Comparison between interventional versus medical therapy in patients with rheumatic mitral valve stenosis in Tanzania.

BACKGROUND: Rheumatic heart disease remains the most common cardiovascular disease in children and young adults. The outcome of interventional versus medical therapy on the long term is not fully elucidated yet. This study provides contemporary data on the clinical profile, treatment and follow up of patients with rheumatic mitral stenosis (MS) in Tanzania. METHODS: Patients' medical information, investigations and treatment data were recorded in this prospective cohort study. They were followed up for 6-24 months to determine the long-term outcome. Interventional therapy was defined as a combination of surgery and percutaneous balloon mitral valvuloplasty. Kaplan-Meier curves and Cox proportional hazards model were used in analyses. p-Value < 0.05 was considered statistically significant. RESULTS: We enrolled 290 consecutive patients. Interventions were done in half of the patients. Median follow up was 23.5 months. Mortality was higher in the medical than interventional treatment (10.4% vs. 4%, log-rank p = 0.001). Median age was 36 years, females (68.3%) and low income (55.5%). Multivalvular disease was found in 116 (40%) patients, atrial fibrillation (31.4%), stroke/transient ischaemic attack (18.9%) and heart failure class III-IV (44.1%). Median (IQR) duration of disease was 3 (4) years, secondary prophylaxis (27.7%) and oral anticoagulants use (62.3%). In multivariable analysis, the risk of death among patients on medical was 3.07 times higher than those on interventional treatment (crude HR 3.07, 95% CI 1.43-6.56, p = 0.004), 2.44 times higher among patients with arrhythmias versus without arrhythmias (crude HR 2.44, 95% CI 1.19-4.49, p = 0.015) and 2.13 times higher among patients with multivalvular than single valve disease (crude HR 2.13, 95% CI 1.09-4.16, p = 0.026). CONCLUSIONS: Intervention is carrying low mortality compared to medical treatment. Arrhythmias and multivalvular disease are associated with a high mortality. Rheumatic MS is more prevalent in young people, females and individuals with low income. There is a late hospital presentation and a low use of both secondary prophylactic antibiotics and anticoagulants.

Suicide Attempt Following Pacemaker Implantation in an Eighty-Three-Year-Old Male: A Case Report.

As the global population ages, cardiac pacing procedures are rising exponentially to keep pace with the increasing incidence of bradyarrhythmias. The efficacy of pacemakers is well established, but recipients may have poor psychosocial adaptation leading to development or exacerbation of mental disorders, that may manifest with anxiety, depressive symptoms or rarely suicidal tendencies. An 83-year-old male of African descent was referred to us for evaluation and expert management. He came with chief complaints of general body malaise, light-headedness, chest pain and fainting spells for about 6 months. He was diagnosed with hypertension 4 years prior, and there was no history of mental illness in the patient or his family. Echocardiography (ECHO) revealed features of hypertensive heart disease while electrocardiogram (ECG) showed features of third-degree heart block. He underwent successful pacing with a resultant ventricular paced rhythm. The patient was stable and symptom free post pacing, but on the fourth day he jumped off the window of the ward in the hospital's second floor. Post suicide attempt examination revealed epistaxis, right periorbital hematoma with a temporal lacerated wound and deformed ankles bilaterally. ECG showed a ventricular paced rhythm and the chest radiograph showed an intact pacemaker. Ophthalmological review was evident for right sided blepharospasm with massive chemosis and bilateral constricted reactive pupils. Radiological investigations showed right orbital fracture, stable C5 and C6 fractures, and bilateral bimalleolar fractures with ankle dislocation. Neurosurgical review was unremarkable and psychiatric review could not be performed. The patient died 18 h after the suicide attempt incidence. Emotional disturbances post pacing impairs the quality of life and in the worst case scenario could lead to unanticipated cessation of life. In view of this, thorough evaluation and monitoring of the patient's psychological well-being both pre and post pacing is paramount.