The global burden of rheumatic heart disease: population-related differences (it is not all the same!)

Abstract Rheumatic heart disease (RHD) remains the most common cardiovascular disease in young adults and adolescents in need of heart surgery in low- and middle-income countries (LMICs). The mean age of patients is 20-25 years, often much younger. By contrast, the few patients with chronic RHD in developed countries present a mean age of around 55 years. It is absolutely fundamental to differentiate these two types of population. Pathology, lesions and surgical methods are different, and the results should not be compared. It is not all the same! A certain enthusiasm for mitral repair has recently surged, with several reports showing excellent results in children and young adults, resulting from the renewed interest of cardiac surgeons, also based on new and modified techniques developed in the meantime. While surgery is easily accessible to patients in developed countries, the situation in LMICs is often dramatic, with countries where there is a complete absence of or few surgical facilities absolutely unable to meet gigantic demands. Many foreign surgical teams conduct humanitarian missions in several of these countries. They are just a "drop of water in the ocean" of needs. In some cases, however, these missions led to the establishment of local teams that now work independently and, in some cases, outperform the foreign teams still visiting.

Evolução Doppler Ecocardiográfica das Lesões Valvares Mitral e Aórtica em Crianças e Adolescentes com Cardite Reumática Subclínica e Leve / Doppler Echocardiographic Follow-Up of Mitral and Aortic Regurgitation in Children and Adolescents with Subclinical and Mild Rheumatic Carditis

Fundamento: As cardites reumáticas leve e subclínica se diferenciam basicamente pela ausculta de sopro regurgitativo mitral. A evolução destas formas não está bem estabelecida na literatura. Objetivo: Avaliar a evolução das cardites reumáticas leve e subclínica, considerando as valvites mitral e/ou aórtica (fase aguda) e a regressão, manutenção ou piora delas ao final do seguimento (fase crônica). Métodos: Estudo retrospectivo, longitudinal, incluindo pacientes com cardites reumáticas leve e subclínica. A evolução ecocardiográfica das valvites mitral e/ou aórtica foi comparada nos dois grupos, considerando a análise ao final do seguimento. Foram utilizados o teste qui quadrado e as curvas de sobrevida de Kaplan-Meier, com nível de significância p < 0,05. Resultados: Foram incluídos 125 pacientes, sendo 69 (55,2%) com cardite reumática subclínica e 56 (44,8%) com cardite reumática leve, com média de idade na fase aguda de 10,4 ± 2,6 anos e, ao final do estudo, de 19,9 ± 4,6 anos. O tempo de seguimento variou de 2 a 23 anos (média: 9,38 ± 4,3 anos). Na fase aguda, a regurgitação mitral leve/ moderada ou moderada foi mais frequente nos pacientes com cardite reumática leve (p = 0,001). A regurgitação aórtica leve ou leve/moderada também foi mais comum no grupo de cardite reumática leve (p = 0,045). Na fase crônica, observou-se que tanto a regurgitação mitral (p < 0,0001) quanto a regurgitação aórtica (p = 0,009) foram mais frequentes nos pacientes com cardite reumática leve, e a sobrevida livre de valvopatia residual foi maior no grupo de cardite reumática subclínica (p = 0,010). A regurgitação mitral residual foi maior no grupo de cardite reumática leve p < 0,0001), e a regurgitação aórtica residual foi semelhante nos dois grupos (p = 0,099). Conclusão: A resolução da regurgitação mitral foi maior nos pacientes com cardite reumática subclínica, e a involução da regurgitação aórtica foi menos frequente e semelhante nos dois grupos

Background: Mild rheumatic carditis (MRC) and subclinical rheumatic carditis (SRC) are basically differentiated through auscultation of mitral regurgitation murmur. The evolution of these forms is not well established in the literature. Objective: To evaluate the evolution of mild and subclinical rheumatic carditis, considering mitral and aortic regurgitation (acute phase) and regression, maintenance or worsening of these diseases at the end of follow-up (chronic phase). Methods: Retrospective, longitudinal study, including patients with mild and subclinical rheumatic carditis. The echocardiographic evolution of mitral and aortic regurgitation was compared in both groups, considering the analysis at the end of follow-up. The Chi-square test and Kaplan-Meier survival curves were used, with significance level established at p < 0.05. Results: A total of 125 patients were included, 69 (55.2%) with subclinical rheumatic carditis and 56 (44.8%) with mild rheumatic carditis, with a mean age in the acute phase of 10.4 ± 2.6 years and, at the end of study, 19.9 ± 4.6 years. The time of follow-up ranged from 2 to 23 years (mean: 9.38 ± 4.3 years). In the acute phase, mild/moderate or moderate mitral regurgitation was more frequent in patients with mild rheumatic carditis (p = 0.001). Mild or mild/moderate aortic regurgitation was also more common in the mild rheumatic carditis group (p = 0.045). In the chronic phase, we observed that both mitral (p < 0.0001) and aortic regurgitation (p = 0.009) were more frequent in patients with mild rheumatic carditis, and survival free of rheumatic heart disease was higher in the subclinical rheumatic carditis group (p = 0.010). Residual mitral regurgitation was higher in the mild rheumatic carditis group p < 0.0001), and residual aortic regurgitation was similar in both groups (p = 0.099). Conclusion: Mitral regurgitation resolution was higher in patients with subclinical rheumatic carditis, and the involution of aortic regurgitation was less frequent and similar in both groups

Risk Prediction of Cardiovascular Complications in Pregnant Women With Heart Disease / Predição de Risco de Complicações Cardiovasculares em Gestantes Portadoras de Cardiopatia

Abstract Background: Heart disease in pregnancy is the leading cause of non- obstetric maternal death. Few Brazilian studies have assessed the impact of heart disease during pregnancy. Objective: To determine the risk factors associated with cardiovascular and neonatal complications. Methods: We evaluated 132 pregnant women with heart disease at a High-Risk Pregnancy outpatient clinic, from January 2005 to July 2010. Variables that could influence the maternal-fetal outcome were selected: age, parity, smoking, etiology and severity of the disease, previous cardiac complications, cyanosis, New York Heart Association (NYHA) functional class > II, left ventricular dysfunction/obstruction, arrhythmia, drug treatment change, time of prenatal care beginning and number of prenatal visits. The maternal-fetal risk index, Cardiac Disease in Pregnancy (CARPREG), was retrospectively calculated at the beginning of prenatal care, and patients were stratified in its three risk categories. Results: Rheumatic heart disease was the most prevalent (62.12%). The most frequent complications were heart failure (11.36%) and arrhythmias (6.82%). Factors associated with cardiovascular complications on multivariate analysis were: drug treatment change (p = 0.009), previous cardiac complications (p = 0.013) and NYHA class III on the first prenatal visit (p = 0.041). The cardiovascular complication rates were 15.22% in CARPREG 0, 16.42% in CARPREG 1, and 42.11% in CARPREG > 1, differing from those estimated by the original index: 5%, 27% and 75%, respectively. This sample had 26.36% of prematurity. Conclusion: The cardiovascular complication risk factors in this population were drug treatment change, previous cardiac complications and NYHA class III at the beginning of prenatal care. The CARPREG index used in this sample composed mainly of patients with rheumatic heart disease overestimated the number of events in pregnant women classified as CARPREG 1 and > 1, and underestimated it in low-risk patients (CARPREG 0).

Resumo Fundamento: Cardiopatia na gravidez é a primeira causa de morte materna não obstétrica. Poucos estudos brasileiros avaliaram o impacto da cardiopatia na gestação. Objetivo: Determinar os fatores de risco associados às complicações cardiovasculares e neonatais. Métodos: Foram avaliadas 132 gestantes cardiopatas, acompanhadas em um Setor de Gestação de Alto Risco, de janeiro de 2005 a julho de 2010. Foram selecionadas variáveis que poderiam influenciar no desfecho materno/fetal: idade, paridade, tabagismo, etiologia, gravidade da cardiopatia, complicações cardíacas prévias, cianose, classe funcional New York Heart Association (NYHA) > II, disfunção/obstrução do ventrículo esquerdo, arritmia, mudança de tratamento, início e número de consultas de pré-natal. Foi calculado, retrospectivamente, o índice de risco materno-fetal de acordo com o Cardiac Disease in Pregnancy (CARPREG) no início do pré-natal. As pacientes foram estratificadas nas três categorias de risco do CARPREG. Resultados: A cardiopatia reumática foi a cardiopatia mais prevalente (62,12%). As complicações mais frequentes foram descompensação cardíaca (11,36%) e arritmias (6,82%). Fatores associados às complicações cardiovasculares na análise multivariada foram mudança do tratamento (p = 0,009), complicações cardíacas prévias (p = 0,013) e classe funcional III NYHA na primeira consulta pré-natal (p = 0,041). O porcentual de complicação cardiovascular foi 15,22% no grupo CARPREG 0; 16,42% no CARPREG 1; e 42,11% no CARPREG >1 − diferentemente do estimado pelo índice original: 5%, 27% e 75%, respectivamente. Na amostra, tivermos 26,36% de prematuridade. Conclusão: Os fatores de risco para complicação cardiovascular nessa população foram a mudança de tratamento, as complicações cardíacas prévias e a classe funcional III NYHA no início do acompanhamento pré-natal. O índice CARPREG, nesta amostra, composta principalmente por pacientes com cardiopatia reumática, superestimou o número de eventos em gestantes classificadas como CARPREG 1 e > 1, e subestimou o risco em pacientes de baixo risco (CARPREG 0).

Prevalence of Rheumatic Heart Disease in a Public School of Belo Horizonte / Prevalência de Valvopatia Reumática Subclínica em Alunos de Escola Pública de Belo Horizonte

Background: Previous studies indicate that compared with physical examination, Doppler echocardiography identifies a larger number of cases of rheumatic heart disease in apparently healthy individuals. Objectives: To determine the prevalence of rheumatic heart disease among students in a public school of Belo Horizonte by clinical evaluation and Doppler echocardiography. Methods: This was a cross-sectional study conducted with 267 randomly selected school students aged between 6 and 16 years. students underwent anamnesis and physical examination with the purpose of establishing criteria for the diagnosis of rheumatic fever. They were all subjected to Doppler echocardiography using a portable machine. Those who exhibited nonphysiological mitral regurgitation (MR) and/or aortic regurgitation (AR) were referred to the Doppler echocardiography laboratory of the Hospital das Clínicas of the Universidade Federal of Minas Gerais (HC-UFMG) to undergo a second Doppler echocardiography examination. According to the findings, the cases of rheumatic heart disease were classified as definitive, probable, or possible. Results: Of the 267 students, 1 (0.37%) had a clinical history compatible with the diagnosis of acute rheumatic fever (ARF) and portable Doppler echocardiography indicated nonphysiological MR and/or AR in 25 (9.4%). Of these, 16 (6%) underwent Doppler echocardiography at HC-UFMG. The results showed definitive rheumatic heart disease in 1 student, probable rheumatic heart disease in 3 students, and possible rheumatic heart disease in 1 student. Conclusion: In the population under study, the prevalence of cases compatible with rheumatic involvement was 5 times higher on Doppler echocardiography (18.7/1000; 95% CI 6.9/1000-41.0/1000) than on clinical evaluation (3.7/1000-95% CI). .

Fundamento: Estudos indicam que o Doppler ecocardiograma possibilita a identificação de um maior número de casos de valvopatia reumática, quando comparado ao exame clínico, em indivíduos aparentemente saudáveis. Objetivos: Determinar a prevalência de valvopatia sugestiva de envolvimento reumático segundo as avaliações clínicas e Doppler ecardiográficas em alunos de escola pública de Belo Horizonte. Métodos: Estudo transversal realizado com 267 escolares entre 6 e 16 anos, selecionados de forma aleatória. Os alunos foram submetidos à anamnese e exame físico com o objetivo de estabelecer critérios prévios para o diagnóstico de febre reumática. Todos realizaram o estudo Doppler ecocardiográfico com o emprego de um aparelho portátil. Aqueles que apresentaram regurgitação valvar mitral (RM) e ou aórtica (RAo) sugestiva de não fisiológica foram encaminhados ao laboratório de Doppler ecocardiografia do Hospital das Clínicas da Universidade Federal de Minas Gerais (HC-UFMG) para a realização de novo estudo. Conforme os achados, os casos de valvopatia reumática foram classificados em definitiva, provável e possível. Resultados: Dos 267 escolares, um (0,37%) apresentou história compatível com o diagnóstico de febre reumática aguda (FRA), 25 (9,4%) apresentaram RM e/ou RAo consideradas não fisiológicas ao Doppler ecocardiograma portátil. Destes, 16 (6%) realizaram Doppler ecocardiograma no HC-UFMG, sendo evidenciadas: valvopatia reumática definitiva em um escolar; valvopatia reumática provável em três; valvopatia reumática possível em um escolar. Conclusão: Na população estudada a prevalência de casos compatíveis com envolvimento reumático foi cinco vezes maior ...

Streptococcal pharyngitis, rheumatic fever and rheumatic heart disease: Eight-year prospective surveillance in Rupnagar district of Punjab, India.

Background. Rheumatic fever (RF)/rheumatic heart disease (RHD) continue to be a neglected public health priority. We carried out a registry-based control project, prospective surveillance and sample surveys to estimate the burden of disease. Methods. We trained healthcare providers and established a surveillance system for the 1.1 million population of Rupnagar district in Punjab. In sample surveys conducted among schools, physicians examined the sampled children. Children with a cardiac murmur were investigated by echocardiography. Throat swabs were obtained from a sub-sample, and group A streptococci (GAS) were identified and emm typed by standard laboratory methods. We estimated the morbidity rates for RF/RHD from surveillance data and school surveys using a correction factor to account for under-registration of cases in the registry. Results. A total of 813 RF/RHD cases were registered from 2002 to 2009. Of the 203 RF and 610 RHD cases, respectively, 51.2% and 36.7% were males. In the age group of 5–14 years, RF was more common (80%) than RHD (27%). The prevalence of RF/RHD in 5–14-year-old students was 1.0/ 1000 (95% CI 0.8–1.3). The school survey indicated that about two-thirds of the RF/RHD cases were enrolled in the hospital-based registries. Based on the school survey, the prevalence of RF/RHD was estimated to be 143/100 000 population. In the registry, the annual incidence of acute RF was estimated to be at least 8.7/100 000 children in the age group of 5–14 years. The prevalence of GAS was 2% (13/656) in children with sore throat and 0.5% (14/2920) among those not having sore throat. Typing of 27 GAS revealed 16 emm types. We estimate that about 1000 episodes of GAS pharyngitis lead to one episode of acute RF. Conclusion. RF/RHD continue to be a public health problem in Punjab, India.

Prevalence of Rheumatic Fever and Rheumatic Heart Disease Among School Children.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are significant public health concerns in the developing countries like India. A total number of 10330 school children were examined clinically for evidence of acute rheumatic fever and rheumatic heart disease . Those suffering with the disease were subjected to electrocardiographic, rontgenographic and echocardiographic examination. Prevalence of acute rheumatic fever and rheumatic heart disease was found to be 0.87 per 1000.

Febre reumática – patogênese e vacina / Rheumatic fever – pathogenesis and vaccine

Há um amplo espectro de doenças causadas por estreptococos do grupo A (GAS), e estas são consideradas um problema de saúde pública em países em desenvolvimento, com aproximadamente 600 milhões de casos/ano. As infecções causadas por GAS podem ocasionar doenças invasivas como faringite e pioderma com seqüelas auto-imunes graves como a febre reumática (FR) e glomerulonefrite. A FR acomete principalmente crianças e jovens, inicia com poliartrite na maioria dos casos. Tem como sequelas principais a coreia de Sydenham e a doença reumática cardíaca (DRC), considerada a forma mais grave da doença e caracterizada por lesões cardíacas valvares progressivas e permanentes, que necessitam de cirurgias cardíacas para correção valvular, com alto custo para os Sistemas de Saúde, no mundo. A presente revisão descreve os principais mecanismos desencadeadores das lesões reumáticas no coração e o desenvolvimento da vacina contra o Streptococcus pyogenes para prevenção das principais sequelas decorrentes das streptococcias.

Group A streptococci (GAS) infections are considered a public health problem in developing countries, with about 600 million cases per year and are responsible for an wide spectrum of diseases, mainly invasive diseases as pharyngitis and pyoderma that lead to rheumatic fever (RF) and glomerulonephritis autoimmune sequelae. RF affects children and young adults, and presents differentmanifestations such as rheumatic heart disease (RHD), Sydenham chorea, erythema marginatum, subcutaneousnodules. RHD is considered the most serious complications leading to cardiac valvular lesions characterized byprogressive and permanent heart-valve damage, which entails high cost to the Healthy System around the world. In the present review we described the mechanisms that lead to rheumatic heart lesions and the development of avaccine against Streptococcus pyogenes.

Efficacy of echocardiographic criteria for diagnosis of carditis in acute rheumatic fever.

Background: There is a great need forECHOcriteria for accurate diagnosis of carditis in acute rheumatic fever. Aim: To propose and test the efficacy of ECHO criteria for accurate diagnosis of carditis. Material and Methods: The 333 cases underwent detailed clinical examination, laboratory tests and meticulous Echocardiographic study.Vijay’s ECHO criteria for the diagnosis of carditis / subclinical valvulitis was used. 220 (66.06%) cases were both Jones’ positive and ECHO positive [True +ve], 52 cases (15.61%), probably had subclinical carditis as murmur was not heard (Jones’-ve) but ECHO was positive [False - ve]. Four cases, clinically diagnosed as carditis were Jones’+ve ,but ECHO showed congenital heart disease [False +ve]. 57 cases (17.11%) were clinically , echocardiographically and Jones’ negative were taken as control (True –ve). Sensitivity is81%and specificity is 93%. Conclusions: Precise diagnosis of both carditis /subclinical valvulitis is possible with Vijay’s ECHO criteria. ECHO should be included as a major criterion in Jones’criteria.

Cardiopatias e gravidez / Heart diseases and pregnancy

As cardiopatias complicam de 0,2 a 4,0% as gestações nos países ocidentais. Apesar de o resultado materno-fetal ser favorável na maioria dos casos, pacientes cardiopatas devem receber aconselhamento pré-concepcional adequado. Nessas pacientes, há risco aumentado para insuficiência cardíaca congestiva e arritmias cardíacas durante a gravidez, o parto e o puerpério. As cardiopatias congênitas e reumáticas são as principais etiologias nesses casos. O pré-natal deve ser realizado em serviços terciários com equipes multidisciplinares, familiarizadas com gestação de alto risco. Neste artigo, revisou-se a literatura sobre cardiopatias na gravidez, enfatizando o aconselhamento pré-concepcional e o manejo pré-natal.

Heart diseases complicate from 0.2 to 4.0% of all pregnancies in Western countries. Although the maternal-fetal outcome obtained in most cases is favorable, patients should receive adequate preconcepcional counseling. In these patients, there is an increased risk for congestive heart failure and cardiac arrhythmias during pregnancy, delivery, and puerperium. Congenital and rheumatic heart diseases are the main conditions involved in these cases. The prenatal care must take place in tertiary services with multidisciplinary staff, well-trained in high-risk pregnancies. In this paper, we have reviewed the literature on heart diseases in pregnancy, emphasizing the preconcepcional counseling and prenatal management.

Prevalence of rheumatic heart disease: Has it declined in India.

Rheumatic heart disease continues to be a major health problem in many parts of the world. The epidemiology of rheumatic heart disease in India is of special interest as it may help to understand the effects of economic transition on this enigmatic disease. Critical appraisal of the published literature suggests the possibility of a real decline in the occurrence of the disease in some parts of the country, but a continuing onslaught in several other regions. The rate of decline seems to correlate more with improved public health facilities than with economic development alone. However, the cumulative burden of the disease remains high, and sustained efforts for the prevention of rheumatic heart disease are warranted.

Enfermedad reumática cardiovascular: observaciones anatomopatológicas en biopsias valvulares de jóvenes con menor e igual a 20 años de edad / Cardiovascular rheumatic disease: pathologic´s observations in biopsies valvulares of young people minor and equal 20 years of age

La fiebre reumática es una enfermedad endémica en los países en desarrollo como Venezuela y es causa importante de valvulopatía crónica progresiva, siendo primeramente afectado el aparato valvular mitral. Evaluar el aspecto morfológico de la valvulitis crónica en su etapa inicial, en individuos quienes han sido sometidos a reemplazo valvular mitral o mitro-aórtico. Se seleccionaron 20 biopsias de válvulas mitrales y mitro/aórticas diagnosticadas como valvulopatía crónica reumática, representativas de la etapa inicial, en pacientes con edad igual o menos de 20 años. Los diagnósticos pre-operatorios fueron: disfunción valvular severa mitral (insuficiencia (60%), doble lesión (10%) y estenosis (5%) y mitro-aórtica (25%). Las biopsias (valvas y aparatos valvulares mitrales) fueron evaluadas macroscópicamente. El estudio histológico se hizo con secciones teñidas con Hematoxilina-eosina e inmunomarcadas con anticuerpos CD 34 y antimúsculo liso. Todos los casos mostraron lesiones morfológicas propias de la valvulitis crónica reumática inicial: inflamación grado 1 (81,6%), con nódulos de Aschoff (35%), fibrosis de grado 2 (40%) y 3 (60%) Con una alta densidad de neovascularización (14,78 ± 1,92). Se hizo el análisis de los hallazgos morfológicos y se consideró que este trabajo puede servir de base para investigaciones comparativas con casos de etapas más avanzadas de la enfermedad valvular en relación a la inflamación, remodelado colágeno y angiogénesis.

Rheumatic fever is an endemic disease in developing countries such as Venezuela and is an important cause of progressive chronic valve disease, the mitral valve apparatus being affected in the first place. To evaluate the morphologic aspect of chronic valvulitis in its initial stage among individuals that have gone through mitral and mitro-aortic valve replacement. Twenty (20) biopsies of mitral and mitro-aortic valves diagnosed with rheumatic chronic valvulopathy in its initial stage were selected from patients aged 20 years or younger. Preoperating diagnoses were as follows: severe mitral valve dysfunction (insufficiency: 60%, double injury: 10%, stenosis: 5%, and mitro-aortic: 25%). The biopsy material (valve apparatuses) was macroscopically evaluated. A histological study was made on haematoxylin-eosin stained and CD34 antibody immunomarked sections and smooth antimuscle. All cases showed morphologic lesions typical of initial chronic rheumatic valvulitis: grade 1 inflammation (81,6%), with Aschoff's bodies or nodules (35%), grade 2 fibrosis (40%), and grade 3 fibrosis (60%) with high density neovascularization (14,78 ± 1,92). Morphologic findings were analyzed, thus concluding that this work can serve as a basis for comparative investigations on case of valvular disease at more advanced stages in terms of inflammation, collagen remodeling and angiogenesis.

Doença arterial coronariana em pacientes com valvopatia reumática e não-reumática acompanhados em hospital público do Rio de Janeiro / Coronary artery disease in patients with rheumatic and non-rheumatic valvular heart disease treated at a public hospital in Rio de Janeiro

OBJETIVO: Avaliar a prevalência de doença arterial coronariana (DAC) na valvopatia de etiologia reumática e não-reumática, examinando possíveis fatores preditivos da presença da doença. MÉTODOS: Estudo transversal, de série de casos obtidos em população pré-definida. Foram avaliados 1.412 pacientes com indicação de cirurgia cardíaca por qualquer etiologia. Destes, foram encontrados e estudados 294 casos com valvopatia primária de etiologias reumática e não-reumática, com idade > 40 anos, submetidos a coronariografia. RESULTADOS: Os valvopatas reumáticos apresentaram menor prevalência de DAC (4 por cento) que os não-reumáticos (33,61 por cento) (p < 0,0001). O modelo de regressão logística evidenciou que idade, dor torácica típica, hipertensão arterial sistêmica (HAS), diabete melito e dislipidemia estavam significativamente relacionados à DAC, e que a etiologia reumática não era determinante da doença. Tabagismo e sexo revelaram-se de importância clínica na DAC, embora sem significância estatística. No grupo total, o modelo de análise Log linear demonstrou que, independentemente da etiologia, sexo, idade > 55 anos, HAS, dor torácica típica, diabete e dislipidemia se relacionavam diretamente com a DAC, sendo as três últimas as variáveis de maior peso para a doença. CONCLUSÃO: A prevalência de DAC é baixa entre valvopatas reumáticos e mais alta entre não-reumáticos; a etiologia reumática não parece exercer efeito protetor sobre a prevalência de DAC; e as variáveis sexo, idade, HAS, dor torácica típica, dislipidemia e diabete melito foram identificadas como fortemente associadas à presença de DAC. É possível definir critérios de indicação de coronariografia pré-operatória nas trocas valvares, podendo-se evitar a indicação rotineira a partir dos 40 anos.

OBJECTIVE: to estimate the prevalence of coronary artery disease (CAD) in valvular heart disease of rheumatic (RVHD) and non-rheumatic (NVHD) etiology, assessing possible predictive factors for the presence of CAD. METHODS: This is a cross-sectional study of a series of cases obtained from a pre-defined population, wherein 1,412 patients referred for heart surgery of any etiology were evaluated. Of these, 294 primary heart disease patients aged >40 submitted to cinecoronary arteriography (CA) were identified and studied. RESULTS: patients with RVHD presented lower prevalence of CAD (4 percent) when compared to NVHD (33.61 percent), p<0.0001. The logistic regression analysis showed that age, typical angina-like chest pain (TACP), systemic arterial hypertension (SAH), diabetes and dyslipidemia were significantly related to CAD, and that the rheumatic etiology was not a disease determinant. Smoking and gender were clinically important in CAD, although not statistically significant. In the whole group, the Log-linear analysis showed that, regardless of the etiology, gender, age >55, SAH, TACP, diabetes and dyslipidemia were all related directly to CAD, with the latter three being the most important variables for the disease. CONCLUSION: the prevalence of CAD among RVHD patients is low, whereas it is high among NVHD patients; the rheumatic etiology does not seem to have any beneficial effects on the prevalence of CAD; gender, age, SAH, TACP, dyslipidemia and diabetes were identified as being strongly associated with the presence of CAD. It is possible to define the criteria that indicate the need for pre-surgical CA in heart valve replacements, so that the standard indication after the age of 40 years can be avoided.

Prevalence of rheumatic heart disease in school-going children of Eastern Uttar Pradesh.

BACKGROUND: Rheumatic heart disease is a major health problem in our country. There is evidence from South India that its prevalence is declining. This study attempts to confirm whether this is so in North India as well. METHODS AND RESULTS: A total of 118,212 (68,357 males, 49,855 females) schoolchildren in the age group of 4-18 years were examined for the presence of heart disease. Evaluation, including echocardiography, confirmed that of a total of 389 suspected to have heart disease, 61 had rheumatic heart disease. Thus, the prevalence of rheumatic heart disease was found to be approximately 0.5 per 1000 children. CONCLUSION: In a fairly large school survey conducted by us, the prevalence of rheumatic heart disease turned out to be approximately 0.5 per 1000 children. This is the lowest figure reported from our country so far and confirms the decline of this disease in our country.

Rheumatic and nonrheumatic valvular heart disease: epidemiology, presentation and management

Valvular disease ranks among the major cardiovascular afflictions in Africa. Acute rheumatic fever and chronic rheumatic valvular disease in their most virulent form are still commonly encountered and impose a huge burden on the limited healthcare resources. There is scarce published data from the Sudan, although open heart surgery and interventional cardiology was re-established as a program in the Sudan in the country since1998. The aim of this study was to investigate the epidemiology and the presentations of patients with valvular lesions as well as the type of procedure expected to help them. The files of 235 patients presented at Ahmed Gasim Cardiac Centre during 1999-2000 were retrospectively reviewed. The study was based on echocardiographic assessment. 235 patients were enrolled; Patients with secondary MR, TR, PR or complex congenital lesions were excluded. Out of the 235 Pts assessed, 182 were young < 40 yrs of age and 185 [78%] had Rheumatic origin, which is preventable. 153 patients 65% were recommended for prosthetic valve replacement with the hazard of long term anticoagulant therapy, 49 patients [23%] with MS, were suitable for PTMC, with a possible risk of restenosis in 10 to 15 years, while 33 patients [12%] only has expected good long term results [patients with PS and elderly, patients for tissue valves or patients for valve repair or excision of a sub-aortic membrane. In conclusion, to launch a nation wide and a sustainable control program for rheumatic fever, the provision of a reliable anticoagulant monitoring and to continue the search for an ideal valve

Oxidative stress and antioxidant status in cardiovascular diseases in population of western Nepal.

OBJECTIVES: To observe if there is any connectivity between oxidative stress and cardiovascular diseases (CVDs). MATERIALS AND METHODS: Patients suffering from different cardiovascular diseases (hypertension, ischemic heart disease, rheumatic heart disease) attending Manipal Teaching Hospital, Pokhara and strictly matched controls were selected for this study. Oxidative stress (OS) was measured by plasma thiobarbituric acid reacting substances (TBARS) where as antioxidant status was measured by estimating vitamin E, vitamin C and total antioxidant activity (TAA) in plasma. RESULTS: The mean level of TBARS, TAA, vitamin C and E were 2.20+0.43 nmol/ml, 547+98 mol/l, 0.88+0.15 mg/dl and 0.75+0.20 mg/dl respectively in patients. The respective values in controls were 1.86+0.43 nmol/ml, 859+139 mol/l, 0.94+0.15 mg/dl and 1.10+0.30 mg/dl. Although the OS seems to be raised in patients, is practically insufficient to oxidize biomolecules and induce CVDs. Despite vitamin C and E levels being well within normal limits, the TAA was significantly and considerably lower in patients. This is a highly interesting observation suggesting that dietary antioxidants other than these vitamins were preferentially consumed to control OS because procedure for TAA used in this study practically measures only total dietary antioxidants. CONCLUSION: OS does not appear to be an etiological factor for the cardiovascular diseases; rather slightly raised OS in patients seems to be a consequence. Further the raised OS was not due to lower nutrient antioxidant (vit. C and vit. E) in the local population studied herein.

Prevalence of rheumatic heart disease in school children in Bikaner: an echocardiographic study.

OBJECTIVE: To determine prevalence of rheumatic heart disease (RHD) using clinical and echocardiographic criteria and to study influence of socioeconomic status (SES) we studied school children in a north-western Indian town. METHODS: 3292 school children, age range 5-14 years, in two private schools, ten middle SES government schools and six low SES government schools were invited to participate in the study. 3002 (1837 boys, 1165 girls) were clinically examined (response 91%) of which 1042 were in private schools, 1002 in middle SES schools and 958 in low SES schools. Prevalence of cardiac murmurs and RHD based on clinical diagnosis was determined in school by a trained team of physicians. Those with a murmur were further evaluated by Doppler-echocardiography in the hospital. Group-specific and age-specific rates (prevalence/thousand) of murmurs and cardiac lesions were determined. RESULTS: A significant cardiac murmur was observed in 55 subjects (18.3/1000) with similar prevalence in boys (20.7) and girls (14.6). The prevalence of murmur was significantly greater in children belonging to low SES schools (29.2/1000) as compared to middle SES (18.9) and higher SES schools (7.6). RHD prevalence based on clinical diagnosis was observed in 50 children (16.7/1000) and was similar in boys (19.1) and girls (12.9). Clinical RHD was more in the low SES school children (28.2/1000) as compared to middle (17.0) and high SES schools (5.8). RHD was demonstrated on echocardiography in 2 children (0.67/1000). Other prevalent cardiac lesions were congenital heart disease in 5 (1.66/1000) and mitral valve prolapse in 37 (12.3/1000). CONCLUSIONS: There is a low prevalence of RHD in school children in this region compared to previous Indian studies. Cardiac murmurs are more prevalent among low SES children.

Prevalence of rheumatic and congenital heart disease in schoolchildren of Kathmandu valley in Nepal.

BACKGROUND: Rheumatic heart disease remains a major public health problem in developing countries with its very high prevalence. Rheumatic and congenital heart disease are significant causes of morbidity and mortality among Nepalese schoolchildren. The aim of our study was to determine the prevalence of rheumatic and congenital heart disease among schoolchildren of the Kathmandu valley in Nepal. METHODS AND RESULTS: The study included 9420 students, of whom 4466 were male and 4954 were female, with ages ranging from 5 to 18 years. A clinical survey was conducted by the examining team in selected schools, and involved answering standard questionnaires. A total of 83 children were suspected of having heart disease. Out of these 83 children, 23 were confirmed to have heart disease; 11 had rheumatic heart disease, and 12 congenital heart disease, giving a prevalence of 1.2/1000 and 1.3/1000, respectively. The commonest cardiac lesions were mitral regurgitation in the rheumatic heart disease group, and atrial septal defect in the congenital heart disease group. A higher prevalence of congenital heart disease was detected in females. CONCLUSIONS: The prevalence of rheumatic heart disease and congenital heart disease among schoolchildren of Kathmandu is 1.2/1000 and 1.3/1000, respectively, with mitral regurgitation and atrial septal defect being the commonest lesions.