Correspondence from the world of cardiology
Rheumatic heart disease (RHD) is the most common acquired heart disease in children in many parts of the world, especially in developing countries. The global burden of disease caused by rheumatic fever and RHD currently falls disproportionately on children and young adults living in low-income countries and is responsible for about 233,000 deaths annually. At least 15.6 million people are estimated to be currently affected by RHD, with a significant number of them requiring repeated hospitalisation and often unaffordable heart surgery in the next five to 20 years.1 Primary prevention of acute rheumatic fever is achieved by treatment of acute throat infections caused by group A streptococcus. Each attack of rheumatic fever further worsens the damage to the heart valves and if regular secondary prophylaxis is taken after initial attack, the valves may remain unaffected. Secondary prevention is thus very important to prevent further attacks of rheumatic fever with procaine penicillin, a cheaper antibiotic, most commonly used for secondary prophylaxis. Secondary prevention programmes are currently thought to be more cost effective for prevention of RHD than primary prevention and may be the only feasible option for low- to middle-income countries in addition to poverty alleviation efforts.2 Stuck valve is an important complication in patients with mechanical valves and poses a significant mortality risk.3
The Indira Gandhi Institute of Cardiology is the largest tertiary cardiac centre in Bihar, a major state of northern India. The mortality due to rheumatic heart disease in this cardiac centre during 2013 was 120 with more deaths in women (n = 67, 56%) than men (n = 53, 44%). Median age at death was 35 years. Minimum age at death was eight years and maximum age was 73 years. Three patients had balloon mitral valvulotomy (BMV), one had closed mitral valvulotomy (CMV), eight had mitral valve replacement (MVR) and four had double valve replacement (DVR). The highest number of deaths was noted in the 31–40 years age group, (19 women 18 men). Out of a total 120 deaths, four had stuck valves (three had MVR and one had DVR).
A register-based project for control of acute rheumatic fever (ARF)/RHD was launched by the World Health Organization (WHO) in 1972, which showed a significant reduction in health costs. WHO then embarked upon a global programme and, by 1990, ARF registers had been established in 16 countries with over 3,000 cases of RHD or prior ARF detected. A later review highlighted improved compliance with secondary prophylaxis4 but subsequently only a few countries expanded their programmes.
Today, well-developed telecommunication systems could be very useful in ensuring secondary prophylaxis. Reminders could be sent through patients’ registered phone numbers in cases of non-compliance. Thus a higher percentage of secondary prophylaxis could be ensured, which would ultimately reduce the overall prevalence of RHD and the presence of severe forms of the disease in society. Regular surveys of schools and villages would also detect new cases. The community also needs to be educated about RHD through posters, banners and television shows advising timely medical attention.
Through these multipronged measures the burden of this crippling disease can be reduced in the underprivileged world.
Conflict of interest
Arun Prasad, Assistant Professor
Sanjeev Kumar, Assistant Professor
All India Institute of Medical Sciences, Patna, India
Birendra Kumar Singh, Deputy Director
Indira Gandhi Institute of Cardiology, Patna, India, 800004
1. Mendis S, Puska P, Norrving B (eds.). Global Atlas on cardiovascular disease prevention and control. World Health Organization, Geneva 2011. Available in full at http://www.world-heart-federation.org/fileadmin/user_upload/images/CVD_Health/Global_CVD_Atlas.pdf
2. Kumar R. Controlling rheumatic heart disease in developing countries. World Health Forum. 1995;16:47–51.
3. Shapira Y, Hirsch R, Jortner R, Nili M, Vidne B, Sagie A. Prosthetic heart valve thrombosis: a 3-year experience. Harefuah 1997;133:169–73, 246.
4. M, Brown A, Noonan S, Carapetis JR. Preventing recurrent rheumatic fever: the role of register-based programs. Heart 2005;91;1131–3. http://dx.doi.org/10.1136/hrt.2004.057570