Endomyocardial fibrosis is the most common restrictive cardiomyopathy observed world wide. The disease occurs in its classical endemic form in the selected coastal belt in Kerala, India, affecting young people of lower socioeconomic families, and attracting worldwide 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, a pathognomonic, but less common feature of the disease, may share the same pathobiology of vascular and valvar calcification occurring in other diseases. Over the past four decades, Kerala has witnessed a tremendous change in its socioeconomic and health status and a corresponding decline in new cases of endomyocardial fibrosis in the younger age group. This decline parallels the decline of rheumatic fever reported earlier in developed nations. Socioeconomic development is, therefore, a major factor in the control of this enigmatic disease
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