Surgery for rheumatic heart disease in the Northern Territory, Australia, 1997-2016: what have we gained?

BACKGROUND: Between 1964 and 1996, the 10-year survival of patients having valve replacement surgery for rheumatic heart disease (RHD) in the Northern Territory, Australia, was 68%. As medical care has evolved since then, this study aimed to determine whether there has been a corresponding improvement in survival. METHODS: A retrospective study of Aboriginal patients with RHD in the Northern Territory, Australia, having their first valve surgery between 1997 and 2016. Survival was examined using Kaplan-Meier and Cox regression analysis. FINDINGS: The cohort included 281 adults and 61 children. The median (IQR) age at first surgery was 31 (18-42) years; 173/342 (51%) had a valve replacement, 113/342 (33%) had a valve repair and 56/342 (16%) had a commissurotomy. There were 93/342 (27%) deaths during a median (IQR) follow-up of 8 (4-12) years. The overall 10-year survival was 70% (95% CI: 64% to 76%). It was 62% (95% CI: 53% to 70%) in those having valve replacement. There were 204/281 (73%) adults with at least 1 preoperative comorbidity. Preoperative comorbidity was associated with earlier death, the risk of death increasing with each comorbidity (HR: 1.3 (95% CI: 1.2 to 1.5), p<0.001). Preoperative chronic kidney disease (HR 6.5 (95% CI: 3.0 to 14.0) p≤0.001)), coronary artery disease (HR 3.3 (95% CI: 1.3 to 8.4) p=0.012) and pulmonary artery systolic pressure>50 mm Hg before surgery (HR 1.9 (95% CI: 1.2 to 3.1) p=0.007) were independently associated with death. INTERPRETATION: Survival after valve replacement for RHD in this region of Australia has not improved. Although the patients were young, many had multiple comorbidities, which influenced long-term outcomes. The increasing prevalence of complex comorbidity in the region is a barrier to achieving optimal health outcomes.

Evaluation of a cardiac prevention and rehabilitation programme for all patients at first presentation with coronary artery disease.

BACKGROUND: A cardiac prevention and rehabilitation (CP&R) programme was established for patients following their first clinical episode of coronary heart disease and 1-year outcomes were evaluated against British targets for coronary prevention. METHODS: Patients were evaluated 1 year after participation and outcomes compared with patients in the same health district registered with a random half of general practitioners not eligible for the programme (internal reference group) and patients identified in other English centres which participated in the EUROASPIRE II survey (external reference group). RESULTS: Three hundred and eighteen patients (76% of 417 incident cases) attended for 1-year screening. Of those who participated in the programme 96/113 (85%) attended (Group 1); 152/194 (78%) attended from all those eligible for the programme (Group 2); 166/223 (74%) attended from those receiving usual care in the same health district (Group 3 - internal reference group). In the EUROASPIRE II survey (Group 4 - external reference group) 362/744 (58%) patients were screened. Current smoking at follow-up was Group 1, 8%, Group 2, 11%, Group 3, 13% and Group 4, 18%. Proportions with a BMI < 25 kg/m were 29%, 25%, 32%, 18%; BP < 140/90 mmHg 58%, 56%, 49%, 48%; total cholesterol < 5.0 mmol/l 60%, 54%, 43%, 46%; antiplatelet therapy 88%, 87%, 86%, 81%; beta-blocker therapy 48%, 46%, 46%, 44%; and lipid lowering therapy 56%, 51%, 36%, 69% respectively. CONCLUSIONS: A CP&R programme was associated with a majority of coronary patients, whether attending the programme or not, achieving the Joint British Society's recommended prevention targets within the same health district. Specifically, a higher proportion of programme patients reached the cholesterol target of <5.0 mmol/l compared with both usual care and other centres elsewhere. This was achieved by using more lipid lowering therapy compared with usual care in the same health district, but less than other centres outside the health district. The overall results for the whole health district show a higher standard of preventive care compared with contemporary EUROASPIRE II results from other health districts in England.