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Rheumatic heart disease has killed fewer people in recent years but it remains a significant threat in the world's poorest regions, data from the 2015 Global Burden of Disease (GBD) study showed.

Such deaths numbered 347,500 in 1990 versus 319,400 in 2015, an 8.1% drop. When adjusted for age, mortality risk around the world from rheumatic heart disease , according to David A. Watkins, MD, MPH, of University of Washington in Seattle, and colleagues in the August 24 issue of New England Journal of Medicine.

"The health-related burden of rheumatic heart disease declined in most countries, but the condition persisted in some of the poorest regions in the world," the researchers noted. "We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015."

Furthermore, heart failure due to rheumatic heart disease nearly doubled in the 25-year period, with counts of mild cases jumping from 156,900 to 295,300; moderate cases 129,500 to 243,700; and severe cases 352,400 to 663,000.

What made the analysis difficult was that many low- and middle-income countries failed to report accurate data, Watkins and colleagues said.

"The GBD 2015 assessment is the best estimate we have to date, but it also highlights the need for concerted efforts to obtain actual prevalence data from remote areas," suggested Eloi Marijon, MD, PhD, of European Georges Pompidou Hospital in Paris, and two colleagues in an .

"Several key messages emerge from this important study. It confirms the marked global heterogeneity of the burden of rheumatic heart disease, with near-zero prevalence in developed countries sharply contrasting with substantial prevalence and mortality in developing areas. In addition, however, the study documents the scarcity of accurately measured data in many locations, especially in areas with the highest prevalence (such as sub-Saharan Africa)," Marijon's group wrote, noting the wide uncertainty intervals around the GBD 2015 estimates.

A consequence of acute rheumatic fever, rheumatic heart disease is associated with overcrowding, poor sanitation, and other conditions of poverty. It is endemic (averaging 444 cases per 100,000 population) to nearly all of Africa, Asia, and parts of the Caribbean, Middle East, and South America.

Most 2015 deaths from rheumatic heart disease were in India, China, and Pakistan. After age adjustment, at least 10 deaths per 100,000 population were estimated for the Solomon Islands, Pakistan, Papua New Guinea, Kiribati, Vanuatu, Fiji, India, Federated States of Micronesia, Marshall Islands, Central African Republic, and Lesotho.

"The GBD 2015 data are a timely reminder to the global community that rheumatic heart disease is far from being conquered. However, its near disappearance in developed nations has led to relative neglect of the disease in recent years," the editorialists commented, urging more research.

"It is important to note that subclinical rheumatic heart disease was excluded from the analysis," Marijon and colleagues said. "We and others have found that for every clinical case of rheumatic heart disease, there are 3 to 10 subclinical cases (detected by means of echocardiography). Thus, the true burden may be even higher than the authors estimate, with subclinical cases representing the submerged part of the rheumatic-heart-disease iceberg."

"This issue is of importance because there is evidence that subclinical rheumatic heart disease may progress to clinical disease. It is also evident that reductions in mortality due to rheumatic heart disease that are achieved by better care for patients with advanced disease are counterbalanced by higher morbidity from heart failure. This fact highlights the critical role that will be played by prevention if we are to meaningfully reduce the burden of rheumatic heart disease."