Population-based assessment of cardiovascular complications of rheumatic heart disease in Fiji: a record linkage analysis

ABSTRACT
Objective To determine population-based rates of non�fatal complications of rheumatic heart disease (RHD).
Design Retrospective cohort study based on multiple
sources of routine clinical and administrative data
amalgamated by probabilistic record-linkage.
Setting Fiji, an upper-middle-income country, where
most of the population has access to government-funded
healthcare services.
Participants National cohort of 2116 patients with
clinically apparent RHD aged 5–69 years during 2008 and
2012.
Primary and secondary outcome measures The
primary outcome was hospitalisation for any of
heart failure, atrial fibrillation, ischaemic stroke and
infective endocarditis. Secondary outcomes were first
hospitalisation for each of the complications individually
in the national cohort as well as in hospital (n=1300) and
maternity (n=210) subsets. Information on outcomes was
obtained from discharge diagnoses coded in the hospital
patient information system. Population-based rates were
obtained using relative survival methods with census data
as the denominator.
Results Among 2116 patients in the national cohort
(median age, 23.3 years; 57.7% women), 546 (25.8%)
were hospitalised for an RHD complication, a substantial
proportion of all cardiovascular admissions in the country
during this period in those aged 0–40 years (heart failure,
210/454, 46.3%; ischaemic stroke 31/134, 23.1%).
Absolute numbers of RHD complications peaked during
the third decade of life with higher population-based rates
in women compared with men (incidence rate ratio 1.4,
95%CI 1.3 to 1.6, p<0.001). Hospitalisation for any RHD
complication was associated with substantially increased
risk of death (HR 5.4, 95%CI 3.4 to 8.8, p<0.001),
especially after the onset of heart failure (HR 6.6, 95%CI
4.8 to 9.1, p<0.001).
Conclusions Our study defines the burden of RHD�attributable morbidity in the general population of Fiji,
potentially reflecting the situation in low-income and
middle-income countries worldwide. Hospitalisation for an
RHD complication is associated with markedly increased
risk of death, re-emphasising the importance of effective
early prevention