Chronic Rheumatic Valvular Heart Disease Research Articles

Simple Criteria, Yet the Dearth Utilization-Antithrombotic Management Practice among Atrial Fibrillation Patients at Hawassa University Comprehensive Specialized Hospital, Hawassa, Sidama, Ethiopia.

Atrial fibrillation (AF) is associated with significant mortality and morbidity from stroke and thromboembolism. Despite the availability of effective oral anticoagulation medication, AF patients remain at a high risk of stroke if not treated properly. The purpose of this study was to evaluate antithrombotic therapy practices in patients with AF in the adult cardiac clinic at Hawassa University Comprehensive Specialized Hospital (HUCSH). It was a retrospective document review study. Total charts of 119 patients who had follow-up at the adult cardiac clinic with a history of documented AF from January 1 to December 30, 2018, were included. Indicators for antithrombotic therapy based on the congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74, and sex category (female) (CHA2DS2-VASc) score were recorded. A p value of 0.05 was considered statistically significant. Data analysis was done using SPSS 23 software. In this study, about 55% of patients with AF were receiving the appropriate antithrombotic treatment. The patients were 48 ± 18.2 years old. Of these, 70% were women. The most frequent underlying cardiac etiology was chronic rheumatic valvular heart disease (50%), followed by cardiomyopathy (14%). In nonvalvular AF, the mean CHA2DS2VASc score was 4.0 ± 1.07. In valvular AF compared to nonvalvular AF, the need for appropriate antithrombotic therapy was substantially greater (p 0.0001). Only 8 (13.6%) of the warfarin-using patients had adequate anticoagulation. The study's findings in regard to antithrombotic usage and maintenance of appropriate antithrombotics for stroke prevention in our patients revealed a discrepancy between recommendations and practice. Therefore, we demand that patients with AF who meet the criteria utilize antithrombotics properly to prevent stroke. Warfarin-taking patients' subpar optimum anticoagulation has to be addressed. Lastly, we advocate proper CHA2DS2-VASc score utilization for nonvalvular heart disease. A regular INR follow-up is also advised for patients who have started taking warfarin.

Valvular heart diseases in immigrants and Swedish-born individuals: a national cohort study

Objectives. The aim of this study was to analyse the risk of valvular heart diseases among foreign-born individuals in Sweden. Design. This was a nationwide study of individuals aged 18 years of age and older (N = 6,118,649; 2,970,055 men and 3,148,594 women). Valvular heart diseases were defined as at least one registered diagnosis in the National Patient Register between 1 January 1998 and 31 December 2012. Cox regression analysis was used to estimate hazard ratios (HR) with 99% confidence intervals (CI) of incident valvular heart diseases in foreign-born individuals compared to Swedish natives. The Cox regression models were adjusted for age, co-morbidities, and sociodemographic factors. Sub-categories were chronic rheumatic valvular heart diseases and non-rheumatic valvular heart diseases. Results. There were 64,979 male cases and 59,075 female cases. Fully adjusted HRs (99% CI) were among immigrant men 0.86 (0.82–0.89) and immigrant women 0.96 (0.92–1.00). For chronic rheumatic valvular disease among immigrant men and women, the HRs were 1.62 (1.37–1.92) and 1.75 (1.52–2.00), respectively, and, for non-rheumatic valvular disease among immigrant men 0.83 (0.80–0.87) and immigrant women 0.92 (0.88–0.96). Increased risks for chronic rheumatic valvular disease were found among men from Southern, Eastern and Central Europe, Africa and Asia and among women from Western, Eastern and Central Europe and Africa, Latin America and Asia. Conclusions. We observed lower risks in general of valvular heart disease, but higher risks of chronic rheumatic valvular heart disease in immigrants, which is important in the clinical situation.

Evaluation of patients' knowledge of warfarin at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

ObjectiveThe study was to assess the knowledge of warfarin in patients using the validated anticoagulation knowledge assessment questionnaire and to evaluate the predictors of the level of knowledge among outpatients receiving warfarin at the Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. MethodsIt was a prospective cross-sectional study carried out from October 2019–January 2020. During the study period a total 401 of them were included in the study. Anticoagulation Knowledge Assessment questionnaire has 29 question items, a single patient should answer at least 21 of the question to be considered as knowledgeable about his/her medication. The data was exported into SPSS version 25 and a one way ANOVA and post hoc were conducted. ResultsThe mean age of the study participants were 36 years old (SD ± 11.83), which was ranges from 18 to 82 and majority of the participants were females (69.6%). Almost in one-third of the participants (35.7%), the reasons for warfarin therapy were Chronic Rheumatic Valvular Heart Disease. The overall AKA mean ± SD score of the respondents was 7.4 (±2.6) that ranges from 2 to 22. From those only (4.2%) of the study participants had succeeds the passing score. Educational level and the duration of warfarin therapy were independent predictors towards patient’s warfarin knowledge. ConclusionThe overall patient’s knowledge about warfarin treatment was poor when it was compared to most other studies. The longer duration of warfarin therapy and advanced educational level showed favored relationship towards better warfarin knowledge of the study participants.

Study on Clinical Value of Color Doppler Echocardiography in Diagnosis of Chronic Rheumatic Valvular Heart Disease

Study on Clinical Value of Color Doppler Echocardiography in Diagnosis of Chronic Rheumatic Valvular Heart Disease

Detecting sub-clinical disease activity in patients with chronic rheumatic valvular heart disease

ObjectiveValve disease progression in rheumatic heart disease(RHD) is generally attributed to recurrent attacks of acute rheumatic fever(ARF). However, persistence of chronic sub-clinical inflammation remains a plausible but unproven cause. Non-invasive means to identify sub-clinical inflammation may facilitate research efforts towards understanding its contribution to disease progression. MethodsPatients with chronic RHD, without clinical evidence of ARF, undergoing elective valve surgery were enrolled. Sub-clinical inflammation was ascertained by histological evaluation of left atrial appendage and valve tissue excised during surgery. We assessed the diagnostic utility of Gallium-67 scintigraphy imaging, and inflammatory biomarkers, hsCRP, IL-2, IL-6, Tumor Necrosis Factor-Alpha(TNF-α), Interferon-gamma(IFN-γ), and Serum Amyloid A(SAA), in identifying patients with sub-clinical inflammation. ResultsOf the 93 RHD patients enrolled(mean age 34 ± 11 years, 45% females), 86 were included in final analysis. Sub-clinical inflammation was present in 27 patients(31.4%). Patients with dominant regurgitant lesions were more likely to have sub-clinical inflammation compared to those with stenotic lesions, though this association was not statistically significant(dominant regurgitant lesions vs isolated mitral stenosis: OR 3.5, 95%CI 0.68–17.96, p = 0.133). Inflammatory biomarkers were elevated in the majority of patients: hsCRP, IL-2, IL-6, TNF-α, and IFN-γ in 44%, 89%, 90%, 79%, and 81% patients, respectively. However, there was no significant association between biomarker elevation and histologically ascertained sub-clinical inflammation. Ga-67 imaging was unable to identify inflammation in the 15 patients in whom it was performed. ConclusionSub-clinical inflammation is common in RHD patients. Conventional inflammatory markers are elevated in the majority, but aren’t discriminatory enough to identify the presence of histologic inflammation.

Study of the relation between serum levels of long-acting penicillin and the inflammatory markers: C-reactive protein and interleukin-6 in patients with chronic rheumatic heart disease

BackgroundThere is an evidence of a chronic inflammatory state in patients with chronic rheumatic valvular heart disease (RHD) as shown by high serum levels of high-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL6). Despite the efficacy of long-acting penicillin (LAP) in secondary prevention of rheumatic fever, its effect on this inflammatory state is still unknown. So, we sought to study the effect of LAP on the inflammatory markers, CRP and IL-6, in patients with chronic rheumatic heart disease.ResultsEighty RHD patients coming to our hospital’s outpatient clinic for rheumatic fever secondary prophylaxis by regular administration of LAP were enrolled in the study. Patients were divided into 3 groups: group A, 70 patients with RHD already on prophylactic LAP, group B, 10 patients with RHD who have not yet started prophylactic LAP, and group C, control group of 10 healthy individuals not known to have RHD. Serum levels of LAP, IL-6, and CRP were measured for the three groups.Group A had significantly lower IL-6 levels than group B (25.22 ± 33.50 vs. 126.1 ± 33.76nng/ml, respectively, p < 0.0001). IL-6 levels were significantly lower in control subjects compared to patients in group B (3.600 ± 2.319, 25.22 ± 33.50 ng/ml, respectively, p < 0.0001). However, IL-6 levels in the control group were lower but non-significantly different compared to group A. CRP level was lower in group A than group B (8419 ± 4935 vs. 14400 ± 3375 mg/dl, respectively, p = 0.0002). CRP levels were significantly lower in control subjects compared to patients in group A and group B. IL-6 values were positively correlated with CRP values (r = 0.6387, p < 0.0001).CRP values were negatively correlated with LAP values (r = -0.5277, p < 0.0001). IL-6 values were negatively correlated with LAP values (r = − 0.4401, p < 0.0001). There was a highly significant difference between LAP level in compliant and non-compliant patients (1.045 ± 1.270 vs. 0.0785 ± 0.1057 ng/ml, respectively, p value < 0.0001).There was also a highly significant difference between CRP level in compliant and non-compliant patients (7640 ± 4558 vs. 13090 ± 4717 mg/dl, respectively, p = 0.005). Moreover, there was a significant difference between IL-6 levels in compliant and non-compliant patients (21.53 ± 32.70 vs. 47.40 ± 30.91 ng/ml, respectively, p value 0.03).ConclusionSerum LAP has a strong negative correlation with IL-6 and CRP levels. Regular administration of LAP strongly ameliorates the inflammatory state seen in patients with RHD.

Colchicine ameliorates the chronic inflammatory state in patients with chronic rheumatic valvular heart disease: a pilot study

BackgroundInflammation is an important contributor to the pathogenesis of rheumatic heart disease (RHD). High serum levels of C-reactive protein (CRP) and interleukin-6 (IL-6) are commonly seen in patients with chronic (RHD) and indicate the presence of a chronic inflammatory state. The aim of this study was to assess the effect of colchicine as anti-inflammatory drug on the serum levels of the inflammatory markers (CRP) and (IL-6) in patients with chronic (RHD).ResultsThis is a prospective controlled study that enrolled thirty-five patients with chronic (RHD) visiting Ain Shams University Hospital’s outpatient clinic for receiving regular long acting penicillin as rheumatic fever prophylaxis. Ten matched healthy individuals were taken as control group. Blood samples for serum levels of CRP and IL-6 were collected before and 1 month after receiving colchicine 0.5 mg BID. Mean (CRP) level was 6.09 ± 4.39 IU/ml versus 0 IU/ml in the control group respectively (P = 0.0001). Mean (IL-6) level was 113.57 ± 37.41 ng/l versus 10.50 ± 5.99 ng/l, in the control group (p = 0.0001). Mean (CRP) was 6.09 ± 4.39 IU/ml before and became 3.34 ± 3.07I U/ml 1 month after colchicine therapy. Mean (IL-6) level was 113.57 ± 37.4 ng/l before and became 45.57 ± 20.39 ng/l 1 month after colchicine therapy (P = 0.001).ConclusionIn this pilot study, using colchicine as anti-inflammatory drug in patients with chronic (RHD) significantly reduced the serum inflammatory markers (CRP) and (IL-6), thus helping in ameliorating their chronic inflammatory state.

Factors associated with sub-optimal control of anticoagulation in patients with prosthetic heart valves taking oral anticoagulants in a sub-Saharan African setting.

Replacement of diseased valves reduces the morbidity and mortality rate associated with native valvular disease but comes at the expense of risking complications related to the implanted prosthetic device. Establishing the desired anticoagulation level in a sub-Saharan African setting may be a challenge. This study was conducted to determine the challenges of maintaining a desired level of anticoagulation and factors associated with sub-optimal anticoagulation in patients with prosthetic heart valves on chronic anticoagulation. We reviewed 73 patients who had undergone prosthetic valve replacement for chronic rheumatic valvular heart disease and were taking warfarin. The follow up ranged from one to 13 years. We studied international normalised ratio (INR) profiles of the patients for the six months preceding the study and defined optimal control as an INR of 2.5-3.5. We aimed to determine if there were factors associated with sub-optimal control of INR. Forty-two patients (57.5%) were female. Mean age of the participants was 21.5 ± 3.1 years (range 14-25 years). Warfarin was the anticoagulant in 55 (75.3%) of the patients and 18 (24.7%) were on combined warfarin and aspirin anticoagulation. Thirty-five (47.9%) patients had optimal control of their INR. Educational level of primary school or less, distance from follow-up medical facility of more than 300 km, quarterly or less-frequent check-up visit, and public health institution as a source of free warfarin supply were found to be significantly associated with sub-optimal control of INR. Educational level, distance from follow-up facility, number of follow-up visits and source of warfarin supply were found to be significantly associated with sub-optimal control of INR.

P3130Relation between serum levels of long acting penicillin and the inflammatory markers: High sensitivity C-reactive protein and interleukin-6 in patients with chronic rheumatic heart disease

Abstract Background There is evidence of a chronic inflammatory state in patients with chronic rheumatic valvular heart disease (RhD) as shown by high serum levels of high sensitivity C-reactive protein (CRP) and interleukin-6 (IL6). Despite the efficacy of long acting penicillin (LAP) in secondary prevention of rheumatic fever, its effect on this inflammatory state is still unknown Objective We sought to study the effect of (LAP) on the inflammatory markers, (CRP) and (IL-6), in patients with chronic rheumatic heart disease. Methods Eighty patients having (RhD) patients coming to our university hospitals outpatient clinic for rheumatic fever secondary prophylaxis by regular administration of (LAP) were enrolled in. the study. Patients were divided into to 3 groups: Group A; 70 patients with (RhD) already on prophylactic (LAP), Group B; 10 patients with (RhD) who have not yet started prophylactic (LAP), Group C; control group of 10 healthy individuals not known to have (RhD). Serum levels of (LAP), (IL6) and (CRP) were measured for the three groups. Results . Group A had significantly lower (IL6) levels than group B (25.22±33.50 vs. 126.1±33.76ng/ml, respectively, p&lt;0.0001). (IL6) levels were significantly lower in control subjects compared to patients in group B (3.600±2.319, 25.22±33.50 ng/ml respectively, p&lt;0.0001). However, IL6 levels in the control group were lower but non-significantly different compared to Group A . (CRP) level was lower in group A than group B (8419±4935 vs. 14400±3375mg/dl respectively, p=0.0002). (CRP) levels were significantly lower in control subjects compared to patients in group A and group B. (IL6) values were positively correlated with (CRP) values (r=0.6387, p&lt;0.0001). (CRP) level negatively correlated with Long acting penicillin level (r=−0.5277, p&lt;0.0001). (IL-6) level negatively correlated with (LAP) level (r=−0.4401, p&lt;0.0001). There was a highly significant difference between (LAP) level in compliant and non-compliant patients (1.045±1.270 vs. 0.0785±0.1057ng/ml, respectively, p value &lt;0.0001). There was also a highly significant difference between (CRP) level in compliant and non-compliant patients (7640±4558 vs. 13090±4717 mg/dl, respectively, p value 0.005).Moreover, there was a significant difference between (IL-6) levels in compliant and non-compliant patients (21.53±32.70 vs. 47.40±30.91 ng/ml, respectively, p value 0.03). Conclusion Serum (LAP) has a strong negative correlation with (IL-6) and (CRP) levels. Regular administration of (LAP) strongly ameliorates the inflammatory state seen in patients with (RhD).

Clinical characteristics of children with chronic rheumatic valvular heart disease in Cardiology Unit, Assiut University Children Hospital

Background: chronic rheumatic heart disease (RHD) is still common in developing countries and associated with major complications and high mortality. Aim: to describe clinical characteristics of children with chronic rheumatic valvular heart disease. Patients and Methods: the study included fifty patients with chronic rheumatic valvular heart disease attending Assiut University Children Hospital over six months. Full through history and clinical examinations were done to all cases. All cases have been subjected to chest X-ray, standard 12-lead ECG, and echocardiography. Results: female patients were slightly commoner than male patients. Mitral valve was the commonest valve affected followed by aortic valve. Regarding ECG, left atrial hypertrophy was the commonest finding and mitral regurge was the commonest valve lesion. While, left atrial hypertrophy was the commonest finding in chest X-ray. Respecting echocardiography, there was slightly increased in left ventricular end diastolic diameter and left atrium. Heart failure was the most common complication that occurs in RHD patients. Patients’ compliant with long acting penicillin (LAP) were more than non-compliant. Conclusion: echocardiography is the most important tool for evaluation of valvular heart disease. Left atrial hypertrophy is the commonest finding by ECG. There is increase in left ventricular end diastolic diameter and left atrium by echocardiography. Left atrial hypertrophy is the commonest finding in chest X-ray. Mitral valve is the commonest valve affected followed by aortic valve. Patients’ compliant with LAP are more than non-compliant patients. Recommendation: echocardiography must be used as a screening tool for early detection of subtle cases of RHD. Application of control programs with special emphasis on the regular use of secondary prophylaxis.

Clinical characteristics of children with chronic rheumatic valvular heart disease in Cardiology Unit, Assiut University Children Hospital

Background: chronic rheumatic heart disease (RHD) is still common in developing countries and associated with major complications and high mortality. Aim: to describe clinical characteristics of children with chronic rheumatic valvular heart disease. Patients and Methods: the study included fifty patients with chronic rheumatic valvular heart disease attending Assiut University Children Hospital over six months. Full through history and clinical examinations were done to all cases. All cases have been subjected to chest X-ray, standard 12-lead ECG, and echocardiography. Results: female patients were slightly commoner than male patients. Mitral valve was the commonest valve affected followed by aortic valve. Regarding ECG, left atrial hypertrophy was the commonest finding and mitral regurge was the commonest valve lesion. While, left atrial hypertrophy was the commonest finding in chest X-ray. Respecting echocardiography, there was slightly increased in left ventricular end diastolic diameter and left atrium. Heart failure was the most common complication that occurs in RHD patients. Patients’ compliant with long acting penicillin (LAP) were more than non-compliant. Conclusion: echocardiography is the most important tool for evaluation of valvular heart disease. Left atrial hypertrophy is the commonest finding by ECG. There is increase in left ventricular end diastolic diameter and left atrium by echocardiography. Left atrial hypertrophy is the commonest finding in chest X-ray. Mitral valve is the commonest valve affected followed by aortic valve. Patients’ compliant with LAP are more than non-compliant patients. Recommendation: echocardiography must be used as a screening tool for early detection of subtle cases of RHD. Application of control programs with special emphasis on the regular use of secondary prophylaxis.

Spectrum of cardiovascular diseases in six main referral hospitals of Ethiopia

BackgroundThe spectrum of cardiovascular diseases varies between and within countries, depending on the stage of epidemiological transition and risk factor profiles. Understanding this spectrum requires regional and national data for...

Throat culture positivity rate and antibiotic susceptibility pattern of beta-hemolytic streptococci in children on secondary prophylaxis for rheumatic heart disease.

BackgroundAmong children diagnosed to have chronic rheumatic valvular heart disease (RHD) in Ethiopia, many have been observed to develop recurrence of rheumatic fever (RF) despite secondary prophylaxis. This study determined the throat culture positivity rate and drug susceptibility pattern of beta hemolytic streptococci (BHS) isolated from children attending a specialized cardiac clinic in Ethiopia.MethodsThroat swabs were collected from 233 children receiving benzathine penicillin injection as secondary prophylaxis for RHD and cultured. The bacterial isolates were characterized using Matrix Assisted Laser Desorption/Ionization-Time of Flight (MALDI-TOF) mass spectrometry. Drug susceptibility was tested with the Kirby Bauer disc diffusion method. Anti-streptolysin O (ASO) titers were determined using ASO latex reagents.ResultsThe throat culture positivity rate for BHS was 24 % (56/233). Among the BHS bacterial strains isolated, four were characterized as S. pyogenes and another four as S. dysgalactiae subsp. equisimilis (Lancefield group A, C and G). All BHS were susceptible to penicillin except one isolate of S. agalactiae. Among 233 children enrolled, 46(19.7 %) showed increased ASO titer. Children who received antibiotic prophylaxis within 2-weeks of last injection had significantly lower BHS throat culture positivity rate than those injected every 4-weeks (p = 0.02). Children who missed at least one prophylaxis within the last 6 months had a higher BHS culture positivity rate than those who did not miss any (p = 0.0003).ConclusionsThe presence of groups A, C and G streptococci in the throat of children under secondary prophylaxis for RHD and increased ASO titer suggests failure of the regimen. This calls for further investigation into the causes of inadequate prophylaxis (including bioavailability of drugs used, optimal duration and patient compliance) and intervention.

Incidental histological diagnosis of acute rheumatic myocarditis: case report and review of the literature.

Rheumatic fever (RF) remains endemic in many countries and frequently causes heart failure due to severe chronic rheumatic valvular heart disease, which requires surgical treatment. Here, we report on a patient who underwent an elective surgical correction for mitral and aortic valvular heart disease and had a post-operative diagnosis of acute rheumatic carditis. The incidental finding of Aschoff bodies in myocardial biopsies is frequently reported in the nineteenth-century literature, with prevalences as high as 35%, but no clinical or prognostic data on the patients is included. The high frequency of this finding after cardiac surgery in classical reports suggests that these patients were not using secondary prophylaxis for RF. We discuss the clinical diagnosis of acute rheumatic myocarditis in asymptomatic patients and the laboratorial and imaging methods for the diagnosis of acute rheumatic carditis. We also discuss the prognostic implications of this finding and review the related literature.

Research Advances in Heart Failure

Without question, the past half century has witnessed spectacular advances in cardiovascular medicine and surgery. In the United States, a full two thirds of the 6-year prolongation of life that has occurred has been a direct consequence of these advances1 that did not spring forth simply from the heads of brilliant, insightful clinicians. Instead, most advances were based on preclinical research that were then translated into improvements in clinical care.2 For instance, the microbiologists who connected streptococcal infection to acute rheumatic fever and, subsequently, the discovery of penicillin by a microbiologist, an experimental pathologist, and a biochemist led to the virtual elimination of acute rheumatic fever, which in turn was responsible for the marked reduction of chronic rheumatic valvular heart disease in large portions of the world. Almost all residual cases of the latter can now be corrected by open heart surgery or catheter-based techniques, which were made possible by the efforts of bioengineers, pharmacologists, and physiologists collaborating with surgeons and cardiologists. The striking reduction in mortality of acute myocardial infarction that has occurred since 19603 would not have been possible had physicists not previously developed the cathode ray oscilloscope, which enabled the continuous monitoring of the ECG, and if engineers had not developed the capacitors that store the electric charge required for ventricular defibrillation. Without pharmacologists and cell biologists, statins, which are enormously useful in preventing the development and progression of atherosclerosis, would not have been developed. These are just a few examples of the seminal scientific efforts that have provided the underpinnings of modern cardiology. However, despite the spectacular advances of the past half century, cardiovascular disease is still the most common cause of death and disability in industrialized nations,4 and its prevalence is rising rapidly in developing nations. Almost one half of all …

Incidental in vivo detection of an epithelioid hemangioendothelioma of the mitral valve

Valvular epithelioid hemangioendotheliomas (EHE) are exceptional. To the authors' knowledge only four cases have been reported. Herein is described an EHE incidentally detected in the mitral valve of a 69-year-old woman with chronic rheumatic valvular heart disease. The 0.4 cm lesion was situated in the anterior leaflet and was discovered in the pathological study after mitral valve replacement. The patient was alive and well 6 months after operation. Review of the literature including the present report, revealed that the mean age was 60.2 years (range, 49-69 years). Symptomatic patients had clinical features of valvular disease or embolism. Each of the four cardiac valves can be affected. Mean tumor size was 2.4 cm (range, 0.4-8 cm). In 40% of cases the EHE was an incidental finding at autopsy or in a removed valve. In two cases the involved cusp was affected by chronic rheumatic disease. In conclusion, EHE is a rare lesion that can be an incidental finding and it should be considered in the differential diagnosis of valve tumors. Although EHE can present a histologically benign appearance, the correct pathological diagnosis is clinically important because the lesion can be potentially malignant. Regular follow up is suggested due to this potential.

Increased Plasma Nitrite Level in Cardiac Failure

Increased Plasma Nitrite Level in Cardiac Failure. Nitric oxide is implicated in the pathogenesis of cardiac failure. Plasma nitrite level (an end product of nitric oxide metabolism) is studied in 15 patients of chronic rheumatic valvular heart disease with myocardial contractile dysfunction and cardiac failure (Group I), 15 patients of chronic rheumatic valvular heart disease with similar valvular lesions, normal myocardial contractile function and without cardiac failure (Group II) and 15 healthy controls (Group III). Patients in Group I had higher nitrite level (242.2±31.7 nm) compared to Group II (142.6±24.4 nm) and Group III (102.7±15.9 nm). Among the patients with rheumatic heart disease, increasing nitrite level correlated significantly with worsening of contractile function [NitritevEnd systolic volume/Body surface area (Txy.z=0.23), NitritevEnd systolic dimension/Body surface area (Txy.z=0.32), Nitritevleft ventricular ejection fraction (Txy.z=−0.24), Nitritevtricuspid annular plane systolic excursion (Txy.z=−0.29)] and worsening New York Heart Association (NYHA) functional class (rs=0.5). We conclude that plasma nitrite, a stable end product of nitric oxide metabolism is increased in patients of rheumatic valvular heart disease with cardiac failure, suggesting increased nitric oxide production. Increased level of nitric oxide might be playing a significant role in myocardial contractile dysfunction and alteration of vascular response in cardiac failure.

HLA-DR typing and lymphocyte subset evaluation in rheumatic heart disease: A search for immune response factors

Several autoimmune diseases have been associated with increased frequencies of specific histocompatibility (HLA) antigens, particularly for the D (DR) locus, that may be linked to immune response genes. Rheumatic valvular heart disease (RHD) has been postulated to have autoimmune features, but HLA associations have not been established. We, therefore, performed HLA-DR typing in 33 consecutive patients with RHD and in 82 normal blood bank control subjects. We also evaluated the frequencies of lymphocyte subsets by means of monoclonal antibodies and immunofluorescence flow cytometry and made functional correlations for the natural killer cell (NKC) in patient subsets. The DR patterns in RHD were heterogeneous. However, significant differences were noted for DR4 and DR6. DR4 was present in 52% (17 of 33) of RHD patients vs 32% (26 of 82) of control subjects ( p < 0.05). DR6 was present in 6% (2 of 33) of patients vs 26% (21 of 82) of control subjects ( p < 0.02). The associated relative odds of DR4 was 2.3 and the etiologic fraction was 0.30. The relative odds of DR6 was 0.19 and the preventive fraction was 0.21. A distinct clinical profile was not associated with DR4 positivity or DR6 negativity. The frequency of lymphocyte subsets was not significantly changed except for OKT8. Median NKC numbers tended to be higher in RHD patients than in control subjects ( p < 0.05). In contrast, NKC functional activity tended to be lower in RHD; median lymphocyte to target cell (K562 line) ratio resulting in 50% killing ( L T 50 ) was 20.5 in RHD patients vs 11.5 in control subjects ( p = 0.05). In conclusion, these findings suggest that chronic RHD is not distinguishable by a consistent HLA-DR or abnormal lymphocyte subset profile; however, immune factors, either DR or lymphocyte subtype associated, may play a role in some cases of RHD and bear further investigation.

CHRONIC RHEUMATIC VALVULAR HEART DISEASE

The incidence of chronic rheumatic valvular heart disease in Iceland was investigated via autopsies performed from November 1965 through December 1974. During this period, approximately 12.400 Icelanders died at the age of 16 years and older and 28.8 per cent of these are included in the study. At autopsy, males were found to outnumber females by 2:1. Rheumatic valvular heart disease was found in 38 subjects, i.e. in 1.08 per cent of the cases, the sex distribution being 0.67 per cent males and 1.83 per cent females. As regards the hearts with chronically deformed valves, the deformity was of rheumatic origin only in 20 per cent of the cases; the majority, or 69 per cent, presented calcified aortic stenosis. Hospital records applying to most of the subjects were available and according to these, only 18 per cent disclosed a history of rheumatic fever. The diagnosis of rheumatic valvular disease was first established at autopsy in 71 per cent of the cases. An evaluation of the functional derangements of the diseased valves was not attempted, but there is reason to believe that many of the lesions were too mild to provoke significant symptoms and signs. Previous doubts about the existence of rheumatic heart disease in Iceland have been settled in this study.

RHEUMATIC NEPHROSCLEROSIS WITH SPECIAL REFERENCE TO RHEUMATIC ENDARTERITIS.

Three instances of rheumatic nephrosclerosis are described in patients with chronic rheumatic valvular heart disease. The underlying mechanism of this renal lesion consists of an obliterating rheumatic endarteritis, involving mainly medium-sized and small arteries of the renal cortex. The arterioles take relatively little part in these changes. The widespread occlusive vascular disease gives rise to innumerable microscopic infarctions, resulting in a coarsely granular external surface of the kidneys. A similar granular appearance of cerebral convolutions may or may not occur in these cases, depending on whether the small meningeal and cortical vessels of the brain are extensively involved.