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Preventable Heart Disease

Yvane is a 34 year old woman who has lived at Real Hope For Haiti since January of this year. She has heart failure that started shortly after the delivery of her son over 3 years ago. When she first came to us she had fluid in her lungs, severe swelling of her legs, fluid in her belly (ascites) and her oxygen was very low. She was started on diuretics and other medications for heart failure. The edema in her legs has slowly resolved. She has had the fluid drained from her abdomen at least 8 times, but it always returns. She still has some fluid in her lungs, but it has improved. She still requires oxygen with any activity.

Rosemene is a 28 year old woman who has a story similar to Yvane. She developed swelling in her legs that started shortly after delivering her son about 4 years ago. She had edema and ascites, though her oxygen has remained normal. She has been to multiple different hospitals but was not sure what her diagnosis was. Her systolic blood pressure was 80 when she first to presented to clinic at RHFH. She was kept at clinic to start diuretics and medications for heart failure so we could closely monitor her blood pressure.

Both of these women have significant heart murmurs on exam. They had the opportunity to go to a heart failure clinic in Mirebalais at Partner’s In Health. This clinic is organized and ran by Haiti Cardiac Alliance. Both women had an echocardiogram and were evaluated by a cardiologist from Texas. Both were diagnosed with chronic rheumatic heart disease causing mitral valve regurgitation. Yvane also has associated severe pulmonary hypertension which gives her a poor prognosis.

Rheumatic heart disease is preventable. It is caused by an immune response against pharyngitis caused by group A beta hemolytic streptococcus (streptococcus pyogenes), otherwise known as strep throat. If strep throat is not treated with antibiotics, some people with strep throat will develop rheumatic fever.  Some of the streptococcus pyogenes antigens recognized by the immune system are very similar to self antigens in the body. Self antigens help to identify normal tissues and prevent the immune system from attacking our healthy cells and organs.  In rheumatic fever, the immune system attacks both streptococcus pyogenes in addition to some tissues with antigens that mimic bacterial proteins. Both cardiac myosin and the cardiac valves have antigens that mimic streptococcus pyogenes antigens. This results in inflammation of these cardiac tissues. Rheumatic heart disease can develop with repeated occurrences of rheumatic fever or with chronic rheumatic fever. Rheumatic heart disease commonly results in damage to the mitral valve and can cause heart failure. Treatment is replacement of the damaged valve.

Cardiac valve replacements are very difficult to obtain in Haiti. In fact, I do not believe that this surgery is available for adults in Haiti at all. Patient’s must go to the Dominican Republic, the United States, or some other country. It is difficult to arrange for a heart valve replacement for any Haitian, but easier to do so for children. Currently, Yvane and Rosemene do not have a lot of hope of obtaining a valve replacement. Haiti Cardiac Alliance works to provide access for children to receive cardiac surgery. They are able to arrange for 4 or 5 adults a year to receive cardiac surgery. They currently have approximately 40 adults on the waiting list.

Rheumatic fever and rheumatic heart disease are preventable by treating strep throat with penicillin. Unfortunately, strep throat is frequently not recognized and/or treated in developing countries and there is a much higher incidence of rheumatic heart disease in countries like Haiti, where valve replacement is not available.

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