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Prevalence and outcome of subclinical rheumatic heart disease in India: The RHEUMATIC (Rheumatic Heart Echo Utilisation and Monitoring Actuarial Trends in Indian Children) study
  1. Anita Saxena1,
  2. Sivasubramanian Ramakrishnan1,
  3. Ambuj Roy1,
  4. Sandeep Seth1,
  5. Anand Krishnan2,
  6. Puneet Misra2,
  7. Mani Kalaivani3,
  8. Balram Bhargava1,
  9. Marcus D Flather4,
  10. Philip P A Poole-Wilson4
  1. 1Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
  2. 2Department of Community Medicine, All India Institute of Medical Sciences, New Delhi, India
  3. 3Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
  4. 4Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
  1. Correspondence to Dr Anita Saxena, Room No. 29, 7th Floor, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi 110029, India; anitasaxena{at}


Objective To study the prevalence and medium term outcome of subclinical rheumatic heart disease (RHD) in India.

Design Cross sectional echocardiographic screening study.

Setting School children aged 5–15 years living in rural areas of north India.

Patients A cross sectional echocardiographic screening study was carried out among 6270 randomly selected school children aged 5–15 years (10.8±2.6 years; 52.7% male). Of all the abnormal cases, 100 children (78%) were restudied at a mean follow-up of 15.4±6.6 months.

Intervention Echocardiographic screening.

Main outcome measure Echocardiography–Doppler criteria based prevalence of RHD.

Results Clinical examination detected mitral regurgitation in five patients and the estimated prevalence of clinical RHD was 0.8/1000 school children. Echocardiography–Doppler diagnosed RHD in 128 cases, giving a prevalence of 20.4/1000 school children (95% CI 16.9 to 23.9/1000 children). On multivariate analysis, older age (OR 1.93, 95% CI 1.29 to 2.88; p=0.001), female sex (OR 1.84, 95% CI 1.25 to 2.72; p=0.002) and government funded school student, which is a surrogate measure of lower socioeconomic status (OR 1.55, 95% CI 1.02 to 2.34; p=0.039) were found to be independent predictors of RHD. On follow up, the severity of subclinical RHD was non-progressive in 68 children (68%) while it worsened in four (4%) and regressed in 28 children (28%).

Conclusions The prevalence of RHD is several fold higher using echocardiographic screening compared with clinical examination. The prevalence is higher among girls and children of lower socioeconomic status. In the majority of cases, subclinical RHD appears to be non-progressive on medium term follow up. Routine echocardiographic screening may be indicated in populations at high risk of RHD.

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  • Funding Partial funding from the United Kingdom India Education and Research Initiative (UKIERI). The funding agency had no role in the design or conduct of the study, collection, management, analysis or interpretation of the data, or the preparation, review or approval of the manuscript.

  • Competing interests None.

  • Ethics approval The study was approved by the All India Institute of Medical Sciences ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.