Epidemiologic profiles of subclinical rheumatic heart disease in children

Main Article Content

Dewi Rahmawati Syam
Deny Salverra Yosy
Achirul Bakri
Ria Nova


Background Rheumatic heart disease (RHD) causes premature deaths every year worldwide. Low socioeconomic level is considered to be a risk factor facilitating the transmission of airway infections due to Streptococcus pyogenes. Subclinical RHD is a stage of RHD in which heart valve abnormalities have occurred according to the WHO or WHF classification but without any complaints to the subject. Echocardiography is used to screen subclinical RHD in several countries.

Objective To estimate the prevalence, risk factors, and echocardiographic features of subclinical RHD in children.

Methods This cross-sectional study was conducted on 250 elementary school children in Palembang, South Sumatera. We interviewed subject's parents about family characteristics, environment, and history of recurrent sore throat. Subjects underwent anthropometric examination, auscultation, and echocardiography. Diagnosis of RHD was based on World Health Organization (WHO) and World Heart Federation (WHF) criteria.

Results Of 250 subjects, 132 (53.8%) were girls. Subjects’ age range was 5-14 years. The prevalence of subclinical RHD was 8% (95%CI 4.8 to 11.6). Of the 20 subclinical RHD subjects, 15 (75%) met the possible RHD criteria, 5 (25%) met the probable RHD criteria, and none met the definite RHD criteria. Multivariate analysis showed that household crowding (OR 8.135; 95%CI 1.048 TO 63.143; P=0.045), history of recurrent sore throat within the previous 6 months (OR 6,476; 95%CI 1.79 to 23.427; P=0.004) and age > 10 years (OR 3.167, 95%CI 1.184 to 8.471; P=0.022) significantly increased the risk of subclinical RHD.

Conclusion The prevalence of subclinical RHD in elementary school children in Palembang was 8%. For echocardiographic features, most cases met the WHO/WHF possible RHD criteria. Factors significantly associated with the incidence of subclinical RHD are age > 10 years, household crowding, and history of recurrent sore throat in the previous 6 months.

Article Details

How to Cite
Syam D, Yosy D, Bakri A, Nova R. Epidemiologic profiles of subclinical rheumatic heart disease in children. PI [Internet]. 13Nov.2020 [cited 26Jan.2021];60(6). Available from: https://paediatricaindonesiana.org/index.php/paediatrica-indonesiana/article/view/2422
Pediatric Cardiology
Received 2020-05-26
Accepted 2020-11-13
Published 2020-11-13


Seckeler MD, Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol.2011;3: 67–84.doi: 10.2147/CLEP.S12977.
2. Watkins DA, Johnson CO, Colquhoun SM, Karthikeyan G, Beaton Andrea, Bukhman Gene, et al. Global, regional, and national burden of rheumatic heart disease, 1990-2015. N Engl J Med. 2017;377:713-22.doi: 10.1056/NEJMoa1603693.
3. Shrestha NR, Karki P, Mahto R, Gurung K, Pandey N, Agrawal K, et al. Prevalence of subclinical rheumatic heart disease in Eastern Nepal: a school-based cross-sectional study. JAMA Cardiol.2016;1(1): 89-96. doi: 10.1001/jamacardio.2015.0292.
4. Rahmawaty NK, Burhanuddin I, Husain A, Dasril D. Faktor risiko serangan berulang demam rematik/penyakit jantung rematik. Sari Pediatr.2012;14(3):179-84. doi: http://dx.doi.org/10.14238/sp14.3.2012.179-84.
5. Beaton A, Okello E, Lwabi P, Mondo C, McCarter R, Sable C. Echocardiography screening for rheumatic heart disease in Ugandan schoolchildren. Circulation.2012;125(25):3127-32. doi: 10.1161/CIRCULATIONAHA.112.092312.
6. Reményi B, Wilson N, Steer A, Ferreira B, Kado J, Kumar K, et al. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease an evidence based guideline. Nat Rev Cardiol.2012; 9(5): 297-309. doi:10.1038/nrcardio.2012.7.
7. Saxena A, Ramakrishna S, Roy A, Seth S, Krishnan A, Puneet M, et al. Prevalence and outcome of subclinical rheumatic heart disease in India: the RHEUMATIC (rheumatic heart echo utilisation and monitoring actuarial trends in indian children) study. Heart.2011;97(24):2018-22. doi: 10.1136/heartjnl-2011-300792.
8. Ikatan Akuntansi Indonesia (IAI). Pernyataan standar akuntansi keuangan, Pendapatan. Jakarta: DSAK-IAI; 2012.
9. Kemenkes RI. Persyaratan kesehatan perumahan (Keputusan Menteri Kesehatan RI Nomor 829/MENKES/SK/II/1999). Jakarta: Kemenkes RI; 1999.
10. National Center for Health Statistics, CDC. 2000 CDC growth charts. [cited 2018 October 26]. Available from: https://www.cdc.gov/growthcharts/cdc_charts.htm.
11. Carapetis JP, Paar J, Cherian T. Standardization of epidemiologic protocols for surveillance of post-streptococcal sequelae: acute rheumatic fever, rheumatic heart disease and acute post-streptococcal glomerulone- phritis. National Institute of Allergy and Infectious Diseases. 2006 Jan;1.
12. Rothenbuhler M, O’Sullivan CJ, Stortecky S, Stefanini G, Spitzer E, Estill J, et al. Active surveillance for rheumatic heart disease in endemic regions: a systematic review and meta-analysis of prevalence among children and adolescents. Lancet Glob Health.2014; 2(12): e717-26. doi: 10.1016/S2214-109X(14)70310-9.
13. World Health Organization. Global action plan for the prevention and control of NCDs 2013 -2020. [cited 2018 September 9]. Available from: http://www.who.int/nmh/events/ncd_ action_plan/en.
14. Rahayuningsih SE. Role of demam rematik akut. Presented at Pendidikan ilmu kesehatan anak berkelanjutan (PIKAB) IX; 2011 Okt 1-2; Bandung.
15. Dajani AS. Rheumatic fever. In: Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s heart disease.2007. 7th ed. Philadelphia: Elsevier Saunders. p. 2093-9.
16. Lewis KD, Conway J, Cunningham C, Larsen BMK. Optimizing nutrition in pediatric heart failure: The crisis Is over and now it’s time to feed. Nutr Clin Pract. 2018 Jun;33(3):397-403. doi: 10.1177/0884533617712502.