218 Early Results of the Rheumatic (Rheumatic Heart Echo Utilization and Monitoring Actuarial Trends in Indian Children) Study

Abstract

urpose: Rheumatic Heart Disease (RHD) is estimated to affect over 20 million people worldwide, the vast majority being children in developing countries. Early detection of milder cases in asymptomatic children may prevent progression to severe valvular lesions by instituting secondary prophylaxis. Conventionally, auscultation has been used for diagnosing RHD, but echo-Doppler is likely to be more sensitive and specific. We carried out a cross sectional survey to diagnose RHD in asymptomatic children aged 5-15 years, living in rural areas and crowded urban areas, using portable echocardiography. Methods: Children, aged 5-15 years, from government schools and private schools, in a pre identified rural area and from a crowded urban area were studied. After a history and physical examination, echo-Doppler was performed, using a bedside portable echocardiography machine. A diagnosis of RHD was made by echo-Doppler if one or more of the following were present: a) Mitral stenosis; b) Mitral regurgitation (MR) and/or aortic regurgitation (AR) with regurgitant jet length of more than 2 cm in at least two echo planes, along with abnormal valve morphology (a bicuspid aortic valve to be excluded in cases with AR); c) MR and/or AR with regurgitant jet length of 1-2 cm, and abnormal valve morphology, in the presence of a history suggestive of rheumatic fever. Results: A total of 5000 children were screened, 1317 from government schools, 3457 from private schools and 226 from the crowded urban area. 2642 were males. The mean age was 10.8+/-2.6 years. All children were asymptomatic. History suggestive of rheumatic fever was obtained in 167 cases. MR was diagnosed by clinical examination in three cases only (clinical prevalence of RHD 0.6/1000). Echo-Doppler diagnosed RHD in 101 cases, giving a prevalence of 20/1000. Trivial to mild MR, suspicious of RHD was present in an additional 42 cases. Thickening of the valve was present in all cases. Doppler revealed mild MR in 80 and moderate MR in 7 cases. Mild AR was detected in 5 and combined MR and AR in 9 cases. Thirteen of these 101 cases had a history suggestive of rheumatic fever. Other cardiac lesions identified by echo-Doppler were: atrial septal defect (10), bicuspid aortic valve (3, one with AR), ventricular septal defect (2), patent ductus arteriosus (4) and other congenital cardiac lesions (4). Conclusions: This preliminary work demonstrates feasibility of echo screening in children for diagnosing RHD. In this study, the prevalence of RHD was found to be several folds higher, when screening echo-Doppler was used.