Abstract              Background: Although once considered a rarity in the Indian subcontinent, the prevalence of rheumatic heart disease (RHD) is now recognized to be very high, particularly among children and young adults Aims and Objectives: To Study Various Demographic distribution among valvular lesions in the Patients with Rheumatic heart disease. Methodology: Present study was carried to study the clinical profile of Rheumatic fever (RF) and Rheumatic heart disease (RHD) in patients of all age groups. The study was approved by the ethics committee prior to commencement of data collection. This cohort study was conducted on all cases diagnosed as Rheumatic fever and Rheumatic Heart Disease. 196 cases fulfilling inclusion criteria Statistical analysis was performed using SPSS. Descriptive statistics (frequency, mean and SD) were used for data presentation T-test, Chi square, z test and ANOVA test were used to test significant difference in mean of variables between two groups and more than two groups respectively. A probability of less than 0.05 was considered statistically significant. Result: MS, AR and AS were found to be common in >30 years age group with 13/17, 04/04 and 08/09 patients respectively. Combined diseases were common in >30 years age and multivalvular diseases were common in ≤30 years age. However in our study, patients of MS, AR, AS and combined diseases were significantly found in >30 years age (p<0.05) and MS was significantly found in ≤30 years age (p<0.05) In our study, MR was found equally distributed among (19/38) males and (19/38)females, MS and AS were more common in females. (16/17 and 08/09 patients respectively) AR was found in 03(75%) males and 01(25%) females. Combined diseases were equally distributed among males (11/22) and females (11/22). Multivalvular diseases were found in 18/37 males and 19/37 females. However in our study MS and AS were significantly found in females (p<0.01) and AR was significantly found in males (p<0.01). All valvular diseases were more common in rural populations and were found to be significant (p<0.05). Conclusion: It can be concluded from our study that MS, AR and AS were found to be common in >30 years age MS and AS were more common in females, All valvular diseases were more common in rural populations and were found to be significant

Key Words: Rheumatic heart disease, MS (Mitral Stenosis), AR (Aortic Regurgitation), AS (Aortic Stenosis).

 

INTRODUCTION

Although once considered a rarity in the Indian subcontinent, the prevalence of rheumatic heart disease (RHD) is now recognised to be very high, particularly among children and young adults¹. Indeed, such was the severity of the problem in developing countries that in 1982 the World Health Organization/International Society and Federation of Cardiology established a committee to combat the disease over a phased period. As a result, the prevalence of RHD has subsided incertain countries in the Middle East and in Thailand².In contrast to previous sources of data upon which to base the prevalence of RHD(for example, necropsies, general population surveys, insurance data) prevalence figures over the past five years have been derived almost entirely from schoolsurveys³. Between 1940 and 1983, the prevalence rate for RHD varied from 1.8 to11 per 1000 (national average 6 per 1000), while between 1984 and 1995 the ratevaried from 1 to 5.4 per 1000. During the same period of time, the prevalence of rheumatic fever ranged from 0.06 to 5.01 and 0.32 to 0.54 per 1000 respectively. Because of the different methods of collecting the data, it is not possible to becertain that these figures represent a fall in the prevalence. By comparison, in western countries the prevalence of RHD in children aged between 5–15 years is below 0.5 per 1000 ³ and for rheumatic fever it is below 1 per 1000.The earliest report of RHD in India dates back to 1910⁴. Even during the 1980s, hospital admission data suggested that RF and RHD accounted for nearly one-half to one third of the total cardiac admissions at various teaching hospitals in India⁵. A more recent survey across various tertiary care hospitals found that hospital admission8rates of RHD had declined (5%–26% of cardiac admissions)⁶. Population-based epidemiological data to ascertain the prevalence of RHD in India are lacking. A properly planned population study in 1993 reported a prevalence of 0.09% forRHD⁷.Studies using echocardiographic validation of clinical diagnoses show a much lower prevalence of RHD. The prevalence estimates range from 0.5/1000 in Gorakhpur¹¹ to 0.67/1000 in Vellore and Bikaner^8,9. The surveys conducted by the Indian Council of Medical Research (ICMR) also indicate a decline in the prevalence of RHD over decades^10,11,12. Several recent studies conducted in India have further highlighted the unacceptably high prevalence of RHD among children and adolescents^13,14 and in patients undergoing balloon mitral valvotomy for juvenile mitral stenosis. Girls and women in particular seem to be severely affected, possibly as a result of being housebound and having to live in overcrowded conditions. Overpopulation, overcrowding, poverty, communities with minority indigenous population and poor access to medical care are undoubtedly the main reasons for the high prevalence of RHD in India. No sex predilection exists, except that Sydenham chorea occur more often in females than in males^15,16,17. Although individuals of any age group may be affected, most cases are reported in

persons aged 5-15 years.^18,4

 

MATERIAL AND METHODS

Present study was carried to study the clinical profile of Rheumatic fever (RF) and Rheumatic heart disease (RHD) in patients of all age groups. The study was approved by the ethics committee prior to commencement of data collection. An informed consent was obtained from father/ mother/ guardian of the patient for participation in the study. Assent consent was also obtained from the patients. The study was conducted in the patients presented to tertiary care hospital. This cohort study was conducted on all cases diagnosed as Rheumatic fever and Rheumatic Heart Disease.196 cases fulfilling inclusion criteria were selected as subjects. These patients fulfilling the inclusion criteria were studied during period of 2 year. The study was both retrospective and prospective cohort study. WHO criteria for the diagnosis of rheumatic fever (BASED ON THE REVISEDJONES CRITERIA), Patients of chronic rheumatic valvular heart disease (2 D ECHO confirmed), Patients of all age groups. Patients who do not give informed consent, Patients other than rheumatic fever and rheumatic heart disease were excluded from the study. Statistical analysis was performed using SPSS. Descriptive statistics (frequency, mean and SD) were used for data presentation T-test, Chi square, z test and ANOVA test were used to test significant difference in mean of variables between two groups and more than two groups respectively. A probability of less than 0.05 was considered statistically significant.

MS, AR and AS were found to be common in >30 years age group with 13/17, 04/04 and 08/09 patients respectively. Combined diseases were common in >30 years age and multivalvular diseases were common in ≤30 years age. However in our study, patients of MS, AR, AS and combined diseases were significantly found in >30 years age (p<0.05) and MS was significantly found in ≤30 years age (p<0.05)

Table 2: Gender wise distribution of valvular diseases

In our study, MR was found equally distributed among (19/38) males and (19/38) females, MS and AS were more common in females. (16/17 and 08/09 patients respectively) AR was found in 03 (75%) males and 01 (25%) females. Combined diseases were equally distributed among males (11/22) and females (11/22). Multivalvular diseases were found in 18/37 males and 19/37 females. However in our study MS and AS were significantly found in females (p<0.01) and AR was significantly found in males (p<0.01).

 

Table 3: Residential distribution among valvular lesions

All valvular diseases were more common in rural populations and were found to be significant (p<0.05).

 

DISCUSSION

The male to female ratio observed in our study was 2.1:1 [TABLE 1]. Similar male predominance was found in previous studies by Aggarwal and Ravisha et al, while Massell et al and Robinson et al have recorded equal incidence of Rheumatic fever in both sexes¹⁹. Increased occurrence of rheumatic fever in males is perhaps related to greater concern for ailing males in the developing countries. Most patients in this study presented between 5-15 years of age [97%] with the mean age being 9.5 years, which is similar to the age of presentation as described in other studies by Shrestha NK and Massell B F et al¹⁹ [TABLE 2]. Two patients presented at 3yrs of age which is lower than the stipulated age for this disease. Both the patients presented with arthritis and had valvular involvement On presentation. Rheumatic fever and particularly rheumatic heart disease have always been regarded as rare conditions below the age of 5 years and as very rare below 3 years²⁰.Reported cases are few and no account of clinical pattern of the disease in small children have been mentioned in the literature. Rosenthal et al. have reported ten cases of acute rheumatic fever in children under three years of age and found high prevalence of rheumatic carditis and congestive heart failure²¹. According to the authors, these findings suggest a strong predisposition to cardiac involvement in the very young children afflicted with rheumatic fever. In a study of Rheumatic fever and rheumatic heart disease in children below 5 yrs of age, Zahira H et al have found the youngest patient with rheumatic arthritis to be of 9 months of age, who eventually developed carditis²².The youngest child with chorea was of 2 years and 758 months of age. In the same study, patients had a positive family history in 3.5%, often in a brother or sister, less frequently in a mother or father²². None of the patients participating in our study had a positive family history. Liability of Rheumatism is far greater in the early than in the later age, although no age is

altogether exempt from its attack.

 

CONCLUSION

It can be concluded from our study that MS, AR and AS were found to be common in >30 years age MS and AS were more common in females, All valvular diseases were more common in rural populations and were found to besignificant.

 

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