Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study)

Eur Heart J. 2015 May 7;36(18):1115-22a. doi: 10.1093/eurheartj/ehu449. Epub 2014 Nov 25.


Aims: Rheumatic heart disease (RHD) accounts for over a million premature deaths annually; however, there is little contemporary information on presentation, complications, and treatment.

Methods and results: This prospective registry enrolled 3343 patients (median age 28 years, 66.2% female) presenting with RHD at 25 hospitals in 12 African countries, India, and Yemen between January 2010 and November 2012. The majority (63.9%) had moderate-to-severe multivalvular disease complicated by congestive heart failure (33.4%), pulmonary hypertension (28.8%), atrial fibrillation (AF) (21.8%), stroke (7.1%), infective endocarditis (4%), and major bleeding (2.7%). One-quarter of adults and 5.3% of children had decreased left ventricular (LV) systolic function; 23% of adults and 14.1% of children had dilated LVs. Fifty-five percent (n = 1761) of patients were on secondary antibiotic prophylaxis. Oral anti-coagulants were prescribed in 69.5% (n = 946) of patients with mechanical valves (n = 501), AF (n = 397), and high-risk mitral stenosis in sinus rhythm (n = 48). However, only 28.3% (n = 269) had a therapeutic international normalized ratio. Among 1825 women of childbearing age (12-51 years), only 3.6% (n = 65) were on contraception. The utilization of valvuloplasty and valve surgery was higher in upper-middle compared with lower-income countries.

Conclusion: Rheumatic heart disease patients were young, predominantly female, and had high prevalence of major cardiovascular complications. There is suboptimal utilization of secondary antibiotic prophylaxis, oral anti-coagulation, and contraception, and variations in the use of percutaneous and surgical interventions by country income level.

Keywords: Atrial fibrillation; Congestive heart failure; Infective endocarditis; Rheumatic heart disease; Stroke; Valve surgery; Valvuloplasty.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Oral
  • Adult
  • Age Distribution
  • Anti-Bacterial Agents / therapeutic use
  • Antibiotic Prophylaxis
  • Anticoagulants / administration & dosage
  • Cross-Sectional Studies
  • Developing Countries
  • Evidence-Based Medicine
  • Female
  • Global Health
  • Heart Valve Diseases / epidemiology
  • Heart Valve Diseases / etiology
  • Heart Valve Diseases / therapy
  • Humans
  • Male
  • Penicillins / therapeutic use
  • Pilot Projects
  • Prospective Studies
  • Rheumatic Heart Disease / complications
  • Rheumatic Heart Disease / epidemiology
  • Rheumatic Heart Disease / therapy*
  • Sex Distribution


  • Anti-Bacterial Agents
  • Anticoagulants
  • Penicillins