Observations on Rheumatic Heart Disease in Pakistan*

Abstract

INTRODUCTION:

Rheumatic heart disease in Pakistan is still a formidable problem. The prognosis of the lesions is variable. Some patients suffer valvular damage in a very short period accountable in months following rheumatic fever and are completely crippled with cardiomegaly. Others present with a prolonged history at middle age or at times in old age when valvular lesion is a chance finding. Some patients with mitral stenosis present with severe symptoms and a short history at a tender age. The percentage of adolescents and children is considerable and sufficient to make a study of the natural history of the disease in Pakistan. This study was started in Bahawalpur, Punjab in 1973 and subsequently carried out in Faisalabad and Lahore.

MATERIAL AND METHODS:

All indoor patients admitted with Rheumatic Valvular lesions we fully documented. A proforma was completed collecting data regarding the age and sex, social status, past history of sore throat and arthritis, presenting symptoms, physical findings, ECG and chest X-ray. Patients were encouraged to attend follow up visits and later on postal communication was maintained to find out the course of the disease. A rheumatic etiology was established in the presence of joint pains, sore throat, prolonged febrile illness, presence of multiple valve lesions, mitral stenosis or active carditis. A total of 303 patients were documented.

RESULTS:

Age and Sex Incidence:

In the whole series, there were 170 females and 133 males giving 56% females and 44% males with a ratio of 4.3 in favour of females. The breakup of valvular lesions with sex distribution is shown in fig.1 and 2 show the age distribution.

2. History of Rheumatic Fever:
Past history of rheumatic fever was obtained in little over 54% of patients. Only 18 patients had active rheumatic fever and carditis.

3. Social Class:
About 80% of the patients belonged to poor socioeconomic groups and were living in slums and congested localities. Division of patients into various socioeconomic classes is shown in fig. 3.

4. Functional Class & Severity of Lesion:
About 70% of the patients belonged to functional class III or IV. Out of these, the worst affected were those with mixed mitral 1ecions. 68% of patients suffering from mitral stenosis had valves tight enough to require immediate surgery.

5.Stunted Growth & Poor Physique:
In severe valvular lesions about one third of patients had stunted growth and poor physique or were malnourished.

DISCUSSION:

The natural history of rheumatic disease in developing countries appears to be different from that of Europe and North America. In Western countries rheumatic heart disease has almost disappeared with improvement in socioeconomic conditions and control of streptococcal infections. Total period of disability from the start of rheumatic fever is also variable. Some of the young patients with fulminant carditis and regurgitant lesions tend to develop cardiac failure and cardiomegaly within a short period from the onset of rheumatic fever. Mixed mitral lesions were more incapacitati ng in our series as compared to pure mitral stenosis; over 80% developed card iomegaly and congestive failure.