How much of the recent decline in rheumatic heart disease in China can be explained by changes in cardiovascular risk factors?

Abstract

Rheumatic heart disease (RHD) used to be the most common heart disease in China [1]. Indeed, when I was an intern in a Shanghai hospital in the late 1940s, children with rheumatic fever (RF) occupiedmany of the beds in the pediatric wards, and adults with RHD occupied many of the beds in the adult medical wards. But both RF and RHD have declined progressively over the past 6 decades from 50% of the total hospital cardiac admissions in Shanghai, China in 1948–1957, to 44% in 1958–1968, 30% in 1969–1979, 24% in 1980– 1989, 10% in 1990–1999 [2], and finally to 2% in 2000–2005 (Fig. 1). As amatter of fact, during several ofmy recent visits to China, I discovered that many of the young Chinese physicians have never seen a patient with RF. None could tell me what the Jones criteria [3] for the diagnosis of RFwere.What happened? Just as RF has virtually disappeared in the United States [4], so it almost did in China. Although the reason for the declining incidence of RHD in developing countries – changing virulence of group A streptococci versus changing living conditions – was debated recently in the New England Journal of Medicine [5,6], the explanation is obvious in China. In China, the most populous country in the world and also the most advanced developing country in the world, the striking decline in rheumatic heart disease in recent years is definitely due to improvement in living conditions. Although improved medical care and widespread use of penicillin prophylaxis of streptococcal infections play a role, the decline in RF morbidity and mortality in the developed world began before anti-streptococcal agents became available [4]. Rheumatic fever is a disease of poverty [7]. With