Rheumatic Heart Disease Mortality Research Articles

Rheumatic heart disease mortality in Indigenous and non-Indigenous Australians between 2013 and 2017

ObjectivesTo generate contemporary age-specific mortality rates for Indigenous and non-Indigenous Australians aged <65 years who died from rheumatic heart disease (RHD) between 2013 and 2017, and to ascertain the underlying...

Age period cohort analysis of rheumatic heart disease in high-income countries.

Rheumatic heart disease is considered well-controlled in high-income countries; however, its actual trends in mortality remain unclarified. We analyzed trends in mortality from rheumatic heart disease in association with age, period, and birth cohort. We analyzed the WHO mortality database to determine trends in mortality from rheumatic heart disease in the UK, Germany, France, Italy, Japan, Australia, USA, and Canada from 2000 to 2020. We used age-cohort-period modeling to estimate cohort and period effects. Net drift (overall annual percentage change), local drift (annual percentage change in each age group) and heterogeneity were calculated. In the most recent year, crude mortality rates and age-standardized mortality rates ranged from 1.10 in the USA to 6.17 in Germany, and 0.32 (95% CI 0.31-0.34) in Japan and 1.70 (95% CI 1.65-1.75) in Germany, respectively. During the observation period, while Germany had a constant trend in overall annual percentage change, all the other countries had significant decreasing trends (p < 0.0001, respectively). Annual percent change was not homogeneous across each group in all 8 countries (pheterogeneity < 0.0001), with 2 peaks in the younger and older age categories. In Germany, Italy, Australia, and Canada, we found increasing mortality rates among older patients. Improving period and cohort risks for rheumatic heart disease mortality were generally observed, excluding Germany where the period effect was worsening and the cohort effect was constant. Mortality trends from rheumatic heart disease were decreasing in the study high-income countries except for Germany where higher mortality and two peaks in annual percentage change in younger and older age groups warrant further investigation.

Analysis of Rheumatic Heart Disease Mortality in the Chinese Population: A JoinPoint and Age-Period-Cohort Study.

(1) Background: We aimed to analyze rheumatic heart disease (RHD) mortality trends in China’s urban and rural areas and to determine the roles of age, period, and cohort effects. (2) Methods: Based on mortality data extracted from the China Health Statistics Yearbook, we calculated the crude mortality rate of RHD. Age–adjusted rates were computed by the direct method using the 2020 census as the standard population. The annual percentage change (APC) and average annual percentage change (AAPC) were determined by the JoinPoint regression model. The age–period–cohort model was used to estimate the effects of age, period, and cohort. (3) Results: From 2006 to 2020, the general trend in RHD standardized mortality declined. The RHD mortality rate was higher in rural than in urban areas and among females than males. The elderly (over 60 years old) were at high risk for RHD deaths in China. The age effect increased with age, and the cohort effect showed a declining trend as chronology grew, but the period effect was not significant. (4) Conclusions: China has achieved great success in RHD, but RHD mortality may increase with age. Compared with the period effect, age and cohort effects dominated the risk of RHD deaths.

Changes in the pattern of valvular heart disease following the epidemiological transition in Brazil from 1990 to 2019: data from the Global Burden of Disease 2019 study

Abstract Introduction Valvular heart disease is one of the leading causes of cardiovascular death in Brazil, with a great contribution of Rheumatic Heart Disease (RHD), the most socially driven etiology. However, as socioeconomic conditions improved, an increasing contribution of non-rheumatic valvular heart disease (NRVD) is being observed. Objectives We aimed to evaluate the changes in trends of prevalence, mortality and burden of RHD and non-rheumatic valvular heart disease in Brazil from 1990 to 2019, according to the Global Burden of Disease (GBD) 2019 study estimates. Methods We used available vital registration data, epidemiological survey data, and hospital claims data to estimate the cause-specific mortality rate, prevalence, and burden of RHD and NRVD using the GBD modelling framework. Burden estimates in Brazil were estimated for each sex, 5-year age group, federal unit, and year from 1990 to 2019. We also explored the correlation of disease burden and the sociodemographic index (SDI). Results From 1990 to 2019, age-standardized prevalence of RHD increased slightly (2.1% (95%UI 0.2–4.0)) in Brazil, from 899.6 (95%UI 699.8–1119.1) to 918.5 (95%UI 716–1142.5) per 100,000, remaining higher in women in the whole period. In contrast, age-standardized prevalence of NRVD had a marked 54.3% increase from 25.3 (95% UI 22.4–27.8) per 100,000 in 1990 to 39 (95% UI 33.9–44.6) per 100,000 in 2019. The percent change was considerably higher for men compared to women (105.9% vs. 20.9%). For mortality, age-standardized rates attributable to RHD significantly decreased 59.4%, from 2.8 (95%UI 2.7–3.0) to 1.2 (95%UI 1.1–1.2) per 100,000, whereas NRVD had a less pronounced 16.2% decrease in the period. However, crude NRVD mortality increased (51.9% (95%UI 39.8–62.7)), with a considerable contribution of older ages, noticeably over 70 years (17.2% (95%UI 5.4–27.4)), specifically driven by calcific aortic valve disease mortality, with a marked 17% (95%UI 2.0–38.5) increase in the elderly. RHD dropped from 12th to 10th in the mortality ranking, while aortic and mitral degenerative diseases rose in the period (Figure 1). There was a significant negative correlation between the percent change in age-standardized RHD mortality rates and SDI in 1990 (r=−0.41, p=0.03) and in 2019 (r=−0.44, p=0.02), and an opposite trend for NRVD, with positive correlations in 1990 (r=−0.55, p=0.003), and 2019 (r=−0.58, p=0.001), suggesting that SDI was a major driver for the observed trends. Conclusion Mortality and disease burden attributable to RHD decreased significantly in Brazil over the past decades, still with a stable prevalence trend. This contrasts with increasing prevalence and crude mortality estimates for NRVD, especially in older ages, and driven by degenerative conditions. Changes in mortality rates strongly correlated with SDI, depicting the effects of socioeconomic markers of the pattern of valve disease in Brazil. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study used data from the Institute of Health Metrics and Evaluation, funded by the Bill &amp; Melinda Gates Foundation. This work was supported by the Brazilian Ministry of Health through resource transfer from the National Health Fund. Figure 1. Ranking of mortality rates.

Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000-2018.

We describe trends in acute rheumatic fever (ARF), rheumatic heart disease (RHD), and RHD deaths among population groups in New Zealand. We analyzed initial primary ARF and RHD hospitalizations during 2000-2018 and RHD mortality rates during 2000-2016. We found elevated rates of initial ARF hospitalizations for persons of Māori (adjusted rate ratio [aRR] 11.8, 95% CI 10.0-14.0) and Pacific Islander (aRR 23.6, 95% CI 19.9-27.9) ethnicity compared with persons of European/other ethnicity. We also noted higher rates of initial RHD hospitalization for Māori (aRR 3.2, 95% CI 2.9-3.5) and Pacific Islander (aRR 4.6, 95% CI 4.2-5.1) groups and RHD deaths among these groups (Māori aRR 12.3, 95% CI 10.3-14.6, and Pacific Islanders aRR 11.2, 95% CI 9.1-13.8). Rates also were higher in socioeconomically disadvantaged neighborhoods. To curb high rates of ARF and RHD, New Zealand must address increasing social and ethnic inequalities.

Abstract 14693: Rheumatic Heart Disease and Deprivation in the United States: A Retrospective Review

Introduction: Rheumatic heart disease (RHD) tracks with other cardiovascular health inequities in the US; however, RHD mortality captures a fraction of those affected and lags behind diagnosis by decades. There is little contemporary data on children living with acute rheumatic fever (ARF) and RHD within the US. This study describes recent pediatric ARF/RHD in the US and examines the association with community deprivation. Methods: Sixty US institutions were invited to participate in a 10-year review (2008-2018). Geocoding was used to determine a census tract-based socioeconomic deprivation index (DI) ranging from 0-1 (1 being most deprived). Independent sample t-test was used to compare DI means. Odds ratios (OR) with 95% confidence intervals were obtained from multivariable logistic regression. The DI was scaled to provide ORs for a one standard deviation increase. Results: Data for 947 cases from 22 institutions showed median age at diagnosis of 9 years, with half identifying as male (51%) and non-white (52%), and three-quarters (74%) identifying as non-Hispanic. Most identified English as their primary language, had health insurance, and were first diagnosed in the US (84%, 89%, and 82%, respectively). Of the 157 (17%) with travel exposure, Pacific Islands (38%) and Africa (21%) were most commonly identified. Nearly three-quarters (73%) were diagnosed with ARF and most (98%) had an echocardiogram at diagnosis. While 96% of patients were prescribed secondary prophylaxis, only half (58%) were prescribed intramuscular Benzathine penicillin (BPG), the gold standard. The mean DI was 0.39±0.15. Higher deprivation was associated with RHD as opposed to ARF at diagnosis (DI 0.42 vs. 0.38, p&lt;0.001). Additionally, higher deprivation was associated with increased risk of severe RHD (OR 1.34; 95% CI 1.11-1.62) and increased use of BPG vs enteral penicillin for secondary prevention (OR 0.67; 95% CI 0.56-0.8). Conclusions: Recent pediatric cases of ARF and RHD in the US are endemic, rather than from foreign exposure and children who live in more deprived communities are at risk for more severe disease. Additional research is needed into why intramuscular penicillin, which has superior efficacy compared to oral penicillin, is prescribed in only half of cases.

Rheumatic heart disease burden, trends, and inequalities in the Americas, 1990–2017: a population-based study

The World Health Assembly 2018 approved a resolution on rheumatic heart disease to strengthen programmes in countries where this condition remains a substantial public health problem. We aimed to describe the regional burden, trends, and inequalities of rheumatic heart disease in the Americas. In this secondary analysis of the Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2017, we extracted data for deaths, prevalence of cases, disability-adjusted life-years (DALYs), years lived with disability, and years of life lost (YLL) as measures of rheumatic heart disease burden using the GBD Results Tool. We analysed 1990-2017 trends in rheumatic heart disease mortality and prevalence, quantified cross-country inequalities in rheumatic heart disease mortality, and classified countries according to rheumatic heart disease mortality in 2017 and 1990-2017. GBD 2017 estimated that 3 604 800 cases of rheumatic heart disease occurred overall in the Americas in 2017, with 22 437 deaths. We showed that in 2017 rheumatic heart disease mortality in the Americas was 51% (95% UI 44-59) lower (1·8 deaths per 100 000 population [95% uncertainty interval 1·7-1·9] vs 3·7 deaths per 100 000 population [3·4-3·9]) and prevalence was 30% (29-33) lower (346·4 cases per 100 000 [334·1-359·2] vs 500·6 cases per 100 000 [482·9-519·7]) than the corresponding global estimates. DALYs were half of those globally (55·7 per 100 000 [49·8-63·5] vs 118·7 per 100 000 [108·5 to 130·7]), with a 70% contribution from YLL (39·1 out of 55·7 per 100 000). A significant reduction in rheumatic heart disease mortality occurred, from a regional average of 88·4 YLL per 100 000 (95% uncertainty interval 88·2-88·6) in 1990 to 38·2 (38·1-38·4) in 2017, and a significant reduction in income-related inequality, from an excess of 191·7 YLL per 100 000 (68·6-314·8) between the poorest and richest countries in 1990 to 66·8 YLL per 100 000 (6·4-127·2) in 2017. Of the 37 countries studied, eight (22%) had both the highest level of premature rheumatic heart disease mortality in 2017 and the smallest reduction in this mortality between 1990 and 2017. The Americas have greatly reduced premature mortality due to rheumatic heart disease since 1990. These health gains were paired with a substantial reduction in the magnitude of income-related inequalities across countries, which is consistent with overall socioeconomic and health improvements observed in the Region. Countries with less favourable rheumatic heart disease situations should be targeted for strengthening of their national programmes. None.

Rheumatic Fever: A Disease without Color.

BackgroundBrazil has approximately 30.000 cases of Acute Rheumatic Fever (ARF) annually. A third of cardiovascular surgeries performed in the country are due to the sequelae of rheumatic heart disease (RHD), which is an important public health problem.Objectivesto analyze the historical series of mortality rates and disease costs, projecting future trends to offer new data that may justify the need to implement a public health program for RF.Methods we performed a cross-sectional study with a time series analysis based on data from the Hospital Information System of Brazil from 1998 to 2016. Simple linear regression models and Holt’s Exponential Smoothing Method were used to model the behavior of the series and to do forecasts. The results of the tests with a value of p < 0.05 were considered statistically significant.Resultseach year, the number of deaths due to RHD increased by an average of 16.94 units and the mortality rate from ARF increased by 215%. There was a 264% increase in hospitalization expenses for RHD and RHD mortality rates increased 42.5% (p-value < 0.05). The estimated mortality rates for ARF and RHD were, respectively, 2.68 and 8.53 for 2019. The estimated cost for RHD in 2019 was US$ 26.715.897,70.Conclusionsaccording to the Brazilian reality, the 1-year RHD expenses would be sufficient for secondary prophylaxis (considering a Benzatin Penicillin G dose every 3 weeks) in 22.574 people for 10 years. This study corroborates the need for public health policies aimed at RHD.

Rheumatic Heart Disease-Attributable Mortality at Ages 5-69 Years in Fiji: A Five-Year, National, Population-Based Record-Linkage Cohort Study.

BackgroundRheumatic heart disease (RHD) is considered a major public health problem in developing countries, although scarce data are available to substantiate this. Here we quantify mortality from RHD in Fiji during 2008–2012 in people aged 5–69 years.Methods and FindingsUsing 1,773,999 records derived from multiple sources of routine clinical and administrative data, we used probabilistic record-linkage to define a cohort of 2,619 persons diagnosed with RHD, observed for all-cause mortality over 11,538 person-years. Using relative survival methods, we estimated there were 378 RHD-attributable deaths, almost half of which occurred before age 40 years. Using census data as the denominator, we calculated there were 9.9 deaths (95% CI 9.8–10.0) and 331 years of life-lost (YLL, 95% CI 330.4–331.5) due to RHD per 100,000 person-years, standardised to the portion of the WHO World Standard Population aged 0–69 years. Valuing life using Fiji’s per-capita gross domestic product, we estimated these deaths cost United States Dollar $6,077,431 annually. Compared to vital registration data for 2011–2012, we calculated there were 1.6-times more RHD-attributable deaths than the number reported, and found our estimate of RHD mortality exceeded all but the five leading reported causes of premature death, based on collapsed underlying cause-of-death diagnoses.ConclusionsRheumatic heart disease is a leading cause of premature death as well as an important economic burden in this setting. Age-standardised death rates are more than twice those reported in current global estimates. Linkage of routine data provides an efficient tool to better define the epidemiology of neglected diseases.

Disparity in Mortality From Rheumatic Heart Disease in Indigenous Australians.

BackgroundRecent estimates of the global burden of rheumatic heart disease (RHD) have highlighted the paucity of reliable RHD mortality data from populations most affected by RHD.Methods and ResultsWe investigated RHD mortality rates and trends for Indigenous and non-Indigenous Australians in the Northern Territory (NT) for the period 1977–2005 and seminationally (NT plus 4 other states, covering 89% of Indigenous Australians) from 1997 to 2005 using vital statistics data. All analysis was undertaken by Indigenous status, sex, and age at death. In the NT, 90% of all deaths from RHD were among Indigenous persons; however, the Indigenous population makes up only 30.4% of the NT population. The death rate ratio (Indigenous compared with non-Indigenous) was 54.80 in the NT and 12.74 in the other 4 states (estimated at the median age of 50 years). Non-Indigenous death rates were low for all age groups except ≥65 years, indicating RHD deaths in the elderly non-Indigenous population. Death rates decreased at a more rapid rate for non-Indigenous than Indigenous persons in the NT between 1997 and 2005. Indigenous persons in other parts of Australia showed lower death rates than their NT counterparts, but the death rates for Indigenous persons in all states were still much higher than rates for non-Indigenous Australians.ConclusionsIndigenous Australians are much more likely to die from RHD than other Australians. Among the Indigenous population, RHD mortality is much higher in the NT than elsewhere in Australia, exceeding levels reported in many industrialized countries more than a century ago. With the paucity of data from high-prevalence areas, these data contribute substantially to understanding the global burden of RHD mortality.

The economic impact of rheumatic heart disease in developing countries

Abstract Background Rheumatic heart disease (RHD) is a neglected disease of poverty that is the most common paediatric cardiovascular condition in developing countries. Most RHD deaths occur in children and working-age adults, in whom the economic impact of premature death is high. Despite RHD being a preventable disease, global research and development funding for RHD was recently estimated at US$1·7 million, or about 0·1% of all global health funding. Decisions to scale up costly medical and surgical interventions for RHD are hindered, in part, by lack of evidence for the so-called return on investment that could be achieved through prevention of RHD-related mortality. We conducted a modelling study using data from 107 countries to estimate the economic impact of excess mortality from RHD. Methods We used the full income approach to quantify the economic losses from RHD in 107 countries where the disease is endemic during 2010. Our analysis synthesised data from the Global Burden of Disease 2010 study, WHO life tables, UN population estimates, and World Bank macroeconomic indicators such as gross domestic product (GDP) per capita that are used in full-income calculations. We used the RHD mortality pattern in Costa Rica in 2010 as a baseline from which to define excess mortality. Data from this country were used because of Costa Rica's demonstrated success in controlling RHD in previous decades as well as its health system's resilience under political and economic constraints. We reported costs discounted at 3% yearly as well as undiscounted. Findings We noted that the cost of the approximately 222 000 excess deaths from RHD in 2010 was around US$ (2014) 2·2 trillion (discounted) or US$5·4 trillion (undiscounted). Most of the economic burden of RHD was in countries with large populations in south Asia and east Asia. Our estimates were roughly proportional to those reported in a full-income study of HIV/AIDS mortality in sub-Saharan Africa, although our estimates were 10–100 times higher than those obtained using other economic methods, such as multiples of GDP per capita per disability-adjusted life-year. Interpretation RHD continues to exert massive economic effects globally, mainly because of premature death in children and working-age adults. The economic cost of RHD in developing countries is over a million times higher than current donor funding levels. Our estimates suggest that careful increases in public-sector and private-sector spending on effective RHD prevention and control measures could provide impressive returns on investment. Future work will compare the full-income results to other economic evaluation methods such as those recommended by the Commission on Macroeconomics and Health. Our results could be the basis for benefit-cost analyses of medical and surgical interventions in resource-limited countries. Funding None.

PT443 Burden of Rheumatic Heart Disease in the Solomon Islands

O ST E R A B ST R A C T S improvements are yet to be seen in many developing countries and in Indigenous populations defined by ethnicity or geographical location. Recent estimates of the global burden of RHD have highlighted the paucity of reliable data documenting mortality from RHD from places where RHD prevalence is high. Objectives: To investigate rheumatic heart disease (RHD) mortality rates and trends for Indigenous compared with non-Indigenous Australians in the Northern Territory (NT) for the period 1977-2005 and semi-nationally from 1997-2005. Methods: Indigenous identification in death registrations has been of high quality in the NT since 1977 and in four other states since 1997. Using national cause of death and population data, we investigated RHD mortality for the NT for 19772005 and five jurisdictions combined, for 1997-2005 examining RHD as the underlying cause of death. These jurisdictions include 84% of Indigenous Australians. We examined the number of deaths, age-specific and age-adjusted death rates; and for theNT only, regression analysis of time trends over a 29year period. All analysis was by undertaken by Indigenous status, gender, age at death. Results: In the NT for the period 1977-2005 there were 280 deaths from RHD; 90% were in Indigenous people and 59% in females. For non-Indigenous people death rates were low for all age-groups except 65+ age-group. Indigenous death rates increased with age and were higher for females than males in all age-groups. Death rates decreased between 1997 and 2005 for both Indigenous and non-Indigenous people in the NT, but the decrease was greater for non-Indigenous people. RHD death rates were lower for Indigenous people in other parts of Australia than in the NT, but were still much higher than non-Indigenous rates. Conclusion: Indigenous people are much more likely to die from RHD than other Australians. Rates of death from RHD among Indigenous people in the NT exceed other states in Australia and those reported in many industrialised countries over a century ago. The majority of deaths among non-Indigenous Australians occur in people aged over 65 years and reflect a time in the mid-last century when rheumatic fever and RHD were more common in the overall Australian population. Disclosure of Interest: None Declared

Mortality and hospitalisation costs of rheumatic fever and rheumatic heart disease in New Zealand

To estimate the annual mortality and the cost of hospital admissions for acute rheumatic fever (ARF) and rheumatic heart disease (RHD) for New Zealand residents. Hospital admissions in 2000-2009 with a principal diagnosis of ARF or RHD (ICD9_AM 390-398; ICD10-AM I00-I099) and deaths in 2000-2007 with RHD as the underlying cause were obtained from routine statistics. The cost of each admission was estimated by multiplying its diagnosis-related group (DRG) cost weight by the national price for financial year 2009/2010. There were on average 159 RHD deaths each year with a mean annual mortality rate of 4.4 per 100, 000 (95% confidence limit 4.2, 4.7). Age-adjusted mortality was five- to 10-fold higher for Māori and Pacific peoples than for non-Māori/Pacific. The mean age at RHD death (male/female) was 56.4/58.4 for Māori, 50.9/59.8 for Pacific and 78.2/80.6 for non-Māori, non-Pacific men and women. The average annual DRG-based cost of hospital admissions in 2000-2009 for ARF and RHD across all age groups was $12.0 million (95% confidence limit $11.1 million, $12.8 million). Heart valve surgery accounted for 28% of admissions and 71% of the cost. For children 5-14 years of age, valve surgery accounted for 7% of admissions and 27% of the cost. Two-thirds of the cost occurs after the age of 30. ARF and RHD comprise a burden of mortality and hospital cost concentrated largely in middle age. Māori and Pacific RHD mortality rates are substantially higher than those of non-Māori/Pacific.

Cardiovascular Disease and Oral Contraceptives: A Reappraisal of Vital Statistics Data

In contrast to an earlier British study of 21 countries using data from the same source a reexamination of vital statistics from these countries found no consistent pattern in the change in total cardiovascular diseases (CVD) mortality in association with the level of oral contraceptive use. Reanalysis of the data was intended to correct for shortcomings seen in the original data analysis. CVD rates were obtained for the years 1955-1976 for the same 21 countries. As a measure of the change in mortality rate the linear regression of the mortality rate by year was calculated for each 10-year age-group in the prepill and postpill period. When chronic rheumatic heart disease mortality was not included in the total CVD mortality rates significant changes in mortality trends occurred in 6 to 9 countries. In all countries with low oral contraceptive use in which a significant difference in pre- and postpill mortality trend was found the pattern was that of a slowing down in the trend of declining mortality. When chronic rheumatic heart diease was included in the total mortality rates significant changes in mortality rates were found in only 4 countries for both the 15-24 and 25-34 age groups.. No significant correlation was found between the change in mortality trend and the level of oral contraceptive use in those countries in which significant changes in prepill and postpill mortality rates were found. For the age-groups 15-24 and 25-34 there was no significant correlation between oral contraceptive use and changes in the prepill and postpill CVD mortality trends. Although the present results are not consistent with those of the earlier report the analysis should not be interpreted as proving either the absence of an association of CVD mortality and oral contraceptive use or a protective effect of pill use. Neither study contributes any information that contradicts what the present study makes clear is the hazard in using vital statistics data to estimate an association between oral contraceptive use and CVD. Prospective studies or well-designed well-controlled retrospective case-studies are the best means now available for estimating associations between hormonal contraception and diease.

Heart disease prevalence in school children in two Colorado communities.

THE FREQUENCIES of heart disease in children of school age are obtained by delineation of a school population at risk of disease. Examinations are performed upon either the whole population or a sample selected from it. Earlier surveys concentrated upon the entity, rheumatic heart disease, a sequela of acute rheumatic fever. This chronic, progressive, life-shortening condition was apparently more common and more severe in western Europe and North America during the early part of this century and the two previous centuries than it is today. Acute rheumatic fever seems to be declining noticeably in severity.70 Rheumatic heart disease mortality rates also seem to have fallen over this same period of time.65 It would be interesting to know whether rheumatic heart disease prevalence rates are lower, too. Unfortunately, direct numerical comparisons cannot be made freely because auscultatory diagnostic criteria have been significantly refined, especially during recent years.72 Improved diagnosis was probably largely due to increasingly successful cardiac surgery, which demanded accurate preoperative diagnosis. As rheumatic fever is becoming less severe, typical cases are fewer. and the diagnosis is probably more difficult in a larger proportion of cases now than in years past. All are familiar with the one-third to one-half of cases of chronic rheumatic heart disease (RHD) which have never experienced an attack of acute rheumatic fever. One may legitimately wonder whether such cases are actually caused by rheumatic fever (undiagnosed or subclinical) or whether a whole spectrum of inflammatory agents can cause endocarditis with valvular deformities. Silber has reported cases of acute and chronic myocarditis with heart murmurs simulating those of RHD, and it is his belief that the label of RHD is too loosely applied in the absence of a positive history of rheumatic stigmata.73 Saphir reports the same phenomena.75 Endocardial elastomyofibrosis occurs predominantly in young adults but has been reported in adolescents and could easily be misdiagnosed as RHD.74 Brucellosis can cause chronic progressive aortic valvular stenosis, although this infection is thought to be rare in children.69 Studies with experimental animals suggest that

Incidence of heart disease among Colorado school children; a state-wide study.

Most physicians and epidemiologists agree that rheumatic heart disease is not distributed uniformly throughout the United States. Thoroughly reliable data on this problem may not become available until the development of some specific diagnostic test that would permit detection of mild or subclinical cases. In the meantime efforts have been made to estimate the distribution of this disease by ( a ) the use of rheumatic heart disease mortality statistics 1 and ( b ) conclusions drawn from morbidity studies in certain segments of the population, such as school children 2 or military personnel. 3 Attempts to check the findings of one method by those of the other, for any given locality, have not been reported, but on one point there seems to be general agreement between the results of the various mortality studies and morbidity reports for this disease, namely, that the Rocky Mountain states have an undue amount of rheumatic fever. The