Cardiac symptoms associated with rheumatic fever in children who visited Damascus Hospital between 2013 and 2020

doi:10.21203/rs.3.rs-4017407/v1

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Research Article

Cardiac symptoms associated with rheumatic fever in children who visited Damascus Hospital between 2013 and 2020

https://doi.org/10.21203/rs.3.rs-4017407/v1

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Background

In addition to assessing the clinical results and prognosis of patients with acute rheumatic fever treated in the Cardiology Clinic at Damascus Hospital, this study intends to ascertain the clinical usefulness of echocardiography (ECHO) in the diagnosis of acute rheumatic fever.

Methods and materials:

A retrospective analysis was conducted on 160 ARF (6–17) patients, with a mean age of 11.7 ± 2.3 years, 88/72 female and male diagnoses based on Jones criteria, who were monitored in the cardiology clinic at Damascus Hospital from October 2013 to December 2020.

Results

Of the 104 patients diagnosed with rheumatic heart disease (RHD), approximately 29.4% had subclinical carditis; in contrast, clinical carditis was frequently associated with chorea (39%) and polyarthritis (37.1%). Sixty-six percent of patients with rheumatic fever were found to be between the ages of 10 and 13; thirty-three percent (n = 50) reported having frequent arthralgia during the winter, and the most common associated symptoms were carditis + arthritis (35%) and carditis + chorea (19.4%). When it came to carditis sufferers, it was The aortic (50.6%) and mitral (63.8%) valves were the most commonly impacted, respectively. In cases diagnosed during and after 2015, the prevalence of subclinical carditis, arthralgia, and uniarthritis rose and 71 out of 104 individuals saw an improvement in their valvular heart disease result. Individuals with carditis (68.2%) Patients with clinical carditis and those who followed prophylactic treatment had a significantly higher rate of regression of heart valve symptoms over the course of around 7 years of follow-up compared to patients with subclinical carditis and those who did not follow prophylactic treatment.

Conclusion

We conclude that early prophylaxis can reduce the prevalence of adult RHD and complications, subclinical carditis is associated with the risk of permanent RHD, and nonadherence to secondary prophylaxis is significantly associated with recurrent ARF. Additionally, ECHO findings should be included in the diagnostic criteria for ARF. potential connected to it.

Infectious Diseases

Child

rheumatic fever

echocardiography

arthritis

and carditis

The immunological reaction of the body to a sore throat brought on by Streptococcus pyogenes, or group A streptococcus bacterium, causes acute rheumatic fever (ARF). Long-term damage to the heart muscle brought on by a single acute incident or multiple, consecutive assaults is known as rheumatic heart disease (RHD). Fever with rheumatism (1)

Around the world, rheumatic heart disease (RHD) is a major cause of morbidity and mortality, particularly in low-income residential settings. Prior to improved living conditions and widespread S. pyogenes treatment, ARF/RHD was common in all populations; however, today, diseases primarily affect people living in low- and middle-income countries, as well as indigenous populations in wealthy countries, where primary S. pyogenes infections may go untreated, allowing harmful sequelae to develop after infection (2)

About two weeks following a Staphylococcus pyogenes infection, ARF starts to develop. The occurrence of subcutaneous nodules, erythema marginale, rashes linked to ARF, arthritis, and carditis are some of the more severe clinical indications and symptoms of the condition. Patients with these symptoms are typically admitted to hospitals. The visible symptoms will go away for two to three weeks at this time, but the cardiac damage might not stop (3)

importance of studying:

In poor nations, rheumatic fever (RF) continues to be a serious public health issue that affects children and teenagers. The purpose of this study is to assess the cardiac symptoms linked to RF in children over a seven-year period.

We conducted a retrospective review of the records of 160 kids who received an ARF diagnosis at the pediatric cardiology clinic at Damascus Hospital between October 2013 and December 2020. The Clinical Research Ethics Committee at the Syrian Private University for Science and Technology granted ethical approval for this work, and the Damascus Hospital administration granted access to the archives. On December 4, 2023, approval was given for patients and the extraction of files to gather data for the study. Samples were then gathered in accordance with a research form that the supervising professor and the researchers created based on the information provided.

Selection of patients:

The medical records of patients who visited the cardiac clinic at Damascus Hospital were retrospectively analyzed for this study. The study comprised 160 participants: 35 patients having a medical history and 125 patients who were clinically and ECHO assessed and were initially diagnosed with ARF based on Jones criteria in the clinic. Between 2013 and 2015, patients with RHD at the time of admission were diagnosed with ARF based on the 2003 WHO criteria and the 1992 Jones criteria [6, 14].

They were diagnosed between 2015 and 2020 using the 2015 Jones criteria [2], which did not apply to patients with chorea, arthritis, or PR prolongation. Nor did they recognize arthralgia as a minor criterion for patients with arthritis or patients with chorea. Eighteen patients with carditis were removed from the study because they did not meet the Jones criteria, the diagnosis was not confirmed, the patient had concomitant vasculitis or other inflammatory diseases (such as FMF or rheumatic diseases), the patient did not show up for follow-up, or the patient did not receive regular penicillin prophylaxis, which suggested that rheumatic fever was consistently controlled.

Clinical and demographic characteristics:

Age, sex, day of diagnosis, admission location, primary complaints at the time of admission, history of upper respiratory tract infection, other known illnesses, history of ARF, family history of ARF, and length of follow-up were all noted from the patient records.

The frequency of recurring attacks as well as the patients' adherence to follow-up and prophylactic use of benzathine penicillin G were assessed. The following systemic examination findings were noted during follow-up: fever, heart rate, blood pressure, cardiovascular examination, erythema marginale, skin examination for subcutaneous nodules, neurological examination for Sydenham's chorea, and arthritis (monoarthritis, polyarthritis). Fever was defined in the patient files as an axillary temperature of 38°C and above.

Complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-streptolysin (ASLO), and liver function tests were performed; CRP > 5 mg/dL was taken into consideration, and ASLO > 250 units. The results of these tests were documented. Clinically severe sedimentation occurs at rates more than 30 mm/h. A 12-lead electrocardiogram (ECG) was performed on patients to detect any arrhythmia linked to rheumatic fever or any Jump into the PR distance. The results of the pharyngeal swab culture were documented and examined in the microbiology laboratory. A white blood cell count exceeding 10,000/mm3 was evaluated to indicate inflammation. Patients with rheumatic fever who had ECHO follow-up data, were monitored for a minimum of a year following their initial rheumatic episode, and were potentially admitted to the pediatric ward were included. Recurrent flare-ups were assessed in two categories: (2) Recurrence attack: cases of recurrence, where clinical and laboratory results indicated recurrence while anti-inflammatory treatment was still being followed, and cases of relapse, where symptoms of ARF reappeared 4–6 weeks after the end of treatment [ 15]. Recurrence: new ARF flare-up caused by group A streptococcal infection which occurred 8 weeks after the end of treatment.

Echocardial findings

Both a pediatrician and a cardiologist performed the ECHO on each patient. The Vivid 7 Pro (General Electric, Horten, Norway) was used to perform echocardiographic examinations on pediatric patients in the supine position without anesthesia, in accordance with standard guidelines published by the American Heart Association. utilizing a Philips iE33 (Netherlands) transducer X5-1 and a 3MHz probe. The presence of mitral insufficiency (MR) was evaluated using an apical four-chamber view during systole, and the presence of aortic valve insufficiency was evaluated using an apical five-chamber view during diastole. M-mode, standard CW Doppler, PW Doppler, and color Doppler ECHO images were acquired [14–16].

Based on ECHO data, a WHO expert committee accepted previously published criteria for the diagnosis of rheumatic carditis [17]. Those with an ECHO diagnostic of valvular insufficiency but no audible murmur were labeled as having "subclinical" or "silent" carditis. Patients with pericarditis received the following assessments: Patients are characterized as having (a) mild carditis and (b) carditis if their only cardiac symptom is a murmur or if they have grade 1 valvular insufficiency on ECHO without associated cardiac hypertrophy. Individuals experiencing heart failure symptoms or those with grade 3 or 4 valvular insufficiency on an ECHO test are characterized as having severe carditis; patients with grade 2 valve insufficiency are defined as having moderate carditis.

statistical analysis:

The statistical package SPSS version 28 (Statistical Package for the Social Sciences, SPSS Inc., Chicago, USA) was used to analyze the data. For categorical variables, descriptive statistics were presented as numbers and percentages, and for continuous variables, as mean ± standard deviation and median (minimum and maximum values). Both analytical (Kolmogorov-Smirnov and Shapiro-Wilk tests) and visual (histogram and probability histograms) techniques were used to evaluate the compliance of continuous variables to a normal distribution. It was found that the continuous variables did not follow a normal distribution. Non-normal data were compared pairwise using the Mann-Whitney U test. When comparing categorical variables with a normal distribution, the chi-square test was utilized, and a value of P < 0.05 was considered statistically significant.

Over roughly seven years, 160 patients were diagnosed with ARF in the Cardiology Clinic at Damascus Hospital. A total of 88 (55%) female patients and 72 (45%) male patients were identified, with an average follow-up period of 3.0 ± 1.9 years. (1–6).60% of patients (n = 96) had their diagnosis between the ages of 10 and 13 years old, with a mean age at diagnosis of 11.7 ± 2.3 years (6–17 years).

Of the 160 patients, 78.1% (n = 125) had a first episode of rheumatic fever; 21.9% (n = 35) had a history of rheumatic carditis; and most patients (n = 50, 31.3%) were admitted in the winter, then in the summer (n = 45, 28.1%), in the spring (n = 44, 27.5%), and in the fall (n = 21, 13.1%).

While fever, dyspnea, chest pain, and tachycardia were among the other complaints (6.3%), joint pain (71.9%), arthritis (54.3%), and involuntary movements (Sydenham's chorea) (25%), were the most common chief complaints upon admission. Thirteen patients (8.1%) reported non-ARF symptoms (headache, dizziness, syncope, and abdominal pain); roughly 68.8% (n = 110) of cases had a history of ARF infection. With the exception of patients with chorea, the average duration of upper respiratory rest was 3.2 ± 1.1 weeks.

The patients' average heart rate ranged from 65 to 140 beats per minute (89.7 ± 13.2), and a cardiac examination found that 17 patients (10.6%) had febrile arrhythmia and 54 patients (33.7%) had a heart murmur. Approximately 75% of the patients (n = 120) had elevated C-reactive protein and acute-phase inflammatory markers (APR).

With a mean ASLO value of 966.3 ± 807.1 IU/ml (209–5730), 99.3% of patients were ASLO positive. The mean CRP level was 6.2 ± 5.9 mg/dL (0.02–26.7). The mean erythrocyte sedimentation rate was 64.7 ± 33.0 mm/h (2–132). Pharyngeal swabs from 9 individuals (5.6%) tested positive for group A beta-hemolytic streptococci.

Whichever year the person was diagnosed, 39.4% (n = 63) satisfied the 2015 Jones criteria, around 60.6% (n = 97) met the 1992 Jones criteria and the 2003 WHO criteria, and roughly 41.3% (n = 26) matched the 2003 WHO criteria. With the current diagnostic criteria, there was a substantial rise in the number of patients diagnosed with ARF (statistical significance = 0.015) among the 63 patients who met the most recent Jones criteria prior to 2015, and 58.7% (n = 37) during or after that year. Furthermore, based on the year, there was no noteworthy variation in the prevalence of rheumatic carditis.

Major and minor criteria for the diagnosis of rheumatic fever distribution:

This figure displays the distribution of outcomes for severe and moderate rheumatic fever at the time of diagnosis prior to and following 2015. Females (61.5%) had a substantially greater prevalence of rheumatic carditis (n = 104) than males (38.5%) (statistical significance = 0.035). The findings were Arthritis and joint pain (68.7%, n = 110) and carditis (65%, n = 104) were the most frequent clinical symptoms. Thirteen patients (15.4%) had monoarthritis, twenty-three (20.9%) had polyarthralgia, and seventy-seven (63.6%) had arthritis and/or arthralgia. When comparing patients diagnosed before 2015 to those diagnosed after 2015, the prevalence of arthritis increased dramatically, but the prevalence of chorea reduced significantly (P < 0.01). After 2015, there was an increase in the incidence of subclinical carditis as well, however there was no statistically significant rise (statistical significance = 0.202).

When it came to concomitant conditions, we discovered that the most prevalent primary symptoms were carditis plus arthritis (n = 56, 35%) and carditis plus chorea (n = 31, 19.4%). There were 47 occurrences of carditis that were evaluated for severity. Ten cases of severe carditis (9.6%), 47 cases of moderate carditis (45.2%), and 45.2% of mild carditis were reported. The mitral (63.8%) and aortic (50.6%) valves were most commonly impacted in patients with carditis. Thirty patients (18.8%) and 71 patients (44.4%), respectively, had concomitant aortic and mitral involvement at the time of diagnosis. Their condition was determined tobe isolated mitral insufficiency. No statistically significant difference was observed in the outcomes of rheumatic heart disease and follow-up treatment (P > 0.05) based on the valve involvement in patients with monoarthritis and joint pain; 16 of these patients were diagnosed with RHD by adding subclinical carditis to the diagnostic criteria. Subclinical carditis was shown to be more prevalent in arthralgia patients (n = 13, 52.2%); On the other hand, arthritis (n = 26, 37.1%) and chorea (n = 16, 39%) were frequently associated with clinical carditis;

Outcomes of rheumatic valve damage during recovery, surveillance, and avoidance:

The distribution of anti-inflammatory therapy among patients with clinical and subclinical carditis is displayed; nonsteroidal anti-inflammatory drugs (NSAIDs) were the most popular medication for treating both clinical and subclinical carditis, with steroids being much more common for treating clinical carditis. Therapeutic (P < 0.001).

A significant proportion of patients (n = 37) with moderate to severe carditis required hospital admission for treatment. Specifically, patients with subclinical carditis (n = 44, 93.6%) and clinical carditis (n = 54, 94.6%) showed a high response rate to treatment (statistical significance < 0.05). During their follow-up, two patients (1.3%) who had significant valve insufficiency had surgical valve repair.

There was no statistical significance even though the group receiving non-steroidal medication had a greater diagnostic rate of rheumatic heart lesions (85.4%; n = 41) than the group receiving steroid treatment (40.2%; n = 41).

The rate of adverse effects was substantially higher in individuals treated with salicylates (n = 6) compared to other NSAIDs (n = 1) (P = 0.001). A statistically significant value was established (statistical significance < 0.05).

Rheumatic carditis findings decreased in 16 patients throughout follow-up; 11 of them (68.7%) had mild carditis, and 5 (31.3%) had moderate carditis. Among those with severe carditis, none made a full recovery. During follow-up, it was shown that patients with mild carditis had a considerably lower rate of RHD Recurrence than patients with moderate and severe carditis.

In terms of valvular involvement, aortic and mitral valve insufficiency was present in 74.5% (n = 41) of patients with clinical carditis, and isolated MR was present in 25% (n = 14) of cases; in contrast, subclinical carditis was seen in 63.8% (n = 30) and 34% (n = 16) of patients. Regarding valvular involvement, there was no statistically significant difference between the two groups (statistical significance = 0.329). Patients with clinical carditis (83.3%) had a significantly lower rate of rheumatic carditis than those with subclinical carditis (55.6%) (P = 0.005).

Recurrence occurred in 37 individuals (77.1%) at a mean of 4.1 ± 1.8 weeks following the initial episode. On the other hand, among patients who experienced recurrence, subclinical carditis (26%, n = 20) was much less common than clinical carditis (74%, n = 20) (statistical significance = 0.019).

Although clinical carditis and mixed valvular insufficiency were considerably more common among patients who had seizures, the majority of these patients—77.8% (n = 21)—had combined valve insufficiency, while only 22.2% (n = 6) had isolated valvular insufficiency. Regular (p = 0.019 for statistical significance).

During approximately 7 years of follow-up (average 36 ± 22.8 months), progression in valvular outcomes was observed in 71 (68.2%) of 104 patients with rheumatic carditis, such that among these patients, valve involvement in the first year decreased by 70.4% (n = 50), in the second year by 11.3% (n = 8), in the third year by 11.3% (n = 8), in the fourth and fifth year by 2.8% (n = 2), and in the 6-year follow-up. For 4.2% (n = 3), follow-up for rheumatic carditis was found to be significantly lower in cases of isolated MR (18%) than in cases with concomitant insufficiency of the valves. concomitant insufficiency of the valves. (50%) (P + 0.024) Individuals with simultaneous carditis and chorea had a considerably higher risk of developing rheumatoid heart disease compared to those with isolated carditis (P < 0.01). Furthermore As a result, at follow-up, valve stenosis was not seen.

Both during follow-up and at the time of admission, mitral valve involvement is observed. In forty-five percent of patients undergoing follow-up, valve insufficiency has totally resolved. The severity of the condition determined this rate, which might be as low as 11.6%. Both during follow-up and at the time of admission, aortic valve involvement is observed. For the majority of patients who had mild aortic insufficiency initially, the outcome of valvular insufficiency totally regressed (64.5% and 55.9%, respectively).

As a preventative measure, all patients received benzathine penicillin G every three weeks. During the follow-up period, the average prophylactic duration was 3.2 ± 1.9 years (1–7 years). The prophylactic compliance rate was around 88.8% (n = 142) of patients; the recurrence rate was 23.5% for patients who did not adhere to prophylaxis and 5.5% for those who did (statistical significance = 0.027). Furthermore, adherent patients receiving prophylaxis experienced a considerably greater drop in rheumatic heart disease outcomes (69.4%) compared to nonadherent patients (33.3%) (statistical significance = 0.035).

Expert agreement has been obtained regarding the idea of subclinical carditis, and ECHO has been widely used in the clinical evaluation of rheumatic carditis, gradually increasing its importance in the diagnosis of ARF over time [2, 7, 17]. In our study, we found that the prevalence of carditis, especially subclinical carditis, has increased and that these individuals have an increased chance of acquiring permanent rheumatic carditis. This is a surprising result made possible by the widespread use of ECHO in patients with suspected ARF. The other is that after 2015, there was a substantial rise (P < 0.05) in the number of individuals with rheumatic fever who were also diagnosed with arthralgia and monoarthritis.

Studies show that patients between the ages of 2 and 45 experience attacks of rheumatic fever, despite the fact that kids between the ages of 5 and 15 are most commonly affected [7, 18–20]. The patients in our study had a mean age of 11.7 ± 2.3 years, 60% of them were in the 10–13 age range, and the female–to–male ratio was 1.22. In contrast to earlier studies, most patients came to the hospital in the winter (31.3%) and spring (27.5%), when infections were more prevalent [18, 20–25]. The literature reports varying prevalence rates for various minor findings, including joint pain (54.6–81.1%), fever (40–62%), prolonged PR (15.9–23%), elevated ESR (81.8–95%), and high CRP (72.8–81.8%) [26–27].

Numerous investigations present several primary outcomes of ARF, evaluated separately or in relation to a certain ailment. With a rate of 68.8%, some studies indicate that the most common result of rheumatic fever is carditis; other studies imply that arthritis is among the most prevalent. First position is 59–57.6%, and additional research [21–23] shows that arthritis and carditis are present.

Studies have started to indicate higher frequencies of carditis in the 64–82% range because to the growing prevalence of ECHO worldwide [11, 24–26]. Carditis and arthritis (35%) were also the most often occurring main concomitant findings in our analysis.

According to the most recent Jones criteria (2015), migrating polyarthritis, monoarthritis, and/or arthralgia are recognized as essential criteria for intermediate and high-risk populations [2]. In one investigation, inflammation was found [19] by Karapetis et al. Of ARF patients, 54% had polyarthritis, 17% had monoarthritis, and 20% had arthralgia without arthritis. According to a Turkish study, the prevalence of monoarthritis ranges from 12.7 to 33.2%. It also highlights the rising incidence of ARF attacks associated with the condition [20, 27, 28]. 68.7% (n = 110) of the participants in our study experienced arthralgia or arthritis.

Furthermore, our findings demonstrated that patients diagnosed during or after 2015 had a significantly higher prevalence of monoarthritis, osteoarthritis, segment lengthening PR, and high APR than those diagnosed prior to 2015. Additionally, a significant decrease in chorea was observed (statistical significance < 0.05), which led to mild carditis in five of our patients with monoarthritis and 13 of our patients with polyarthritis.

In patients with rheumatic carditis, various studies indicate varying percentages of MR (25–96%), AR (9–35%), and MR with AR (25–36%) [26, 27, 29]. The mitral valve was the most frequently impacted cardiac valve (63.8%). In line with earlier research [2], 71 individuals (44.4%) had both AR and MR at the time of diagnosis, while 30 patients (18.8%) had MR as one of the causes. The numerous damaged heart valves are what adversely impacts the disease's progression, and as carditis severity increases, so does the number of damaged heart valves and the likelihood of complications during follow-up [7].

Our study's findings indicate that patients with mild carditis (40.7%) had follow-up for persistent rheumatic carditis at significantly lower rates than patients with moderate or severe carditis (59.3%) (P < 0.05). Furthermore, RA-associated carditis patients had a higher risk of developing RHD compared to isolated carditis patients (P < 0.01). During the course of this study, which lasted an average of 36 ± 22.8 months, we followed up on 104 patients with rheumatic carditis, and 71 of them (68.2%) did not exhibit any major valvular output failure. This result is in line with previous research, which shows that 70.4% of patients with carditis had significant heart valve damage during the first year, but by the sixth year, the percentage had dropped to 4.2% [30].

Rheumatic valve involvement was not observed to be substantially correlated with the degree of carditis (P > 0.05). However, patients with mixed valve insufficiency had a higher chance of developing RHD at follow-up than patients with isolated MR (50% vs. 18%). (P less than 0.05) Our findings demonstrate a considerable increase in the risk of developing problems associated to RHD when there is involvement of the common valve along with accompanying arteritis and/or chorea.

Subclinical carditis was added as a crucial criterion for low-, intermediate-, and high-risk groups in the most recent update of the Jones criteria (2015), in light of the growing significance of ECHO in the diagnosis of ARF [2, 31–33].

According to a number of studies, the prevalence of subclinical carditis is rising over time, with estimates ranging from 20.1–24.3% to 26.6% [11, 12, 28].

Although not statistically significant, our analysis revealed that 29.4% of patients with rheumatic fever also had subclinical carditis. Notably, patients from 2017 to 2020 had a higher frequency of subclinical carditis (30.7%) than those from 2013 to 2016 (23.5%). Another noteworthy observation is the high percentage of ARF patients diagnosed with monoarthritis (29.4%) and subclinical carditis and arthralgia (52%) which are also Main criteria, indicating the significance of early ECHO investigations in ARF and their inclusion in diagnostic criteria [2, 31].

According to our research, patients with polyarthralgia (n = 13, 52.2%) and polyarthritis (n = 14, 34.1%) were the groups most likely to have subclinical carditis. It was least prevalent in patients with polyarthritis (n = 12, 17.1%) and unilateral (n = 5, 29.4%).

Although the exact causes of subclinical carditis prognosis remain unknown, it is known that most mild MR patients who get consistent secondary prophylaxis for five to ten years have better clinical symptoms [27]. In their research, Ozdemir et al. [11] and Özkutlu et al. [13] found that, respectively, 42.5% and 45% of subclinical carditis subjects experienced permanent valve insufficiency. Similarly, throughout around 7 years of follow-up, we found that RHD decrease was considerably lower in patients with subclinical carditis (55.6%) than in patients with clinical carditis (83.3%) (statistical significance = 0.005), suggesting This implies that persistent rheumatic heart disease may occur in persons with subclinical carditis.

Recurrent bouts are the hallmark of rheumatic fever, and they are mostly to blame for chronic RHD. Recurrence rates were shown to be lower in patients who got regular secondary prophylaxis than in those who did not [20, 34]. recurring attacks were reported by 30% (n = 48) of patients with rheumatic fever in this investigation; however, individuals with recurring attacks were substantially more likely to have coupled valvular insufficiency and clinical carditis (P < 0.05). According to our findings, patients who complied with prophylaxis had a considerably lower recurrence rate (5.5%) compared to nonadherent patients (23.5%) (P < 0.05). Additionally, those who adhered to prophylaxis saw a noticeably greater drop in RHD outcomes.

It is noteworthy that there was a strong correlation in our study between cases of subclinical carditis and monoarthritis and arthritis. The frequency of carditis, and particularly the number of cases of subclinical carditis, has increased in all years due to the routine use of ECHO in patients with suspected ARF in the Cardiology Clinic of Damascus Hospital. Additionally, patients with subclinical carditis are at risk of developing ARF permanently. One significant factor contributing to recurrent ARF in rheumatic carditis has been non-adherence to secondary prophylaxis. Consequently, early secondary prophylaxis and early diagnosis of subclinical carditis may help to lower the occurrence of RHD in adults in the future.

Ethics approval and consent to participate:

The study protocol was approved by the relevant ethical committees at the Damascus Hospital and the Research Ethics Committee at the Syrian Private University. Prior to participation, each subject gave their verbal informed consent. The 1964 Helsinki Declaration and its subsequent amendments, as well as equivalent ethical norms, were followed in all procedures carried out in studies involving human subjects, whether they were national or institutional research committees.

Consent for publication:

Not applicable.

Availability of data and materials:

All data related to this paper’s conclusion are available and stored by the authors. All data are available from the corresponding author on a reasonable request.

Conflict of interest:

The authors declare that they have no conflict of interest

Funding:

This research received no specific grant from SPU or any other funding agency in the public, commercial or non-profit sectors.

Authors’ contributions:

While A.A. prepared the study protocol, carried out the statistical analysis, assisted with data collecting, and conducted a literature search, M.A. designed the study. A.N. edited the draft manuscript while M.A. prepared the main manuscript and took part in the literature search and result interpretation. The final manuscript was read and approved by all authors.

Acknowledgments:

We are appreciative of the Syrian Private University's administration and their assistance with medical education and research. We also thank Dr. Ahmad Nabulsi for his guidance and support throughout the paper. I also thank the Damascus Hospital doctors for helping with the data collection.

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The authors declare potential competing interests as follows: Not thing

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Cardiac symptoms associated with rheumatic fever in children who visited Damascus Hospital between 2013 and 2020

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Abstract

Background

Methods and materials:

Results

Conclusion

Introduction

importance of studying:

Methods and materials

Selection of patients:

Clinical and demographic characteristics:

Echocardial findings

statistical analysis:

Results

Major and minor criteria for the diagnosis of rheumatic fever distribution:

Outcomes of rheumatic valve damage during recovery, surveillance, and avoidance:

Discussion

Conclusion

Declarations

References

Additional Declarations

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