Prevalence of pulmonary hypertension and associated factors among rheumatic heart disease patients having follow up at public referral hospitals in Bahir Dar, Ethiopia, 2023.

doi:10.21203/rs.3.rs-4719714/v1

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Research Article

Prevalence of pulmonary hypertension and associated factors among rheumatic heart disease patients having follow up at public referral hospitals in Bahir Dar, Ethiopia, 2023.

https://doi.org/10.21203/rs.3.rs-4719714/v1

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Background

In developing countries evidences regarding pulmonary hypertension in rheumatic heart disease patients are lacking, despite being responsible for significant morbidity and mortality. As a result, identifying the factors that influence pulmonary hypertension is crucial to improve the quality of care.

Objective

To determine prevalence of pulmonary hypertension and its associated factors among rheumatic heart disease patients at the public hospitals of Bahir Dar city, 2023.

Methods

An institution based cross sectional study was conducted among Rheumatic heart disease patients who had follow up at the two public hospitals of Bahir Dar city form January 2022 to December 2023. It involved 310 patients selected by systematic random sampling technique. Pretested, structured, and interviewer-administered questionnaires were used to collect sociodemographic and diseases related parameters. Trans thoracic echocardiography by cardiologist was used to assess pulmonary hypertension. Data were entered using Epidata Manager version 4.6 and analyzed using SPSS version 27. Multivariate logistic regression analysis was used to identify determinants of glycemic control, considering with a p-value of < 0.05 as statically significant, with a 95% confidence interval.

Results

The mean sPAP of the participants were 50.2 mmHg [SD ± 25.0mmHg]. The prevalence of pulmonary hypertension among RHD patients were 56.5% (95% CI 50.9–61.9) from which 51.4% had severe pulmonary hypertension. Severe mitral valve stenosis (AOR 7.8, 95% CI 2.4–25.7), duration of illness ≥ 3 years (AOR 7.7, 95% CI 2.1–28.5), diuretics use (AOR 5.6, 95% CI 2.2–14.3,), valvular intervention (AOR 0.06, 95% CI 0.01 0.29) and LVEF ≥ 50% (AOR 0.14, 95% CI 0.02–0.81) were factors associated with pulmonary hypertension.

Conclusions

This study revealed more than half of the participants had pulmonary hypertension. And this was associated with having sever mitral valve stenosis, long duration of illness, diuretics use, valvular intervention and LVEF of ≥ 50%. Effective and tailored interventions are needed to mitigate these risk factors to improve pulmonary hypertension related comorbidities in rheumatic heart disease patients.

Pulmonary hypertension

Rheumatic heart disease

Ethiopia

Pulmonary hypertension (PH) is a diverse disease defined by a mean pulmonary arterial pressure (mPAP) > 20 mmHg at rest using right heart catheterization[1] or by echocardiography with a right ventricular systolic pressure (RVSP) > 35 mmHg, absence of pulmonary stenosis and acute RHF, and usually accompanied by shortness of breath, fatigue, peripheral edema and other cardiovascular symptoms [2].

Globally 1% of the world population is affected by PH from which about 80% reside in underdeveloped nations where most patients with pulmonary hypertension are younger and frequently linked to chronic infection such as rheumatic heart disease, HIV and schistosomiasis, but they are not well studied [3].

Currently PH classified in to five groups based on pathophysiology[1]. Globally left side heart disease (including RHD) is the commonest cause of PH followed by lung disease, especially chronic obstructive lung disease[3]. Independent of the cause development of PH in these patients was associated with adverse outcomes and increased mortality[3].

Right heart catheterization is the gold standard for diagnosis and treatment decision of patients with pulmonary hypertension. However, its invasive as a result echocardiography is recommended as the first-line, non-invasive, diagnostic investigation in suspected PH [1]. Trans - thoracic echocardiography measures the systolic pulmonary arterial pressure (SPAP) with acceptable accuracy in rheumatic heart disease (RHD) patients [4].

RHD is a chronic sequalae of acute rheumatic fever. During 1990–2019, the global RHD prevalence have increased by 70.49% and reached 40.50 million in 2019. However, the death number due RHD was 0.31 million globally in 2019, with a decrease of 15.60% since 1990 [5]. Despite the global reduction in death due to RHD, it is important cause of cardiovascular death and disability in low and middle income regions, including Sub-Saharan Africa [6].

The REMEDY study showed most cases of newly diagnosed rheumatic heart disease patients present with advanced diseases and complications. Heart failure and pulmonary hypertension were the most commonly observed complications in many hospital-based studies [7].

The prevalence of pulmonary hypertension in RHD is variable since different studies use different tools to measure pulmonary hypertension. In Indian study which included 2005 patients with RHD from 2011–2016 showed PH prevalence to be 30.5%[8]. Similarly, in Iranian study using 558 RHD patients between 2007 and 2015, which defines significant PH as mean PAP > 40 mmHg, showed a prevalence of 27% [9].

A prospective study done in Saudi Arabia between 1989 and 2003 among 559 RHD patients who undergone MBV for severe MS, the prevalence of PASP > 50mmHg was 38%. The study also shows that the Doppler-monitored PASP fell to normal after 6–12 months of the intervention [10]. However, a study from south Yemen showed a high prevalence (80.4%) and most of it (60.1%) was from patients with mitral valve stenosis [11].

The epidemiology of PH in RHD is poorly understood in Africa despite the high incidence of PH risk factors, unique genetic backgrounds and lifestyles, and low access to healthcare[2]. A large multi centered prospective cross-sectional study called REMEDY study, which includes 3343 patients in 25 hospitals in 12 African countries (including Ethiopia), India and Yemen, between 2010 and 2012 showed that, the prevalence of PH in RHD was 28.8% [7]. Similarly, a study form Uganda showed a prevalence of 32.7% [12]. However, a study from Nigeria showed a high prevalence rate (72.1%) [13].

In Ethiopia, a study conducted in Saint Paul Hospital Millennium Medical College (SPHMMC) using 384 RHD patients in 2022, next to heart failure, pulmonary hypertension was the second most common complication that existed in 53.9% of patients [14]. Similarly, in a study conducted in Jimma (2019), including pediatric and adolescent RHD patients, PH was prevalent in 60.3% [15].

Several factors have been identified as associated with pulmonary hypertension development in RHD. For instance, in the REMEDY study using large sample size of RHD patients having moderate to severe mitral valve lesions and low income were found to be associated with PH [7]. In the Iranian study echocardiographic findings, absolute MVA, indexed MVA, and mean trans-mitral valve gradient were associated with the presence of PH [9].

Other factors identified in the literature associated with pulmonary hypertension development in RHD patients includes valvular intervention [16, 17], only diuretics usage [18], long duration of disease [19], raised filling pressures, LV systolic dysfunction, LV dilation [20] and low income[7].

This study tried to fill the epidemiologic data gaps regarding PH-RHD and its associated factors in one of the Sub-Saharan countries, where the prevalence of RHD is high.

Study area and study period

The study was conducted at two public referral hospitals, Tibebe Ghion Specialized Hospital (TGSH) and Felege Hiwot Comprehensive Specialized Referral Hospital (FHCSRH), of Bahir Dar city, Ethiopia. These hospitals are located in Bahir Dar city Amhara region, 578km from the capital city, Addis Ababa. TGSH & FHCSRH are tertiary-level teaching and referral hospitals that serves as the referral center for more than 15 district hospitals in the area, catering to a total catchment of 8 million people. Each hospital has more than 600 beds and offers health services to patients with various diseases in the outpatient and inpatient departments.

The cardiac unit under department of internal medicine provides different variety of inpatient and outpatient services. There is once weekly cardiac referral clinic service, thrice a week trans-thoracic echocardiography session by cardiologist and it provides basic diagnostic tests and treatments for cardiac patients. ECG and serum biochemicals, such as lipid panel, renal function test, serum electrolyte, random and fasting blood sugar tests are conducted. The cardiac clinic has 04 rooms and currently there are 07 nurses and 10 physician including medical residents, internist, 04 cardiologist and 01 interventional cardiologist who are working there. The study was conducted among RHD patients who visited Bahir Dar public referral clinics from January 2022 to December 2023.

Study design and population

Facility based cross sectional study was conducted from January 2022 to December 2023 at FHCSRH and TGSH, Bahir Dar, Ethiopia. The study populations were all RHD patients who visited cardiac clinic of TGSH & FHCSRH during the study period.

All patients who were at least 15 years old and had clinical and echocardiographic evidence of RHD by cardiologist were included in the study. Patients without proper ECHO (not done by cardiologist), incomplete medical record, patient with RV out tract obstruction, patients with diagnosis of other causes of PH were excluded.

Sample size and sampling procedure

The sample size was calculated using the single population proportion formula with the following assumptions: a confidence level of 95%, a 5% margin of error, and a prevalence of 28.8% from a previous study [7]. With these assumptions the sample size was calculated to be 315. All eligible patients who visited cardiac referral clinic during the study period were recruited using every 2nd sampling fraction until the required sample size is reached. Lottery method was used to choose the first participant.

Study variables

The dependent variable was the presence of pulmonary hypertension in RHD patients. The independent variables includes sociodemographic variables (Age, sex, residency), clinical factors ( duration of symptoms, history of admission, heart failure and New York Heart Association (NYHA) class, treatment modalities including medication or definitive intervention and presence of other complication) and echocardiography parameters (type and severity of valve lesion, left ventricular end diastolic diameter (LVEDD), LV size and volume, LA size and volume, LV systolic and diastolic function).

Data collection procedure

Data were collected through outpatient department nurses & ECG personnel under close supervision by the principal investigator using pretested questionnaire. Patients were interviewed to obtain socio-demographic data, and the patients’ medical records were reviewed to obtain information on relevant medical history, ECG and echocardiographic parameters.

Trans thoracic echocardiography was performed by board certified cardiologist using GE Vivid E9 echocardiographic machine. Patients had transthoracic 2-D, M-Mode, and Doppler studies (including continuous wave, pulsed wave, color, and Tissue Doppler). Echocardiographic studies were performed according to the American Society of echocardiography standards [21–23]. Pulmonary hypertension was calculated using pulmonary artery systolic pressure (sPAP) estimated from the peak velocity of the tricuspid regurgitation jet plus the estimated right atrial pressure. It classified in to mild PH if sPAP 35-50mmHg, moderate if 50–70mmHg and severe if ≥ 70 mmHg [24]. Each ECG was performed by trained ECG nurses and it was confirmed and interpreted by cardiologist.

Data processing and analysis

The data were entered into EPI data version 4.6 and then transferred to SPSS 27.0 statistical packages for analysis. Data cleaning was conducted before performing the descriptive analysis. The baseline characteristics are presented as numbers and percentages. The findings were summarized in tables and figures. All statistical tests were performed using two-sided tests at the 0.05 level of significance. Odds ratio with 95% confidence intervals and associated p-values were computed to assess the presence and degree of association between dependent and independent variables.

All variables with p values less than 0.25 in the bivariate analysis were exported to multivariate analysis and variables were entered hierarchically to fit the logistic regression model. Consequently, statistically significant associations were determined based on the adjusted odds ratio (AOR) with its 95% CI and the P-value < 0.05. Hosner-Lemeshow test was used to assess model fitness and multicollinearity test was conducted to check the absence of correlation between independent variables.

Operational definitions

For the purpose of this study PH defined as estimation of systolic pulmonary artery pressure (sPAP) (TR pressure gradient plus the estimated right atrial pressure) in the absence of pulmonary stenosis, RVOTO and acute decompensated HF. It classified in to mild PH if sPAP 35-50mmHg, moderate if 50–70mmHg and severe if ≥ 70 mmHg [24].

RHD

diagnosed by cardiologist doing the echocardiography based on 2012 World Heart Federation criteria [25].

Left ventricular ejection fraction (LVEF)

for the purpose of this study it was classified in two as reduced LVEF when EF < 50% and preserved LVEF when EF ≥ 50% [26].

Left atrial (LA) diameter

represented the anterior posterior dimension of the left atrium measured using echocardiography and considered as enlarged for male, if > 40 mm and for female, if > 38mm [26].

Left ventricle end diastolic diameter (LVEDD)

represented the anterior posterior dimension of the left ventricle measured using echocardiography at the end of diastole. Elevated for male, if > 58mm and for female, if > 52mm [26].

Type of heart valve disease

represented either stenotic or regurgitant lesion of heart valves. There are four types of heart valves - mitral, aortic, pulmonic and tricuspid valve [26].

Severity of heart valve disease

described the degree of stenosis or regurgitant lesion of affected heart valve and it is graded according to American society of echocardiography as mild, moderate or severe by echocardiography [26].

Sociodemographic and clinical characteristics

A total of 310 patients with diagnosis of RHD were recruited with a response rate of 98.4%. Of these, 223 (71.9%) were females. The mean age of the study population was 29.9 years [SD ± 9.0 years]. Majority 212 (68.4%) were from rural area. The mean duration of illness at the time of first presentation was 17.9 months [SD ± 13.2 months].

Having history of heart failure were the commonest complication 70.3%, from which 93 (42.7%) participants were having NYHA class IV heart failure. Similarly, atrial fibrillation, left atrial thrombus, stroke and infective endocarditis were seen in 32.6%, 4.2%, 2.6% and 1.6% of participants respectively.

Regarding medication, 67.7% participants were on diuretics, 34.5% on beta blocker and 33.9% on warfarin. However, only 25 (8%) participants had valve intervention, from which valve replacement was done for 13 participants.

Table 1

sociodemographic & clinical characteristics of participants at TGSH & FHCSRH Bahir Dar, Ethiopia, 2023
Variables	Cathagory	Frequency (n)	Percentage (%)	Pulmonary hypertension Yes (175) No (135)
Sex	Male	87	28.1	56 31
	Female	223	71.9	119 104
Age in years, mean		29.94 ± 9.05		30.90 ± 8.77 28.69 ± 9.29
Residency	Urban	98	31.6	50 48
	Rural	212	68.4	125 87
Duration of symptoms	< 3 years ≥ 3years	237 73	76.5 23.5	106 131 69 4
Heart failure		218	70.3	162 56
Atrial fibrillation		101	32.6	929
LA thrombus		13	4.2	112
Stroke		8	2.6	35
IE		5	1.6	32
Valve intervention		25	8.1	1411
On Diuretics		210	67.7	16248
On beta Blocker		107	34.5	9215
On warfarin		105	33.9	9015
Other drugs^a		6	1.9	33
Other drugs^a : Angiotensin converting enzyme inhibitors, anti-thyroid medication, IE: Infective Endocarditis, LA: Left Atrium

Pulmonary hypertension prevalence and echocardiographic parameters

The mean sPAP of the participants were 50.2mmHg [SD ± 25.0mmHg]. Among the study participants 56.5% had pulmonary hypertension. Among those who developed pulmonary hypertension more than half of them 90 (51.4%) had severe pulmonary hypertension, 27.4% had moderate pulmonary hypertension and only 21.1% of them had mild pulmonary hypertension.

The transthoracic echocardiography pattern of valve involvement of the participants were MR (75.5%), MS (66.8%), AR (27.1%), AS (4.2%), and TR (34.8%). Mixed mitral valve disease (MR + MS) was present in 59% of the participants. Majority of participants with MS 160 (77.3%) had sever valvular lesion, moderate in 15 (7.2%) participants and mild in 32 (15.5%) participants. However, more than half (53%) cases of MR were mild, sever only in 20% of cases. The mean LA, LVEDD diameter and LVEF of the participants were 46.1mm [SD ± 11.9 mm], 45.5mm [SD ± 11.7 mm] and 60.5% [SD ± 11.7%] respectively.

Table 2

Transthoracic echocardiography characteristics of participants at TGSH & FHCSRH Bahir Dar, Ethiopia, 2023
Variables	Cathagory	Frequency(n)	Percent (%)	Pulmonary Hypertension Yes (175) No (135)
sPAP in mmHg	< 35	135	48.6	- -
	35–50	37	21.1	- -
	50–70	48	27.4	- -
	≥ 70	90	51.4	- -
Valve lesions	MR	234	75.5	126 108
	MS	207	66.8	154 53
	AR	84	27.1	52 32
	AS	13	4.2	8 5
LAD†	≤ 38/40mm > 38/40mm	102 208	32.9 67.1	12 90 163 45
LVEDD‡	≤ 52/58mm > 52/58mm	267 43	86.1 13.9	142 125 33 10
LVEF	< 50% ≥ 50%	32 278	10.3 89.7	29 3 146 132
† LAD: Considered as elevated for female, if > 52mm and for male, if > 58mm
‡ LVEDD: Considered as elevated for female, if > 52mm and for male, if > 58mm
AR: Aortic Regurgitation, AS: Aortic Stenosis, LAD: Left Atrial Diameter, LVEDD: Left Ventricular End Diastolic Diameter, LVEF: Left Ventricular Ejection Fraction, sPAP: systolic Pulmonary Arterial Pressure

Factors associate with pulmonary hypertension in RHD patients

The association between independent and dependent variable, pulmonary hypertension was assessed using both univariable and multivariable logistic regression. On univariable logistic regression Sex, residency, duration of symptom, diuretics use, beta blocker use, warfarin use, valvular intervention, moderate or sever MS, LA diameter, LVEDD and LVEF were found to be associated with pulmonary hypertension presence in RHD patients.

All the factors associate with p value of < 0.25 were included in the multivariable logistic regression analysis and resulted duration of illness ≥ 3 years (p = 0.002), diuretics use (p < 0.001), valve intervention (p < 0.001), sever MS (p < 0.001) and LVEF ≥ 50% (p = 0.028) were found to be statically significant independent factors of pulmonary hypertension in RHD patients with p value of < 0.05 as depicted in the Table 3.

Participants with diuretics use had 5.6 times higher risk of having PH compared to those without diuretic use (AOR 5.6, 95% CI 2.2–14.3, P = 0.001). In addition, individuals with ≥ 3 years of symptom were 7.7 times more likely to have PH than those with < 3 years of symptoms (AOR 7.7, 95% CI 2.1–28.5, P = 0.02). Similarly, participants with severe MS were approximately 7.8 times more likely to develop Pulmonary Hypertension compared to those without MS (AOR 7.8, 95% CI 2.4–25.7, P < 0.001). However, the risk of developing PH was reduced in participants who had valve intervention and ≥ 50% LVEF by 94% (AOR 0.06, 95% CI 0.01 0.29, P < 0.001) and 86% (AOR 0.14, 95% CI 0.02–0.81, P = 0.028) respectively.

Table 3

Bivariate and multivariate logistic regression analyses of factors associated with pulmonary hypertension in RHD patients in TGSH & FHCSRH, Bahir Dar, Ethiopia, 2023.
		Bivariate analysis		Multivariate analysis
Variable	Categories	COR (95% CI)	P value	AOR (95% CI)		P value
Sex	Male Female	1 1.57 (1.057)	0.08		1 1.86(0.73–4.73)	- 0.18
Residency	Urban Rural	1 1.379 (0.852–2.232)	0.19		1 1.27(0.53–3.01)	- 0.58
Duration of symptoms	< 3 years ≥ 3 years	1 21.3(7.59–50.31)	< 0.001		1 7.78 (2.12–28.52)	- 0.002*
On diuretics	No Yes	1 22.58(11.60-43.95)	< 0.001		1 5.66(2.24–14.29)	- < 0.001*
On beta blocker	No Yes	1 8.86(4.80-16.37)	< 0.001		1 2.13(0.82–5.50)	- 0.11
On warfarin	No Yes	1 8.47(4.58–15.63)	< 0.01		1 1.38(0.49–3.83)	- 0.53
Valve intervention	No Yes	1 0.58 (0.25–1.32)	0.19		1 0.06(0.01–0.29)	- < 0.001*
MS	No Mild Moderate Sever	1 1.56(0.61–3.70 3.41(1.11–10.49) 24.4(12.69–47.25)	0.36 0.03 < 0.001		1 1.47(0.23–9.30) 7.81(2.37–25.70)	- - 0.68 < 0.001*
LAD†	≤ 38/40 mm > 38/40 mm	1 27.1(13.66–53.9)	< 0.001		1 2.78(0.79–9.74)	- 0.11
LVEDD‡	≤ 52/58 mm > 52/58mm	1 2.9(1.37–6.13)	< 0.005		1 2.49(0.69–8.99)	- 0.16
LVEF	< 50% ≥ 50%	1 0.11 (0.03–0.38)	< 0.001		1 0.14(0.027–0.81)	- 0.028*
† LAD: Considered as elevated for female, if > 52mm and for male, if > 58mm
‡ LVEDD: Considered as elevated for female, if > 52mm and for male, if > 58mm
*Statically significant, COR: Crude Odds Ratio, AOR: Adjusted Odds Ratio, CI: Confidence Interval, LAD: Left Atrial Diameter, LVEDD: Left Ventricular End Diastolic Diameter

The presence of pulmonary hypertension in RHD patients associated with high morbidity and mortality. This study showed that the prevalence of pulmonary hypertension in RHD was 56.5% (95% CI 50.9–61.9), of which 51.4% had severe pulmonary hypertension. This result is comparable to previous studies conducted in Uganda (53.3%) and SPHMMC (53.9%) [14, 27]. However, this finding is higher than some previous studies conducted in Iran (27%), the REMEDY study (28.8%), India (30.5%), Uganda (32.7%) and Saudi-Arabia (38%) [7–10, 12]. This difference may be due to the difference in the study population, early presentation of participants and early valvular intervention given.

Compared to some previous studies this prevalence is lower than studies conducted in Nigeria (72.1%) and South Yemen (80.4%) [11, 13]. These differences may be due to the variability in the diagnostic criteria used, age group studied, time of patient presentation, diagnosis and treatment given (definitive surgical intervention).

Patients with severe mitral valve stenosis were tends to have pulmonary hypertension compared to those participants without mitral stenosis. This result is in line with studies conducted from Nigeria, Saudi-Arabia and the REMEDY study [7, 10, 13]. Pulmonary hypertension development in sever MS is produced due to an elevation in the diastolic filling pressure, which results in a ‘‘passive’’ increase in pulmonary venous pressure [28].

Participants with longer duration of illness at the time of presentation were more likely to have pulmonary hypertension compared to those who had short duration of illness. This association is in line with a study conducted from Spain [19]. The possible explanation may be those who have longer duration of illness are more likely to have sever valvular lesions, raised filling pressures, LV systolic dysfunction, and LV dilation which are independent factors for pulmonary hypertension development [20, 29].

Those who had undergone valvular intervention were less likely to have pulmonary hypertension compared to those who didn’t undergo valvular intervention. This outcome is in line with a study conducted from Saudi-Arabia [10]. The possible explanation for this observation may be maladaptive changes to the LV, LA, and finally pulmonary vasculature especially in the early course of the process may be reversed after valve intervention and resulting reduction in PH [16, 17].

Those participants who had LVEF of ≥ 50% were less likely to have pulmonary hypertension compared to those who have LVEF of < 50%. This result is in line with PARAGON-HF (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ARB [Angiotensin Receptor Blocker] Global Outcomes in HF with Preserved Ejection Fraction) trial and a community-based study [28, 30]. The possible explanation may be those who have HFpEF has more likely to have mild LV dilation, atrial functional MR and raised pulmonary vascular pressure as maladaptive remodeling changes compared to HFrEF [31]. However, a contrary outcome were seen with a higher Cpc-PH rate (38%) in PH-HFpEF compared with PH-HFrEF (17%) [32].

Participants with diuretics use were more likely to develop pulmonary hypertension compared to those who didn’t use diuretics. Similar outcome was seen in the study conducted in Egypt [18]. The possible explanation may be patients who need diuretics medications are those who do have decompensated state of the disease with left ventricular and left atrial dysfunction with exhausted compensatory mechanism and advanced heart failure is independent factor for pulmonary hypertension [20, 29].

Strength and limitations of this study

To our knowledge this study is the first study to assess the prevalence of pulmonary hypertension in RHD patients at Amhara region, Ethiopia using transthoracic echocardiography, which was conducted by board certified cardiologists. Another strength of this study is, it comprises a relatively large sample size compared to other African country studies. However, this study adopted a cross-sectional study design and PH was not measured using right heart catheterization.

Despite the presence of cardiac clinic and monthly benzathine penicillin G administration more than half of the participants (56.5%) had pulmonary hypertension, of which 51.4% had severe pulmonary hypertension. Long duration of illness, sever mitral valve stenosis, diuretics use, having valvular intervention and LVEF ≥ 50% were significant factors associated with pulmonary hypertension presence in RHD patients.

Greater efforts have to be made to address the factors associated with pulmonary hypertension in RHD patients. Special attention should be paid to valvular intervention, those with long duration of illness, sever mitral valve stenosis and on diuretics use by encouraging those who have indication for valvular intervention to undergo early intervention at each visit.

Further research is needed with a larger sample size and case control study to ensure representativeness and investigate the association between pulmonary hypertension and different factors that affects it.

AOR

Adjusted Odd Ratio

Aortic Regurgitation

Aortic Stenosis

Confidence Interval

COR

Crude Odd Ratio

ECG

Electrocardiography

ECHO

Echocardiography

FHCSRH

Felege Hiwot Comprehensive Specialized Referral Hospital

Left Atrium

Left Ventricle

LVEDD

Left Ventricular End Diastolic Diameter

Mitral Stenosis

Mitral Regurgitation

NYHA

New York Heart Association

RHD

Rheumatic Heart Diseases

RVSP

Right ventricular systolic pressure

SPAP

Systolic Pulmonary Artery Hypertension

Pulmonary Hypertension

SPHMMC

Saint Paul Hospital Millennium Medical College

SPSS

Statistical Package for the Social Sciences

Tricuspid Regurgitation

TGSH

Tibebe Ghion Specialized Hospital

WHO

World Health Organization.

Ethical considerations

This study was conducted according to declarations of Helsinki. Ethical clearance was obtained from the Research Ethical Review Board of College of Medicine and Health Sciences, Bahir Dar university (protocol number 802/2023). Written informed consent was obtained from the participants including legal guardians and or parents, and patient data confidentiality was respected at all levels from patient interview, chart retrieving and data analysis which was handled by the investigators. During the data collection process, those patients who were found to have pulmonary hypertension were linked to the treating physicians for any farther management.

Consent for publication

Not applicable.

Availability of data and material

The datasets used and/or analyzed during the current study are not publicly available due to confidentiality issues but are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was funded by Bahir Dar University. The funder has no role in research design, data collection, result writing and manuscript preparation.

Authors' contributions

AG conceived and designed the research protocol. AT and GW approved the proposal with extensive revisions. YY, AK and TD participated in the data analysis and wrote the manuscript. All the authors have read and approved the final manuscript.

Acknowledgments

We would like to thank study participants. In addition, we would thank Bahir Dar University and data collectors.

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No competing interests reported.

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Prevalence of pulmonary hypertension and associated factors among rheumatic heart disease patients having follow up at public referral hospitals in Bahir Dar, Ethiopia, 2023.

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Abstract

Background

Objective

Methods

Results

Conclusions

Background

Methods And Materials

Study area and study period

Study design and population

Sample size and sampling procedure

Study variables

Data collection procedure

Data processing and analysis

Operational definitions

Results

Sociodemographic and clinical characteristics

Pulmonary hypertension prevalence and echocardiographic parameters

Factors associate with pulmonary hypertension in RHD patients

Discussion

Strength and limitations of this study

Conclusions and recommendations

Abbreviations

Declarations

Ethical considerations

Consent for publication

Availability of data and material

Competing interests

Funding

Authors' contributions

Acknowledgments

References

Additional Declarations

Status:

Version 1