What does this research mean for the field?

Echocardiogram-detected rheumatic heart disease prevalence in endemic regions is 24 per 1,000 in children and adolescents, with female predominance already manifest in latent disease stages alongside increased risk in rural, low-income, and public school populations. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

November 6, 2025Frontiers in Cardiovascular MedicineOpen Access

Global prevalence and sex differences in rheumatic heart disease: a systematic review and updated meta-analysis

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Why the study?

While acute rheumatic fever shows equal prevalence among sexes in children, clinically manifest rheumatic heart disease in adulthood is more prevalent in females, prompting an evaluation of global prevalence, sex disparities, and risk factors.

Structured PICO

Population

215,552 individuals aged 5-20 years from endemic areas across 58 cross-sectional studies, evaluated through echocardiogram-based screening for latent rheumatic heart disease.

Outcome

Echocardiographic prevalence of RHD in endemic areas

This meta-analysis demonstrates a global prevalence of echo-detected latent rheumatic heart disease of 24 per 1,000 in endemic regions, with a significantly higher prevalence in females, rural areas, public schools, and low-income families.

Limitations

Varying inclusion criteria, ethnicities, baseline characteristics, and risk factors increasing heterogeneity
Different regional prevalences between studies

Implication

May inform sex-stratified RHD screening in endemic regions; leaves open drivers of female predominance.

Abstract

Background Rheumatic heart disease (RHD), a sequela of acute rheumatic fever (ARF), remains as the leading cause of acquired cardiac disease in children, posing a significant burden to health systems, especially in low-to-middle-income countries. While ARF shows equal prevalence among sexes in children, clinically manifest RHD in adulthood is strikingly more prevalent in females, with at least a 2:1 ratio. We conducted a meta-analysis to evaluate the global prevalence of RHD and sex disparities alongside risk factors. Methods PubMed, Embase, Cochrane, and Lilacs were searched for cross-sectional studies on RHD prevalence in individuals aged 5–20, evaluated through echocardiogram-based screening in endemic areas. Studies relying on auscultation were excluded. RHD was defined as borderline/definite by 2012 WHF criteria or possible/probable/definite by WHO criteria. Results Fifty-eight studies with 215,552 subjects were included. Echo-detected RHD prevalence was 24/1,000 (95%-CI: 20-30) globally. Subgroup analyses showed consistently lower RHD prevalence in males (RR: 0.70; 95%-CI: 0.61–0.80; p < 0.01). Definite RHD prevalence was 9/1,000 (95%-CI: 7–12), with lower rates among males (RR: 0.71; 95%-CI: 0.59–0.86; p < 0.01). Children in private schools (RR: 0.68; 95%-CI: 0.48–0.97; p = 0.03), medium-high-income families (RR: 0.57; 95%-CI: 0.41–0.81; p < 0.01), and urban areas (RR: 0.49; 95%-CI: 0.26–0.93; p = 0.03) exhibited reduced RHD prevalence. Conclusion This meta-analysis highlights early gender disparities in RHD, with female predominance preceding established valve lesions. Prevalence remains higher in rural areas, public schools, and low-income families, with global prevalence in endemic regions at 24/1,000. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD42023491941 , PROSPERO CRD42023491941.