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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 45-49

Prevalence, profile, and pattern of congenital heart disease in Central India: A prospective, observational study


Department of Paediatrics, Government Medical College, Nagpur, Maharashtra, India

Date of Web Publication7-May-2018

Correspondence Address:
Dr. Rajkumar Motiram Meshram
Department of Paediatrics, Government Medical College, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njc.njc_22_17

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  Abstract 


Objective: The objective of this study was to assess the prevalence and pattern of congenital heart disease (CHD) using echocardiography.
Materials and Methods: Patients of 0–12-year-old attending outpatient and inpatient of pediatric department clinically diagnosed with heart disease were further evaluated with chest radiography, twelve-lead electrocardiograms, and the confirmation of the diagnosis was done using two-dimensional echocardiography.
Results: Among a total of 42,423 patients availing outpatient and inpatient facilities at the pediatric department of a tertiary referral center, 655 were clinically suspected as having heart disease among which 430 patients were identified as CHD, giving a prevalence of 10.13/1000 live births. About 56.28% patients were below 1 year and male:female ratio was 1.3:1. Consanguinity was observed in 42.09% and most of them were of third degree. Breathlessness was the most common symptom and tachycardia was the most common sign. About 66.74% of patients were diagnosed with acyanotic and 33.26% with cyanotic type. The most common CHD was ventricular septal defect (VSD) (30.01%) followed by atrial septal defect (20.70%), tetralogy of fallot (TOF) (16.05%), and patent ductus arteriosus (10.23%). The most common cyanotic CHD was TOF followed by transposition of great vessels, total anomalous pulmonary venous connection, and single ventricle. Case fatality rate was 19.23% and most of the deaths in neonatal age group due to complex CHD, refractory congestive cardiac failure, sepsis, and pneumonia.
Conclusion: The prevalence of CHD in this study was 10.13/1000 live births. VSD and TOF were the most common acyanotic and cyanotic CHD, respectively. Case fatality rate was 19.23% and most of the deaths occurred in neonatal age.

Keywords: Central India, congenital heart disease, echocardiography, pattern, prevalence


How to cite this article:
Meshram RM, Gajimwar VS. Prevalence, profile, and pattern of congenital heart disease in Central India: A prospective, observational study. Nig J Cardiol 2018;15:45-9

How to cite this URL:
Meshram RM, Gajimwar VS. Prevalence, profile, and pattern of congenital heart disease in Central India: A prospective, observational study. Nig J Cardiol [serial online] 2018 [cited 2019 May 19];15:45-9. Available from: http://www.nigjcardiol.org/text.asp?2018/15/1/45/231967




  Introduction Top


Congenital heart disease (CHD) is defined as a gross structural abnormality of the heart or intrathoracic great vessels that causes significant functional impairment.[1] Twenty-eight percentage of all major congenital anomalies consist of heart defects and along with neural tube defects they account for two-thirds of all congenital malformations.[2] The estimated birth prevalence of CHD is 8/1000 live births with a significant geographical difference.[3] A recent systemic review reported the highest prevalence (9.3/1000 live births) in Asia due to high birth rate and consanguineous marriages and the lowest prevalence in Africa (8.2/1000 live births).[4] In India, over 180,000 children are born with CHD every year with state-wise variation and contribute to 10% of the present infant mortality.[5] Nearly one-third of the CHD are critical requiring intervention in the 1st year of life.[6]

Most of the CHD are thought to be multifactorial and result from a combination of genetic and environmental insult. According to recent update report of the American Heart Association, atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of fallot (TOF), patent ductus arteriosus (PDA), pulmonary stenosis, aortic stenosis, coarctation of aorta, and atrioventricular septal defect accounts for 85% of all CHDs.[7]

In the recent years, advances in the cardiovascular diagnostics and therapeutics have increased the survival of infants and have facilitated diagnosis of the even asymptomatic lesions of CHD; hence more patients with CHD reach adulthood, requiring special follow-up care for such population. However, this privilege of early diagnosis and timely intervention is restricted to the children of developed countries. Unfortunately, the majority of children of developing countries with CHD are deprived of necessary care hence leading to high morbidity and mortality. Early detection of CHD is of paramount importance to improve the quality of life and to reduce morbidity and mortality of children. There is a paucity of data of prevalence and pattern of CHD in Central India. Hence, this prospective study was conducted to know the prevalence and pattern of CHD using echocardiography.


  Materials and Methods Top


This prospective, observational study was carried out at one of the largest tertiary care and referral hospital that provide care for the underprivileged, socioeconomically deprived population of Central India. The study was conducted from January 2016 to December 2016. The cases included those attending the outpatient or inpatient of pediatric department of age 0–12 years suspected of having CHD after approval from the Institutional Ethics Committee and written valid consent from parents or legal guardian/caretaker. Only patients with first-time diagnosis were included, and those presenting on follow-up visit were excluded from the study. Neonates <2 weeks of the age with a diagnosis of PDA were also excluded from the study. A detailed history and clinical examination were carried out and CHD was suspected in the presence of a cardiac murmur, presence of cyanosis, feeding difficulties, squatting position, digital clubbing, differential cyanosis, failure to thrive, and features of congestive cardiac failure.[1] We classified our patients according to the Modified Kuppuswamy's Socioeconomic Scale into lower, middle, and upper socioeconomic class.[8] Nutritional status was assessed by the Indian Academy of Pediatrics Classification.[9] Patients with a clinical diagnosis of heart disease were further evaluated with chest radiography, twelve-lead electrocardiograms, and the confirmation of the diagnosis was done using echocardiography.

A 12-lead ECG was performed on a commercially available Schiller Cardiovit AT-101 twelve-lead machine. The ECG was evaluated by two independent observers who were unaware of the clinical condition of the patients. Echocardiographic evaluation was done on a Standard Philips IE33 2D ECHO ultrasound imaging system using 50 Hz transducer for mono and two-dimension imaging. All echocardiography examinations were performed by the two cardiologists who were not aware of the clinical condition of patients. The technique involved performing transthoracic echocardiography and Doppler and color flow imaging in various views. All patients were followed up 3–6 months after discharge, in the outpatient department or earlier as per the clinical condition.

Statistical analysis

Data were managed and entered in MS Excel sheet. Data regarding the numerical variables were summarized through average, median, and deviation pattern. Categorical data were summarized and presented in the form of frequency. The value of P < 0.05 was considered statistically significant.


  Results Top


A total of 42,423 patients (Outpatients 35,932 and 6491 Inpatients) were examined during the study. Outpatients who required admission were included among inpatients only. Out of that, 655 (445 outpatients and 210 inpatients) were clinically suspected of having CHD and were referred for echocardiographic examination. Among them 430 (outpatient 300 and inpatient 130) were identified with CHD. About 56.28% of patients were below 1 year. CHD was more common in male (56.98%) giving rise to a male:female ratio was 1.3:1. Consanguinity was observed in 42.09%, among them 72.93% comprised third degree. About 60.93% of patients were from urban areas and middle and lower class [Table 1].
Table 1: Demographic profile of patients (n=430)

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Among the clinical presentation, breathlessness was the most common symptom in 377 (87.67%) followed by fever in 305 (70.93%), failure to thrive in 209 (48.60%), features of congestive cardiac failure in 205 (47.67%) while cyanosis occurred in 172 (40.00%), and cyanotic spell in 98 (22.79%) patients. Tachycardia was the most common sign noted in 382 (88.84%) followed by tachypnea 361 (83.95%) while facial dysmorphism was noted in 73 (16.98%) patients. Extracardiac anomalies were associated in 55 (12.79%) patients [Table 2].
Table 2: Clinical presentations of the study patients (n=430)

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A total of 287 (66.74%) patients were diagnosed with acyanotic type of CHD while 143 (33.26%) were cyanotic type. The most common CHD was VSD 129 (30.01%), followed by ASD 89 (20.70%), TOF 69 (16.05%), and patent ductus arterious 44 (10.23%), respectively. The most common cyanotic CHD was TOF followed by transposition of great vessels, total anomalous pulmonary venous connection, and single ventricle [Table 3].
Table 3: Prevalence of significant congenital heart diseases in the study (n=430)

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On chest roentgenogram, cardiomegaly was observed in 309 (71.86%), pulmonary plethora 262 (60.93%), and pulmonary oligemia in 98 (22.79%) patients. The left ventricular hypertrophy in 94 (21.86%), the right ventricular hypertrophy in 232 (53.95%) while biventricular hypertrophy in 43 (10%) were detected on ECG. Pansystolic murmur was auscultated in 223 (51.86%) patients, followed by ejection systolic murmur in 154 (35.81%) and continuous murmur in 43 (10.00%).

Growth failure was the most common complication in inpatients followed by congestive cardiac failure and pneumonia. Stroke was observed as a complication in cyanotic CHD [Figure 1]. 25 patients expired among inpatients (case fatality rate in inpatients 19.23%). Causes of death included complex CHD 13 (52%), refractory congestive cardiac failure 5 (20%), sepsis 4 (16%), pneumonia 2 (8%), and meningitis 1 (4%). Most of the deaths were in neonatal age due to complex CHD and associated complications such as sepsis.
Figure 1: Complications of congenital heart disease in patients

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  Discussion Top


CHD may be diagnosed at virtually any age. Certain conditions are usually discovered in neonate; others rarely are identified during infancy.[10] CHD is the most common cause of major congenital anomalies, representing a major global health problem. The estimated prevalence of 8 per 1000 live births is accepted as the best approximation.[3] Available Indian studies had reported a wide variation in the prevalence of CHD from 2.25 to 26 per 1000 live births.[11],[12],[13] A recent systemic review also reported a higher prevalence in Asia due to high birth rate and consanguinity, especially in Iran and India. In this study, the prevalence is 10.13 per 1000 live births. This may be high by being the largest referral center in Central India, availability of better diagnostic modalities, improved survival of premature infants, and high birth rate.

In the present study, 56.28% of patients were below 1 year of age including 20.47% of neonates. Gender distribution was 56.98% of males with a male: female ratio of 1.3:1. Similar type of distribution and gender prevalence were reported by various studies.[14],[15] Most of (60.93%) the patients were from the urban area and around 80% from middle and lower socioeconomic class, as our institute mainly caters to the socioeconomically deprived population of Central India. Nutritional deficiencies and growth failure in CHD are multifactorial and include genetic syndromes, feeding difficulties, poor absorptions; increased calories requirement to sustain the increase myocardial, respiratory, and neurohumoral function. Furthermore, chronic hypoxia in CHD impairs cellular metabolism and cell growth. We found that 44.19% of patients were severely (Grade III and IV) malnourished. Okoromah et al. reported 90.4% prevalence of CHD-related malnutrition with 61.2% severe malnutrition.[16] Increase in the incidence of CHD with a higher birth order is the indirect evidence of the presence of environmental influence in the causation of the disease.[17],[18],[19] We also observed that the higher the birth order more the incidence of disease. Hence, family planning to reduce the size of the family may possibly contribute toward lowering the incidence of CHD.

Of the different clinical symptoms, breathlessness was the most common, followed by fever and failure to thrive. Features suggestive of congestive cardiac failure were in both acyanotic and cyanotic heart disease. Cyanosis was noted in 40% of patients and the cyanotic spell was present in 22.79%. Convulsions were the presenting symptom in 10% of patients. Tachycardia and tachypnea were noted in 88.84% and 83.95%, respectively, while clubbing was observed in cyanotic CHD and these observations correlated well with other studies.[20],[21],[22] Facial dysmorphism and extracardiac anomalies were observed in 16.89% and 12.79% of patients, respectively, in the present study. Musculoskeletal, gastrointestinal anomalies, and syndromic association were more common and included Down syndrome, Pierre Robin syndrome, microcephaly, polydactyly, and CTEV. Aravind et al.[23] reported extracardiac anomalies in 21.42% of patients while Harshangi et al. encountered the same in 12 of 50 patients. Hence, musculoskeletal affection was the most common. Our radiological, electrocardiographic, and auscultatory findings were similar to Harshangi et al. and Chanda et al.[24]

In this study, out of 430 diagnosed CHD patients, acyanotic heart disease constituted 287 (66.74%) and cyanotic 143 (33.26%), which is in congruence with studies by Shah GS et al. 69% and 31%, Pate et al.[25] 60.6% and 38.6%, and Sani et al.[26] 68.9% and 31.1%. While few studies differ from our finding, these studies include Wanni et al.[13] 88.6% and 11.4%, Saxena et al.[27] 79.88% and 20.12, and Bakhtyar Zahid et al.[28] 52.8% and 47.2%. VSD (30.01%) was the most common CHD, followed by ASD (20.70%), TOF (16.05%), and PDA (10.23%). VSD was the most common acyanotic CHD while TOF was the most common cyanotic CHD. Most of the studies in the literature reported similar observation from India and other countries;[13],[14],[15],[20],[25],[26],[29] however, few studies reported a higher incidence of PDA compared to ASD.[13],[28] Among other cyanotic CHD, our findings are comparable with Saxena et al. and Abquari et al.[30] while Wani et al. reported a higher incidence of transposition of great vessels, single ventricle, total anomalous pulmonary venous connection, and double outlet right ventricle.

Growth failure was the most common complication in inpatients followed by congestive cardiac failure, pneumonia, and subacute bacterial endocarditis. Sepsis was observed in neonatal age while stroke and meningitis were common in cyanotic CHD. A study done by Harshangi et al. reported growth retardation (56%), congestive cardiac failure (56%), and bronchopneumonia (22%) as complications in their study. Case fatality rate among inpatients in the present study was 19.23% and most of the deaths were in neonatal age due to complex CHD, refractory congestive cardiac failure, sepsis, and pneumonia. The study results are comparable with Harshangi et al. (17%) and Shah et al. (20%).


  Conclusion Top


The prevalence of CHD in this study was 10.13/1000 live births. Acyanotic heart disease constituted 66.74% and cyanotic 33.26%. VSD and TOF were the most common acyanotic and cyanotic CHD, respectively. Growth failure and congestive cardiac failure were the most common complications in inpatients. Case fatality rate inpatients in the present study were 19.23% and most of the deaths in neonatal age were due to complex CHD, refractory congestive cardiac failure, sepsis, and pneumonia. Therefore, we recommend that all murmur should be screened unless thought to be physiological. Cardiac evaluation should be done in all cases of repeated chest infection and failure to thrive. CHD needs regular monitoring to permit optimal growth and development. Early diagnosis and timely intervention will reduce the morbidity and mortality to a large extent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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