Prevalence of pulmonary hypertension and associated factors among rheumatic heart disease patients in Ethiopia

Abstract

Background

In developing countries evidences regarding pulmonary hypertension (PH) in rheumatic heart disease (RHD) patients are lacking, despite being responsible for significant morbidity and mortality. As a result, identifying the factors that influence PH 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, Ethiopia.

Methods

An institution based prospective cross-sectional study was conducted among RHD patients who had follow up at the two public hospitals of Bahir Dar city from 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.Transthoracic echocardiography by cardiologist was used to assess PH. 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 PH, considering with a p-value of < 0.05 as statically significant, with a 95% confidence interval.

Results

The mean systolic pulmonary arterial pressure (sPAP) of the participants was 50.2 mmHg [SD ± 25.0 mmHg]. The prevalence of PH among RHD patients was 56.5% (95% CI 50.9 – 61.9) from which 51.4% had severe PH. 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), and diuretics use (AOR 5.6, 95% CI 2.2–14.3) were factors associated with PH. In contrast, valvular intervention (AOR 0.06, 95% CI 0.01–0.29) and LVEF ≥ 50% (AOR 0.14, 95% CI 0.02–0.81) were found to be protective factors.

Conclusions

The prevalence of PH among RHD patients in Ethiopia is high and it’s associated with delayed presentation & complications. Special attention should be paid to early surgical or percutaneous valvular intervention for those who have indication, before they develop permanent cardiac remodeling and LVFE become reduced. As a result, access to valvular intervention need to be addressed to improve PH related morbidity & mortality among RHD patients in Ethiopia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-025-04476-3.

Introduction

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(Right side Heart Failure), 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 RHD, 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, 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 RHD patients [4].

RHD is a chronic sequel 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 mortalitydue RHD was 0.31 million globally in 2019, with a decrease of 15.60% since 1990 [5]. Despite the global reduction in mortality due to RHD, it is an important cause of cardiovascular mortality and morbidity in low and middle income regions, including Sub-Saharan Africa [6].

The Global Rheumatic Heart Disease Registry (the REMEDY study) showed most cases of newly diagnosed rheumatic heart disease patients presented 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. an Indian study, which included 2005 patients with RHD from 2011 – 2016, showed PH prevalence to be 30.5% [8]. Similarly, in Iran a study using 558 RHD patients between 2007 and 2015, which defined 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 underwent MBV for severe MS showed that the prevalence of PASP > 50 mmHg was 38%. The study also showed that the Doppler-monitored PASP normalized 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 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 include 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 tries 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.

Methods and materials

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, 578 km from the capital city, Addis Ababa. TGSH & FHCSRH are tertiary-level teaching and referral hospitals that serve 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 plasma glucose 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 prospective 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 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 35–50 mmHg, moderate if 50–70 mmHg 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 35–50 mmHg, moderate if 50–70 mmHg 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 > 38 mm [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 > 58 mm and for female, if > 52 mm [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].

Results

Sociodemographic and clinical characteristics

A total of 310 patients with diagnosis of RHD were recruited with a response rate of 98.4%. As depicted in Table 1, 223 (71.9%) participants 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 median duration of illness at the time of first presentation was 18.6 months.

Table 1.

sociodemographic & clinical characteristics of participants at TGSH & FHCSRH Bahir Dar, Ethiopia, 2023

Variables	Category	Frequency (n)	Percentage (%)	Pulmonary hypertension
				Yes (175)	No (135)
Gender	Male	87	28.1	56	31
	Female	223	71.9	119	104
Age in years, mean		29.94 ± 9.056		30.90 ± 8.77	28.69 ± 9.296
Place of residence	Urban	98	31.6	50	48
	Rural	212	68.4	125	87
Duration of symptoms	< 3 years  ≥ 3 years	237 73	76.5 23.5	106 69	131 4
Heart failure		218	70.3	162	56
Atrial fibrillation		101	32.6	92	9
LA thrombus		13	4.2	11	2
Stroke		8	2.6	3	5
IE		5	1.6	3	2
Valve intervention		25	8.1	14	11
Diuretics use		210	67.7	162	48
Beta blocker use		107	34.5	92	15
Warfarin use		105	33.9	90	15
Other drugsa		6	1.9	3	3

IE Infective Endocarditis, LA Left Atrium

Other drugs^a: Angiotensin converting enzyme inhibitors, anti-thyroid medication

Among those who developed RHD related complications, history of heart failure was the commonest complication 70.3%, from which 93 (42.7%) participants were having NYHA class IV heart failure, followed by atrial fibrillation (32.6%), left atrial thrombus (4.2%), stroke (2.6%) and infective endocarditis (1.6%).

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.

Pulmonary hypertension prevalence and echocardiographic parameters

The mean sPAP of the participants were 50.2 mmHg [SD ± 25.0 mmHg]. 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 21.1% of them had mild pulmonary hypertension.

The transthoracic echocardiography patterns of valve involvement of the participants were MR (75.5%), MS (66.8%), AR (27.1%), AS (4.2%), and TR (34.8%), depicted in Table 2. Mixed mitral valve disease (MR + MS) was present in 59% of the participants. Majority of participants with MS 160 (77.3%) had severe 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, severe in 20% of cases. The mean LA, LVEDD diameter and LVEF of the participants were 46.1 mm [SD ± 11.9 mm], 45.5 mm [SD ± 11.7 mm] and 60.5% [SD ± 11.7%] respectively.

Table 2.

Transthoracic echocardiography characteristics of participants at TGSH & FHCSRH Bahir Dar, Ethiopia

Variables	Category	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†	< 40 mm	102	32.9	12	90
	≥ 40 mm	208	67.1	163	45
LVEDD‡	< 53 mm	267	86.1	142	125
	≥ 53 mm	43	13.9	33	10
LVEF	< 50%	32	10.3	29	3
	≥ 50%	278	89.7	146	132

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

^†LAD: Considered as elevated for female, if > 52 mm and for male, if > 58 mm

^‡LVEDD: Considered as elevated for female, if > 52 mm and for male, if > 58 mm

Factors associated 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 severe 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.

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
Variables	Category	COR (95% CI)	P value	AOR (95% CI)		P value
Gender	Male	1			1	-
	Female	1.57 (1.057)	0.08		1.86(0.73–4.73)	0.18
Place of residence	Urban	1			1	-
	Rural	1.379 (0.852–2.232)	0.19		1.27(0.53–3.01)	0.58
Duration of symptoms	< 3 years	1			1	-
	≥ 3 years	21.3(7.59–50.31)	< 0.001		7.78 (2.12–28.52)	0.002*
Diuretics use	No	1			1	-
	Yes	22.58(11.60–43.95)	< 0.001		5.66(2.24–14.29)	< 0.001*
Beta blocker use	No	1			1	-
	Yes	8.86(4.80–16.37)	< 0.001		2.13(0.82–5.50)	0.11
Warfarin use	No	1			1	-
	Yes	8.47(4.58–15.63)	< 0.01		1.38(0.49–3.83)	0.53
Valve intervention	No	1			1	-
	Yes	0.58 (0.25–1.32)	0.19		0.06(0.01–0.29)	< 0.001*
MS	No	1			1	-
	Mild	1.56(0.61–3.70	0.36		1	-
	Moderate	3.41(1.11–10.49)	0.03		1.47(0.23–9.30)	0.68
	Sever	24.4(12.69–47.25)	< 0.001		7.81(2.37–25.70)	< 0.001*
LAD†	< 40 mm	1			1	-
	≥ 40 mm	27.1(13.66–53.9)	< 0.001		2.78(0.79–9.74)	0.11
LVEDD‡	< 53 mm	1			1	-
	≥ 53 mm	2.9(1.37–6.13)	< 0.005		2.49(0.69–8.99)	0.16
LVEF	< 50%	1			1	-
	≥ 50%	0.11 (0.03–0.38)	< 0.001		0.14(0.027–0.81)	0.028*

^†LAD: Considered as elevated for female, if > 52 mm and for male, if > 58 mm

^‡LVEDD: Considered as elevated for female, if > 52 mm and for male, if > 58 mm

^*Statically significant, COR Crude Odds Ratio, AOR Adjusted Odds Ratio, CI Confidence Interval, LAD Left Atrial Diameter, LVEDD Left Ventricular End Diastolic Diameter

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.

Discussion

The presence of pulmonary hypertension in RHD patients is 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, since most of the study participants in this study were from rural area, had late presentation, heart failure, atrial fibrillation, and didn’t undergo valvular intervention compared to the studies.

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.

Patients with severe mitral valve stenosis 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 severe MS results due to 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 RHD patients who have longer duration of illness are more likely to have severe 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 which 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 (RHC), which is currently the gold standard diagnostic test for PH, rather we used sPAP for PH determination, which will under or over estimated the actual PH value, though it’s less invasive and cheap. Another limitation of this study was, patients were only followed for three years, their long term outcomes were not assessed.

Conclusions and recommendations

Most of the participants with RHD have PH, of which 51.4% had severe PH. Long duration of illness, severe mitral valve stenosis, and diuretics use were factors associated with PH presence. However, undergoing surgical or percutaneous valvular intervention and having LVEF ≥ 50% were found to be protective factors.

Greater efforts have to be made to address the factors associated with PH development in RHD patients. Special attention should be paid to early surgical or percutaneous valvular intervention for those who have indication, before they develop permanent cardiac remodeling and reduced LVFE.

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

Abbreviations

AOR

Adjusted Odd Ratio

AR

Aortic Regurgitation

AS

Aortic Stenosis

CI

Confidence Interval

COR

Crude Odd Ratio

ECG

Electrocardiography

ECHO

Echocardiography

FHCSRH

Felege Hiwot Comprehensive Specialized Referral Hospital

LA

Left Atrium

LV

Left Ventricle

LVEDD

Left Ventricular End Diastolic Diameter

MS

Mitral Stenosis

MR

Mitral Regurgitation

NYHA

New York Heart Association

RHD

Rheumatic Heart Diseases

RVSP

Right ventricular systolic pressure

SPAP

Systolic Pulmonary Artery Hypertension

PH

Pulmonary Hypertension

SPHMMC

Saint Paul Hospital Millennium Medical College

SPSS

Statistical Package for the Social Sciences

TR

Tricuspid Regurgitation

TGSH

Tibebe Ghion Specialized Hospital

WHO

World Health Organization

Authors’ contributions

A.G. conceived and designed the research protocol. A.T. and G.W. approved the proposal with extensive revisions. Y.Y., A.K. and T.D. participated in the data analysis and wrote the manuscript. All the authors have read and approved the final manuscript.

Funding

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

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was conducted according to declarations of Helsinki. Ethical clearance was approved by 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.

Competing interests

The authors declare no competing interests.