To assess the quality of Life in patients with Chronic Rheumatic Heart Disease

 

Sabreena S Sheikh¹, Anwar H Ansari², Manoj K Mudigubba³, Saurabh Dahiya⁴

¹Department of Pharmacy, Lingayas University, Faridabad, Haryana-121002, India

²Department of Cardiology, Safdarjung Hospital, Ansari Nagar, New Delhi-110029, India

³Department of Pharmacy, M.S Ramaiah University of Applied Sciences, Banglore-560054, India

⁴Department of Pharmaceutical Chemistry, DIPSAR, Delhi Pharmaceutical Sciences and Research University, New Delhi-110017, India

 

ABSTRACT:

Rheumatic heart disease (RHD) is an inflammatory disease of the heart, and it has major cause of morbidity and mortality in developing countries. It has significant impact on the quality of life of RHD patients. Objective: To assess the Quality of life in patients with chronic Rheumatic heart disease. Materials and methods: This prospective observational study was conducted at the Safdarjung Hospital, New Delhi for a period of 18 months. Study subjects are the patients who were diagnosed with chronic rheumatic heart disease at the outpatient department. A total of 500 subjects suffering from RHD and 100 Controls without RHD were identified during the study period. SF-36 health survey questionnaire was used to interview the subjects. The scores of health survey questionnaire was analysed descriptively and ANOVA is used to find out the significant differences. SPSS version-20 was used for data analysis. Results: Out of 600 subjects, 500 were the cases and 100 were the controls. 54.4% were males and 45.8% were females. Majority of the cases were belonged to the age group 36-40 years (19%) with the mean age group 35.7±9.2 years. 80% of the subjects were identified with moderate rheumatic heart disease and 20% were severe. Physical functioning, role of limitations due to physical health and emotional problems, social functioning and health change has shown the significant difference. Conclusion: It was seen that most of the domains of SF-36 were significant from which we can conclude that there is the relation between RHD and quality of life. Considering the poor quality of life in rheumatic heart disease patients, multimodal approach (psychiatric consultation, enrolment in mental support group, and occupational help) to provide overall care to a rheumatic heart disease patient should be considered.

 

 

INTRODUCTION:

Rheumatic Heart disease (RHD) is a chronic heart disease caused by rheumatic fever which can be preventable and controllable. Group-A streptococcal infection can cause the rheumatic fever, which often involves the damages to heart valves. It further leads to the improper opening and closing of the heart valves, interferes the blood flow. [1]

 

Treatment of streptococcal pharyngitis with the penicillamines is the effective primary treatment for the prevention of RHD, but it has limitations, and preventive measures for reoccurrence are the secondary treatment. According to the American Heart Association [AHA], Injection Benzathine penicillin at the dose of 1.2 million units with the frequency of every 3 weeks is recommended for a minimum period of 5 to 25 years or lifelong [2].

 

For individuals who have had an initial attack of rheumatic fever, or on diagnosis of RHD, continuous administration of an antibiotic drugs is mandatory to prevent acquisition and infection of the upper respiratory tract. Secondary prophylaxis has been documented to reduce significantly the risk of recurrent attacks with their attendant morbidity and mortality [3]. Antibiotic regimens for secondary prophylaxis are different. The regular intramuscular injection of repository penicillin (benzathinebenzylpenicillin) is the most effective available treatment. Although classically given every four weeks, recent data indicates that 1,200,000 units of benzyl-benzathine penicillin for every three weeks is more effective in preventing recurrences of rheumatic fever, especially in high-risk patients. Phenoxy-methyl penicillin is an alternative treatment in the patients who were not tolerated to the benzyl-benzathine penicillin.[3]

 

This rheumatic heart disease has showing more impact on the quality of life in elderly patients [3-6]. The global burden of RF and RHD over the past century has shifted to fall almost entirely on people living in the developing world, who constitute 80% of the world population [5-6].

 

Over 2.4 million children aged 5-14 years are affected with RHD. In addition, 79% of all RHD cases came from less developed countries. Further, they estimated the annual number of ARF cases in children aged 5-14 years was more than 336,000. This was extrapolated out to an estimate of 471,000 ARF case in all age groups [6].

 

India is in the phase of ‘epidemiological transition’. On one hand there is a substantial burden due to RHD for the treatment of which enormous money is spent, on the other hand the government resources are scare to treat and prevent the disease. India contributes to nearly 25% to 50% of the global burden of RHD [6].

 

A summary report on the global burden of group A streptococcal disease, commissioned by the World Health Organization, was released that encapsulated population-based data relating to ARF and RHD published between 1985 and 2005. This study found an overall global burden of 471,000 annual cases of ARF, with the incidence of ARF in children ages 5 to 15 years ranging from 10 cases per 100,000 in industrialized countries to 374 cases per 100,000 in the Pacific region. The overall burden of RHD was estimated to be 15.6 million prevalent cases with 282,000 new cases and over 233,000 deaths per year [8].

 

An effective measure to reduce the global burden of RHD represents an ongoing challenge involving reduction in overcrowding, improving hygiene, increasing public awareness and facilitating access to healthcare. In the absence of fundamental socioeconomic changes improving primordial prevention, systemic screening of RHD based on public and private education represents the most comprehensive approach and aims at a reduction of the late complications of RHD by early implementation of secondary prevention [4,8].

 

Although RHD occurs in children’s but its prevalence is more in adulthood between the ages of 25 years to 45 years [9]. Psychological implications are a significant part of chronic illnesses and they can affect the prognosis and outcome [10]. People with heart disease vary in terms of severity of illness and in terms of impact of that illness on their quality of life and psychosocial functioning. [11] Patients suffer from psychosocial morbidities resulting from their circulatory abnormalities and the medical and surgical therapies they receive. These morbidities significantly impact the neural functioning and diminish their quality of life [12].

 

SF-36 form (short form-36) is a short form which helps to survey patient reported patient’s health and emotional status [13]. Quality of life (QoL) and cognitive function in Danish Fontan patients using SF-36 score had showed the poor quality of life [14].

 

The current study was undertaken to evaluate the quality of life in subjects diagnosed with chronic rheumatic heart disease by using short form-36 instrument.

 

MATERIALS AND METHODS:

This prospective observational study was conducted at tertiary care hospital (Safdarjung Hospital), New Delhi, India, for a period of 18 months. Ethics approval was taken from the Institutional Ethics Committee of Safdarjung Hospital. The patients with RHD were considered as cases while subjects with no evidence of RHD were considered as controls. These subjects were identified at the out-patient department of cardiology. The subject and their relatives   were interviewed about the current clinical manifestations, previous medical history, medication history, life style and diet. Monitoring of the health status of the participating patients was done by assessment of vital signs and electrocardiogram of the patients. The data was collected and stored in the individual case report forms by the study personnel and were checked for completeness by the principal investigator. Confidentiality of the data and the identity of the study participants will be maintained and access to the data was limited to the study personnel only.

 

SF-36 (Short Form-36) scale was administered to assess the quality of life of subjects.  The study was conducted in accordance with the Basic Principles defined in US 21 CFR Part 320, the ICH (62FR 25692, 09 May 1997) 'Guidance for Good Clinical Practice' and the principles enunciated in the Declaration of Helsinki (Edinburgh, October 2000).

 

Data was analysed by using the SPSS version- 20.  Qualitative data was presented as frequencies and percentages. Quantitative data were presented as the mean and standard deviation. Analysis of variance (ANOVA) was used to compare SF-36 domain.

 

RESULTS:

500 RHD subjects and 100 Control group (without RHD) were included in the study. Analysis of demographic profile had (n=500) revealed that majority of the subjects were identified at the age group of 36-40 years old (n=95; 19.0%) with mean age being 35.7±9.2 years (mean age ± standard deviation) (Table 1).

 

Table 1: Distribution of cases according to age group

Age group	Frequency	Percent %
18-20	18	3.6
21-25	69	13.8
26-30	74	14.8
31-35	86	17.2
36-40	95	19.0
41-45	89	17.8
46-50	45	9.0
51-55	14	2.8
56-60	7	1.4
66-70	2	.4
71-75	1	.2
Total	500	100.0

Males (n=271, 54.2%) were more prone to develop the RHD compared to the females (Table 2).

 

Table 2: Distribution of cases according to gender

Cases	Frequency	Percent
Male	271	54.2
Female	229	45.8
Total	500	100.0

Distribution of the subjects according to the duration of disease had shown that 53.2% of subjects were found to be with 1-5 years followed by 44% with 11-15 years of duration (Table 3).

 

Table 3: Distribution of cases according to duration of disease

Duration of disease	Frequency	Percent
1-5 Years	266	53.2
6-10 Years	14	2.8
11-15 Years	220	44
Total	500	100.0

 

80% of the subjects were identified with moderate degree of rheumatic heart disease, whereas severe degree of disease was found only in 20% of subjects (Table 4).

 

Table 4: Distribution of cases according to diagnosis

Diagnosis	Frequency	Percent
Moderate RHD	400	80.0
Sever RHD	100	20.0
Total	500	100.0

 

Significant difference with respect to the means of case group and control group was identified using ANOVA and the difference was seen in physical functioning, role limitations due to physical health; emotional problems, social functioning and health change (Table 5).

 

Table 5: represents the ANOVA test to find out is there any significant difference their mean values among both the group.

Parameters	Groups	N	Mean	Std. Deviation	95%Confidence Interval for Mean		Range	F-test &
					Lower Bound	Upper Bound		p-value
Age	Cases	500	35.77	9.285	34.95	36.59	18-75
	Controls	100	37.66	7.458	36.18	39.14	23-53	3.668 &
	Total	600	36.09	9.028	35.36	36.81	18-75	p=0.058
Physical functioning	Cases	500	53.97	22.327	52.01	55.93	0-100
	Controls	100	39.94	15.759	36.81	43.07	10-80	35.88
	Total	600	51.63	21.993	49.87	53.40	0-100	p=0.000*
Role limitations due to physical health	Cases	500	45.89	24.093	43.77	48.00	0-100
	Controls	100	32.85	16.435	29.59	36.11	0-75	26.766
	Total	600	43.71	23.491	41.83	45.60	0-100	p=0.000*
Role limitations due to emotional problems	Cases	500	45.23	27.833	42.78	47.67	0-100
	Controls	100	33.14	18.004	29.57	36.71	0-70	17.393
	Total	600	43.21	26.819	41.06	45.36	0-100	p=0.000*
Energy/fatigue	Cases	500	45.99	8.912	45.21	46.77	20-70
	Controls	100	43.89	7.931	42.32	45.46	25-60	4.79
	Total	600	45.64	8.785	44.94	46.34	20-70	p=0.029
Emotional well-being	Cases	500	49.71	9.839	48.84	50.57	24-76
	Controls	100	47.01	11.191	44.79	49.23	15-68	5.967
	Total	600	49.26	10.117	48.45	50.07	15-76	p=0.015
Social functioning	Cases	500	51.46	13.612	50.26	52.66	0-88
	Controls	100	46.95	12.103	44.55	49.35	20-88	9.477
	Total	600	50.71	13.468	49.63	51.79	0-88	p=0.002*
Pain	Cases	500	49.40	18.847	47.74	51.06	10-100
	Controls	100	44.43	17.335	40.99	47.87	15-80	5.946
	Total	600	48.57	18.682	47.07	50.07	10-100	p=0.015
General health	Cases	500	47.38	7.496	46.72	48.03	25-75
	Controls	100	46.28	8.065	44.68	47.88	25-65	1.736
	Total	600	47.19	7.598	46.58	47.80	25-75	p=0.881
Health change	Cases	500	53.74	23.021	51.72	55.76	0-100
	Controls	100	37.31	16.187	34.10	40.52	0-75	46.32
	Total	600	51.00	22.855	49.17	52.83	0-100	p=0.000*

DISCUSSION:

Literature search has Revealed that studies assessing the quality of life (QoL) of rheumatic heart disease patients are quite rare globally. Contrast to the huge burden of rheumatic heart disease in India, data regarding the QoL of rheumatic heart disease patients in India is meager [14]. The current study is the first to the author’s knowledge whose objective is to study on QOL in adults suffering from RHD in India.

 

Since the turn of early nineteenth century, documents are available regarding existence of rheumatic heart disease in Indian population. In the past 50 years rheumatic heart diseases has emerged as one of the major contributing factors in cardiac mortality and morbidity in India. It is reported that every year around 50,000 new cases of rheumatic fever occur in India. Like other developing countries juvenile onset of rheumatic heart disease plays an important role in overall cardiac mortality and morbidity [13].

 

Present data demonstrated that there is the significant relationship between the RHD and the QOL in the subjects. Our study represented that likelihood of the poor quality of life in RHD subjects than the healthy subjects. From medical point of view impact of heart disease is significant on the physical health [17]. Many studies on QOL also resulted with the low score for psychosocial aspect [18,19] which supports our study. QOL study on congenital heart disease also showed that there is a low QOL in subjects with chronic diseases [20]. Different studies have used different questionnaires like Paediatric Quality of Life Inventory (PedsQL), which was given to the children and their parents conflicting resulting were seen regarding the QOL of children [21]. Patients with chronic RHD had an intellectual decline [22]. Study showed that RHD and Arthritis affect negatively several aspects in QOL like home and work activities compared to that of subject without RHD [23] which also confirms our study. Anxiety and stress are also the symptoms which can hinder with the QOL in subjects and leads to reduce the QOL [4 which we will discuss in our next paper.

 

CONCLUSION:

Therefore from the findings of this study it can be said that rheumatic heart disease not only leads to increase in cardiac mortality and morbidity but also affects the patient’s QoL besides making him/her more prone to mental disorders like anxiety and depression. The present study is not free from limitations; keeping in mind the huge burden of rheumatic heart disease in India, sample size is relatively smaller. We only included those patients attending the cardiology outpatient Department of the Safdarjung hospital, New Delhi; it would be better if similar studies are conducted in different part of the country to get a fair assessment of the situation. Quality of life was found to be significantly affected in rheumatic heart disease patients along with increased risk of mental stress. Therefore, the actual burden of rheumatic heart disease should be assessed not only in terms of disease related direct morbidity and mortality but also in terms of other indirect causes of morbidity and mortality associated with poor quality of life.

 

Treating physicians therefore should also consider all these factors besides medical management of the actual disease (rheumatic heart disease). Also physician can refer the subject to the counseling session for better QOL.

 

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

 

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Received on 07.10.2019           Modified on 17.12.2019

Accepted on 20.01.2020         © RJPT All right reserved