|Clinical Research Article
Mukul Misra et al
Prevalence and Pattern of Congenital Heart Disease in School Children
Eastern Uttar Pradesh.
Mukul Misra, Mahim Mittal, A. M. Verma, Rajendra Rai, Gyan Chandra, D. P. Singh, Rahul Chauhan,
Vijay Chowdhary, R. P. Singh, A. K. Mall, Mohd. J. Khan, Suyash Khare, K. B.
Yadav, Rajendra Kumar,
A. R. Aeron, Pramod K. Verma
Department of Medicine, BRD Medical College, Gorakhpur, India
Background and Aim: The prevalence of congenital heart disease (CHD) is not known in our country. The
aim of present study was to find out the prevalence of CHD in school children of eastern Uttar Pradesh.
Method: A team consisting of a cardiologist, physicians and junior residents visited schools in the area. All
the children were examined for presence of cardiac murmur or history of heart disease or any intervention.
Those with murmurs or previous history of heart disease were called to the Medical College Hospital for
evaluation by ECG, chest X-ray and echocardiography for confirmation of the lesion.
Results: Out of 118,212 children examined, 142 were found to have CHD. The prevalence was 1.3 per
1000 children and the commonest lesions were ventricular and atrial septal defects, aortic stenosis with or
without regurgitation, and pulmonary stenosis.
Conclusion: CHD prevalence is 1.3 per 1000 school children that is nearly two and a half times more than
that of RHD. Knowing it is important for development of facilities for CHD care in our setup.
Keywords: Congential heart disease, Venticular Septal Defects, Atrial Septal Defects, Aortic Stenosis,
Aortic regurgitation, Pulmunory Stenosis.
There are several reports of prevalence of rheumatic
heart disease (RHD) that have been published from our country
in past 25 years1. It is heartening to note that there is a
decline in the prevalence of RHD in our country according to
the latest survey reports1,2, although it remains 25 to 50
times higher than in Western Europe and United
States3. However, we do not have any data on prevalence and pattern
of congenital heart disease (CHD). Further more it has
not drawn as much attention in our country as have RHD
and coronary artery disease. The present study reports
prevalence and pattern of CHD in eastern Uttar Pradesh of North
India. Accurate assessment of prevalence of CHD in a society
is needed since it is critical in understanding the
demands placed on the health care system and the social and
economic burdens placed on the patients and their families.
The study was conducted by the Department of
Medicine, BRD Medical College, Gorakhpur with help of
local politicians and volunteers.
A team of examiners was constituted which included
an experienced cardiologist (MM), 4 senior physicians, and
4 junior residents in medicine in rotation. The team
visited various schools located in and around Gorakhpur (urban
and semi-urban). All children between the ages of 4 to 18
years were examined within a period of 2½ years from July
2003 to January 2006. Of all the children examined, those
with cardiac murmurs or history of treatment for heart
disease (medical or surgical) were identified for further
evaluation. They were then re-examined by the cardiologist on
site. Those with suspected cardiac lesions were called to
Medical College Hospital for ECG, chest radiography and
color Doppler echocardiographic examination for confirmation
of the diagnosis.
In a total of 1,18,212 (68,357 males, 49,855 females)
children examined, 142 were identified as having congenital
heart defects, thus giving a prevalence of 1.3 per 1000.
The prevalence of RHD has been reported previously in an
earlier communication1. The pattern of various CHDs observed is
Correspondence:Prof. Mukul Misra, Professor & Head, Department of Medicine, BRD Medical College, Gorakhpur - 273013
Indian Heart J. 2009; 61:58-60
Prevalence and Pattern of CHD in UP
Abbreviations: AR-aortic regurgitation, AS-aortic stenosis,
ASD-atrial septal defect, CHB-complete heart block,
C-TGA-corrected transposition of great arteries, DORV-double outlet right
ventricle, HCM-hypertrophic cardiomyopathy, PDA-patent ductus
arteriosus, PS-pulmonary stenosis, SSS-sick sinus syndrome,
VSD-ventricular septal defect.
The common CHDs identified were ventricular septal
defect (VSD, n=58) followed by atrial septal defect (ASD,
n=26). Amongst the valvular defects, aortic stenosis (AS, n=24)
was seen twice more commonly than pulmonary stenosis
(PS, n=12). Other defects were seen rarely. No child with
congenital cyanotic heart defect was identified.
Out of 142 children, 11 (7.7%) had undergone surgery
or intervention (balloon dilatation). One child with an
ASD underwent surgery after diagnosis and motivation. Only
34 out of the remaining 131 children were aware of their defects.
Most of the surveys done in the past 10 to 20 years in
the United States have identified birth prevalence of CHDs of
4 to 12 children per 1000 live births, and a rate of 10 per
1000 (or 1% of all live births) is often
cited4. Other studies have reported birth prevalence ranging from 8.3 to 10.4 per
1000 live births5-9. The incidence from other countries is
remarkably similar to that reported from the United States (Table
The rates of occurrence of CHD in different reports
vary because prevalence varies due to duration and intensity
of case finding and the sensitivity of the diagnostic
method used. The use of 2-D echocardiography has helped
in diagnosing even very small defects and prevalence rates
have increased as diagnosis has been enhanced. However, we
do not know much about the prevalence of CHD in school
|Table 2. Congenital heart disease in defined
children i.e. between the ages of 5 to 15 years. This is
an important population group and constitutes nearly
1/4th (23.6%) of the total population of our country according
to the latest census report (2001) that poses major burden on
our limited healthcare resources18. According to one
estimate from our country nearly 50,000 children with CHD
require surgery or some form of intervention in
childhood19. Although there have been attempts to quantify the burden of CHD
in India in the past, they fail to reflect the true
The present survey is an attempt to find the prevalence
of CHD in school children of eastern Uttar Pradesh using
ECG, chest radiography and 2-D echocardiography for
confirmation of the diagnosis. The prevalence of CHD observed in
our study is 1.3 per 1000 school children that is more than
two and a half times than that of RHD (0.5 per 1000).
As expected, the commonest defect seen was VSD followed
by ASD. The 6 defects viz. VSD, ASD, AS, PS, patent
ductus arteriosus and VSD with PS accounted for more than 90% of
the lesions identified. This pattern corresponds with the pattern
of CHD identified at birth (Table
|Table 3. Incidence of specific congenital heart defects
aTotal number of cases=103,590
bIncludes tetralogy of Fallot
cIncludes partial and complete
The most important fact that emerges from our study is
lack of awareness; only 11 out of 142 children had
undergone surgery or interventional procedure, one child
underwent closure of ASD after identification of the defect and
|Indian Heart J. 2009; 61:58-60
|Mukul Misra et al
motivation, and only 34 out of the remaining 131(26%)
were aware of their defects. It may be due to the fact that that
most of the defects were mild and not causing any symptoms
and in the absence of routine medical examination,
remained unidentified. The value and need of proper routine
medical examination before entry in schools, therefore, needs to
be emphasized. We did not identify any children with
cyanotic CHD in this survey; possibly because such children are too
sick to attend schools and are therefore school dropouts.
This highlights the pitfall in finding true prevalence of CHD
by school children based surveys, and the need and importance
of population based surveys for identifying true
As such, we do not know any identifiable causes of CHD
in most of the affected children. Prevention therefore,
appears a far-fetched possibility. The best that can be offered is
early identification and management of the problem. This may
be achieved only by awareness and early examination
and investigations. Many affected children may achieve cure
or long-term palliation by this approach. Knowledge
of prevalence of CHD is important because it can assist in
co-ordination of pediatric cardiology services as well as
advanced diagnostic and treatment facilities within a region.
Prevalence of CHD in school children of eastern
Uttar Pradesh is 1.3 per 1000 and is more than that of
RHD. Prevention is not possible in absence of known causes for
the problem. Early identification and management appear
the key to the solution of the problem. Proper medical
examination of children taking admission to schools may be helpful in this regard. Only community based surveys can provide the
exact estimate of the burden.
1. Misra M, Mittal M, Singh RK, et al. Prevalence of rheumatic heart disease in
school-going children of eastern Uttar Pradesh. Indian Heart J 2007; 59: 42-43.
2. Jose VJ, Gomathi M. Declining prevalence of rheumatic heart disease in rural
school children in India. Indian Heart J 2003; 55: 158-60.
3. Essop MR, Omar T. Rheumatic fever. In Crawford MH
et al., eds. Cardiology. Elsevier Limited 2004:1061-1069.
4. Hoffman JIE, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol
2002; 39: 1890-1900.
5. Mitchell SC, Korones SB, Berendes HW. Congenital heart disease in 56, 109
births. Circulation 1971; 43: 323-332.
6. Hoffman JIE. Incidence of congenital heart disease: Postnatal incidence. Pediatr
Cardiol 1995; 16: 103-13.
7. Fulton DR, Freed MD. The pathology, pathophysiology, recognition and treatment
of congenital heart disease in Hurst's. The Heart, ed Valentin Fuster et al,
McGraw-Hill Medical Publishing Division, New York 2004; 1786.
8. Fyler DC. Nadas' Pediatric Cardiology. Philadelphia: Hanley and Belfus; 1992.
9. Keith JD. Prevalence, incidence and epidemiology. In: Keith JD, Rowe RD, Vlad P,
eds. Heart Disease in Infancy and Childhood,
3rd ed. New York: Macmillan; 1970: 3.
10. Khalil A, Aggarwal R, Thirupuram S, Arora R. Incidence of congenital heart
disease among hospital live births India. Indian Pediatr 1994: 31: 519-527.
11. Wren C, O'Sullivan JJ. Survival with congenital heart disease and need for follow up
in adult life. Heart 2001: 85: 438-443.
12. Subramanyan R, Joy J, Venugopalan
P, et al. Incidence and spectrum of congenital
heart disease in Oman. Ann Trop Paediatr 2000; 20: 337-341.
13. Samanek M, Voriskova M, Congenital heart disease among 815, 869 children
born between 1980 and 1990 and their 15-year survival: a prospective Bohemia survival
study. Pediatr Cardiol 1999; 20: 411-417.
14. Roy DL, McIntyre L, Human DG, et al. Trends in the prevalence of congenital
heart disease: comprehensive observations over a 24-year period in a defined region of
Canada. Can J Cardiol 1994; 10: 821-826.
15. Robida A, Folger GM, Hajar HA. Incidence of congenital heart disease in Qatari
children. Int J Cardiol 1997; 60: 19-22.
16. Fixler DE, Pastor P, Chamberlin
M, et al. Trends in congenital heart disease in
Dallas County births. 1971-1984. Circulation 1990; 81: 137-142.
17. Bitar FF, Baltaji N, Dbaibo
G, et al. Congenital heart disease at a tertiary care center
in Lebanon. Middle East J Anesthesiol 1999; 15: 159-164.
18. Census of India. 2001 report projected online at http://www.censusindia.net
19. Grover A, Vijayavergiya R, Thingam ST. Burden of rheumatic and congenital heart
disease in India: lowest estimates based on the 2001 census. Indian Heart J 2002; 54: 104-107.
Indian Heart J. 2009; 61:58-60