Endomyocardial fibrosis is the most common restrictive cardiomyopathy observed world wide. The disease occurred in its classical endemic form in the selected coastal belt in Kerala, India affecting young individuals of lower socioeconomic families, attracting world wide attention. Geographical identification of high levels of cerium in the soil samples of this coastal belt generated a new “geochemical hypothesis” for endocardial injury. Endocardial calcification, pathognomonic, but less common feature of the disease, could share the same patho-biology of vascular and valvar calcification occurring in other diseases. Over the last four decades, Kerala has witnessed a tremendous change in its socioeconomic and health status and a corresponding decline in the newer cases of endomyocardial fibrosis in younger age group. This decline parallels the decline of rheumatic fever reported earlier in developed nations and socioeconomic development is therefore a major factor in the control of this enigmatic disease
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