Dying Young Hearts

When I first met Marie* I had just started my junior clerkship course in pediatrics. It was a warm Monday morning in mid-January. I rushed into the Upendo ward hoping to see what cases had come in over the night. As it was my morning routine, I picked up the new patient file at the nursing station. It read Marie K, a 12 year old girl from Webuye, Kenya. Unlike the other new files, this one was bulky, which made me realize that she had been here before. I walked over to the bed indicated and met a young angel. She lay in a propped-up bed with labored breathing, each breathe heavier than the last. A middle-age lady sat on the side of the bed looking in my direction with despair. ‘What could have gone wrong?’ she was too young to be in such a state: toxic. I exchanged pleasantries with mum and tried to elicit the culprit. As she spoke it became clear. Marie was suffering from Rheumatic Heart Disease (RHD). Her heart valves had completely given up and I could see her chest heave up and down with every beat. She was now in failure.

Rheumatic heart disease is the leading cause of cardiovascular disease in the developing nations. This is 80% of the world’s population. It is considered a disease of poverty. In Kenya alone it is reported that 62 per 1,000 of the population show signs of RHD on Echo (A form of ultrasound that is used to view the heart, its valves and the major vessel). Therefore for every 100 people you meet, six may have the disease, albeit sometimes being silent. It accounts for a quarter of all heart failure cases in endemic countries. Heart failure is when the heart is unable to adequately pump blood.

So what is RHD, how is it acquired, can it be prevented, how will I know whether I, or someone I know suffers from it and what next? RHD is a spectrum of heart damage, either the outer covering of the heart (pericardium); heart muscle (myocardium) or valves, evolving over years after acute rheumatic fever (ARF).   ARF is a non-infective sequela that occurs two to four weeks following bacterial pharyngitis caused by specific bacteria known as group A streptococcus (GAS). The disease may consist of arthritis, carditis, chorea (involuntary rhythmic movements) and skin lesions. It affects children between the age of 5-15 years, which Marie subscribed to. GAS is responsible for 15-30% of pharyngitis in children between 5-15 years. Unfortunately there is no specific symptom other than those of the common cold. It can be transmitted from child to child especially in school going children. Remember I said that ARF is non- infective, let me explain. GAS has molecules that are similar to that of the heart valves, so when the body is busy producing antibodies for its defense against GAS, it targets the heart as well. This results in progressive damage of the heart structures leading to RHD.

Patients slowly progress into failure, which is graded based on its limitation to normal activity. The most common symptom of heart failure is increased fatigue and awareness of heartbeat. In stage one, patients experience symptoms with over the ordinary activity; in stage two, with normal activity; in stage three, less than ordinary and stage four at rest. Marie was in grade IV. She had to watch helplessly as her siblings went out to play. She had dropped out of school a year ago because she couldn’t keep up with her peers. Marie was unable to get out of failure and after relentless attempts at attaining hemodynamic stability she silently passed on three days later.

The truth of the matter is that RHD is preventable. By placing our focus on the cause and addressing ways in which we can alter or stop the sequence of events. Save the young hearts of tomorrow. The first measure is to focus on ventilation, avoid crowding. Always make sure that the windows in a room constitute up to 10-15 percent of the floor area. Please consider this when you are setting up a structure, be it mud, wood, brick or stone. Emphasize on hand washing in all children and handlers. Use of hand sanitizers can also prove beneficial for both children and teachers. If you have a cough, cover your mouth during the episodes or use a face mask while handling children, and remember to wash your hands. If your child has a cough, seek urgent medical attention. A course of penicillin may be all that is required to reduce the risk of developing ARF and subsequent RHD. If your child experiences suspected heart failure symptoms, visit your cardiologist. An echo can go a long way in determining whether this is the case or not. Your cardiologist will also take measures to prevent heart failure and other complications such as infective endocarditis (infection of the inner lining of the heart).

This article is dedicated to all the children who suffer from RHD, all those who have lost their lives and those still fighting the battle…