diagnosed with severe RHD. The proportion with severe RHD at diagnosis did not vary significantly between sex (P=0.29) or age group (P=0.33; Tabular array 2). Still, within the subgroup of 5‐ to 14‐year‐old children, a greater proportion of girls than boys presented with severe disease (P=0.03; Figure 3).
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Figure 3. Number and severity at diagnosis of cases of
Surgery
A total of 131 surgeries were performed in 97 patients; 83 valve repairs (63.4%), and 46 valve replacements (35.1%); surgery type was not specified in 2 cases. Lxx‐three patients had a single procedure, eighteen had 2 surgeries, and half-dozen had ≥three surgeries. The number of patients requiring at least 1 surgery did not statistically differ betwixt historic period groups (P=0.32) or sex (P=0.11). The median fourth dimension to surgery for children diagnosed with severe RHD was ii years. The age at first surgery is presented in Effigy 4.
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Effigy iv. Age of
Death
There were eighteen deaths during the study menstruum. Of these, ten had astringent RHD at the time of diagnosis, and 16 had severe RHD at the time of expiry. Eleven had undergone surgery. There was no statistical difference in the number of deaths past age group at diagnosis (Fisher's exact examination, P=0.xi) or sex (P=0.58). The age at death is presented in Effigy 5 and included 2 deaths in children under xv years of age.
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Figure v. Age of
Disease Progression Over Fourth dimension: A Multi‐State Model for RHD
Transition probabilities between all RHD wellness states were calculated for each month over the fourteen‐yr study menstruum. The probabilities that a patient volition be in a given health state ane, 5 and 10 years afterwards RHD diagnosis are presented in Tabular array iii. For instance, of the patients diagnosed with mild RHD, 93.9% remained mild ane twelvemonth after diagnosis while four.seven%, 1.1%, and 0.3% progressed to moderate, astringent, and severe with surgery, respectively. Probabilities for age groups five to 14 and xv to 24 years are presented separately in Tables S1 and S2 and Figures S1 and S2.
| Severity at Diagnosis | Severity Subsequently×Years | Time (×Years) Since RHD Diagnosis | |||||
|---|---|---|---|---|---|---|---|
| I Yr | 5 Years | 10 Years | |||||
| % | 95% CI | % | 95% CI | % | 95% CI | ||
| Mild (n=334) | Mild | 93.9 | ninety.vi to 97.2 | 73.seven | 66.8 to lxxx.7 | 63.9 | 51.0 to 76.eight |
| Moderate | 4.seven | ii.5 to 6.9 | 17.1 | xiii.two to 20.ix | 18.3 | 12.8 to 23.nine | |
| Severe | ane.one | 0.2 to 1.9 | 4.four | 2.7 to half-dozen.1 | 6.3 | 3.six to nine.ane | |
| Surgery | 0.3 | 0.0 to 0.6 | 2.iv | 1.3 to iii.5 | v.i | 3.0 to 7.two | |
| Death | — | — | 0.5 | 0.0 to 1.two | 1.0 | 0.2 to 1.9 | |
| Inactive | — | — | 1.9 | 0.iv to 3.4 | five.3 | ii.ii to viii.3 | |
| Moderate (n=161) | Mild | eight.1 | four.0 to 12.2 | 26.0 | 20.1 to 32.0 | 34.0 | 25.v to 42.5 |
| Moderate | 85.6 | 79.iv to 91.7 | 50.two | 42.3 to 58.0 | 31.4 | 22.7 to 40.0 | |
| Astringent | 5.1 | ii.i to 8.1 | 13.two | 8.7 to 17.seven | 13.2 | eight.0 to xviii.iv | |
| Surgery | 1.2 | 0.3 to 2.2 | nine.3 | 5.7 to xiii.0 | 15.vii | x.ane to 21.2 | |
| Death | 0.0 | 0.0 to 0.03 | 0.9 | 0.2 to 1.half-dozen | 2.4 | 0.vii to 4.1 | |
| Inactive | — | — | 0.4 | 0.1 to 0.8 | 3.4 | 0.ix to 5.9 | |
| Astringent (n=96) | Balmy | 0.5 | 0.1 to 1.0 | 3.6 | 1.7 to 5.iv | five.6 | 2.9 to 8.3 |
| Moderate | seven.one | 2.4 to eleven.9 | 10.0 | 5.7 to 14.iii | 7.0 | 3.7 to 10.2 | |
| Astringent | 49.half dozen | 39.3 to lx.0 | 19.three | 11.8 to 26.7 | 11.5 | 6.0 to 17.i | |
| Surgery | 41.six | 32.0 to 51.iii | 59.7 | 48.5 to seventy.8 | 62.vii | 46.6 to 78.7 | |
| Death | one.0 | 0.0 to 3.0 | 7.5 | 2.4 to 12.5 | 12.6 | 5.7 to 19.5 | |
| Inactive | — | — | 0.0 | 0.0 to 0.1 | 0.6 | 0.1 to 1.2 | |
Illness progression over time, based on RHD severity at diagnosis, is graphically represented in Figure 6.
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Figure 6.
Young people who had severe RHD at the time of diagnosis had rapid disease progression and a poor prognosis; 50% of this group had surgery within 2 years, and 10% were expressionless within six years of their diagnosis. Patients diagnosed with moderate RHD had a mixed prognosis; ten years after diagnosis, roughly one third had progressed to severe RHD (with or without surgery), one third remained moderate, and i third had regressed to mild RHD. Those who had mild RHD at diagnosis had the well-nigh favorable prognosis, with over lx% remaining balmy after 10 years, and 10% being inactive by the stop of the 14‐twelvemonth study period. Still, about 30% of this grouping demonstrated disease progression (xviii.3% moderate, 11.4% severe, half of whom had surgery) by x years.
Discussion
This is the first fourth dimension a multi‐country model for RHD progression has been adult using real patient data. The NT annals contains the best bachelor data on a contemporary accomplice of RHD patients in the world, and we believe that our analysis provides an authentic picture of the trajectory of RHD for young Indigenous Australians today. Furthermore, nosotros believe that our model may exist informative for other populations in RHD‐endemic settings who face up similar socioeconomic disadvantage, poor adherence to BPG, and high rates of ARF recurrence.
Overall, 16.2% of our cohort had severe illness at diagnosis (Table 2). We were surprised that this proportion did not vary significantly between age groups, and that 15% of 5‐ to 9‐year‐olds presented with severe disease. This suggests either that the first episode of ARF is occurring very early (and is being missed), or that there is a group of children who have a fulminant presentation with ARF carditis that quickly progresses to severe RHD. This notion could be supported by a number of earlier studies describing presentations with congestive cardiac failure and/or cardiomegaly in 10% to 20% of first ARF episodes.i , 2 , 3 , 14 , xv , 16 In all of these studies, severe carditis at presentation universally correlated with the poorest prognosis. Unfortunately in this group of children, screening is unlikely to make a difference to their disease progression, although, in the Australian setting, where cardiac surgery is readily bachelor, before surgery would be expected to improve clinical outcomes and reduce bloodshed.
Over the xiii‐year written report menses, 176 patients (29.8%) were diagnosed with severe RHD, which is comparable to the 28% reported in Lawrence's audit of NT information,8 despite our younger cohort. It should be noted that the majority of children with severe RHD in the Australian context would be considered New York Eye Association Functional Class I or Ii, as opposed to New York Heart Association Functional Class III or IV, equally was the case in the recently published Global Rheumatic Heart Disease Registry (the REMEDY study)five (a multi‐center hospital‐based registry of RHD patients in depression‐ and heart‐income countries). The ready availability of cardiac surgery in Commonwealth of australia means that children with severe RHD in New York Center Association Class II automatically go on to surgery.
The prognosis of patients diagnosed with severe RHD is bleak. Figure 6 shows the rapid progression to surgery, with 41.6% having surgery within 12 months of their diagnosis (Tabular array 3). The proportion proceeding to surgery starts to plateau at about lx% by four years postdiagnosis, at which phase mortality starts to increase. This is particularly marked in the fifteen‐ to 24‐twelvemonth‐old age group (Table S2) which had 13.vii% mortality by 5 years (95% CI 3.iv–24.0) and 22.0% past 10 years (95% CI 9.0–35.0). By 10 years postdiagnosis with astringent RHD, over 3 quarters of fifteen‐ to 24‐yr‐olds had progressed to surgery or death (Effigy S2).
The implications of valve surgery in this population are particularly significant. Among Indigenous Australians receiving surgery for ARF or RHD, nigh 45% are under 25 years of historic period.17 The immature age at surgery means that about of these patients will need multiple operations over their life, and that, while valve repair is the initial procedure of selection, mechanical valve replacement will exist required in many, including women of childbearing age. The requirement for anticoagulation adds substantial risk, due to the challenges of international normalized ratio (INR) monitoring in this setting. A contempo audit of Ethnic RHD patients on warfarin found that merely lx% had adequate INR testing and that, of these, but 25% had INRs in the recommended range, putting these individuals at high hazard for hemorrhagic or thromboembolic complications.18
The natural history of patients diagnosed with moderate RHD is the most dynamic, with roughly equal proportions likely to progress, regress, or remain moderate at 10 years. We have previously undertaken a large echocardiographic screening survey of Indigenous children in the NT,19 and of the 18 new cases of Definite RHD detected, 7 (39%) were considered to be moderate by the reporting cardiologist. Given that this group is asymptomatic, yet has established RHD on echocardiogram, these children may stand to benefit most from screening. Hither, our information confirm that this group is capable of regressing or remaining static in the moderate state, and information technology would be hoped that early on detection and instigation of regular secondary prophylaxis would farther reduce the proportion progressing to severe illness.
Over one-half of all new RHD diagnoses in this cohort were categorized as mild. It is perhaps most pertinent to look at the prognosis of this grouping, equally these are the children that are most probable to be detected by screening. The mild group was the most stable in terms of affliction evolution, with the majority remaining mild over fourth dimension (73.7% and 63.9% at 5 and 10 years, respectively, Table iii). However, the fact that over ten% had progressed to severe affliction later 10 years, including 5.one% who underwent surgery, represents unacceptable morbidity in this grouping, which should have a beneficial prognosis.
2 Markov models looking at RHD progression have recently been published, but both rely on probability estimates derived from the literature, rather than data from an actual patient cohort. Manji et altwenty compared iii different strategies for RHD prevention, i of which was detection of early RHD using echocardiography, followed by lifelong secondary prophylaxis. Their model is limited by the fact that it only describes 2 states following diagnosis with RHD: RHD and death. In that location is no distinction made between balmy and severe disease despite the significantly different clinical trajectories and associated costs of these 2 states.
The model published by Zachariah et al last year21 aimed to evaluate the cost‐effectiveness of RHD screening in the Northern Territory of Australia, and it is interesting to compare their theoretical piece of work with ours. Following a diagnosis of RHD, they describe six clinical states, similar to ours. Definitions of severe disease were equivalent; all the same, their surgical state only considered valve replacement surgery, not valve repair that is the preferred intervention for young Indigenous patients in Australia. Zachariah'due south assumptions around the progression of astringent disease do not appear to exist appropriate for the current Australian context. They required that a patient be in the "RHD Congestive Eye Failure" land for at least one yr prior to undergoing surgery. As previously outlined, our data suggest that disease progression is considerably more rapid than this.
Our study provides a reliable picture of RHD development in a contemporary cohort of Ethnic Australians. Nonetheless, there are some limitations to our data. Firstly, patient severity levels, our outcomes of involvement, are assigned by clinicians and are open to a degree of subjectivity. While specific echocardiographic definitions of RHD severity are provided in the Australian guidelinesthirteen (Table 1), it is recognized that grading severity of mixed (stenotic and regurgitant) and multivalvular disease is challenging, and that clinical experience is of import. It was noted in the data assay procedure that at that place was some overlap betwixt patients labeled as Priority 3 (mild RHD) and Priority 2 (moderate RHD) despite like clinical and echocardiographic reports. Echocardiographic reports of Priority 1 cases (severe RHD) consistently demonstrated associated hemodynamic event (eg, sleeping room dilatation, impaired left ventricular part, pulmonary hypertension) so nosotros do non believe that severity was overestimated in this category. It is not possible to further clarify the potential impact of this suspected interobserver variability; however, it is reassuring that the patterns of disease progression nosotros observed were what we expected based on our experience, and from the literature.
Detailed mortality data is some other limitation of our data. Decease in this age group remains a rare upshot, so complete observation is important, nonetheless we had to exclude iii deaths due to incomplete information. We are therefore unable to make any comment about absolute survival rates, or about cause of death (ie, RHD‐ or non‐RHD‐related) as this was not consistently specified on the annals. Similarly, we are unable to comment on other clinically significant outcomes such as infective endocarditis, atrial fibrillation, or stroke, every bit this information is presently not systematically recorded in the NT register. While these are of paramount importance in the adult RHD population, it is unlikely that the incidence of these outcomes would have been loftier enough in our young cohort to meaningfully incorporate into our model.
Our model has not explicitly taken into consideration adherence to secondary antibody prophylaxis or ARF recurrences, both of which plain affect affliction progression. However, these figures are bachelor from previous reports based on the NT register, and we believe that it is reasonable to assume similar rates for our accomplice. Effective BPG delivery remains a meaning challenge in our setting, and while adherence has improved since 2005, in 2010, merely 28.one% of patients on the NT RHD register were receiving >80% of prescribed BPG doses.6 Consequently, ARF recurrence rates remain high, consistently representing betwixt 1 quarter and one third of ARF notifications over the concluding 10 years.half-dozen , seven The affliction trajectory that we accept described, therefore, is more likely to reflect natural disease progression than disease modified by prophylaxis, supporting the notion that our model may be applicative to other disadvantaged populations.
It is highly likely that the trajectory of mild and moderate RHD would be improved with improved BPG adherence, and this is a parameter that will be varied in the sensitivity analysis equally function of our proposed cost‐effectiveness analysis. Conspicuously, comeback in BPG delivery must exist a priority if RHD screening is to exist implemented. Indeed, if RHD screening is to fulfill the international criteria for a disease suitable for screening, the delivery of successful treatment that improves the natural history of affliction is a prerequisite.22
Conclusions
Nosotros take developed a robust multi‐state model for RHD using data from a contemporary cohort of Indigenous Australian RHD patients. Our data highlight the dour prognosis for immature Indigenous Australians diagnosed with severe RHD, and reinforce the demand to discover and treat the disease prior to this stage. Echocardiographic screening provides an opportunity for before detection, and our model of disease progression can be used to evaluate the cost‐effectiveness of different screening strategies.
Sources of Funding
Cannon was supported by an Australian Postgraduate Award from the University of Western Australia. Roberts was supported by an Australian Postgraduate Award from Charles Darwin University.
Disclosures
None.
Acknowledgments
We gratefully acknowledge the support of the staff from the NT RHD annals and the cardiology expertise of Dr Bo Remenyi.
Footnotes
References
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Source: https://www.ahajournals.org/doi/10.1161/jaha.116.003498
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