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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 5, September/October 2018
AFRICA
297
evaluate these parameters in terms of heart valve involvement
during the acute phase.
Methods
The authors assert that all procedures contributing to this work
comply with the ethical standards of the relevant national
guidelines on human experimentation and with the Helsinki
Declaration of 1975, as revised in 2008. The study was approved
by the institutional committee of Erciyes University. Detailed
consent forms were signed by the parents of all subjects before
participating in the study.
In this matched case–control study, 120 consecutive patients
diagnosed with ARC at the Department of Paediatric Cardiology
between February 2010 and March 2016, were enrolled in the
study. As the Jones criteria for the diagnosis of ARF were
modified in 2015,
15
older criteria had been used for the diagnosis
of earlier patients. A diagnosis of ARF was established when the
last Jones criteria were fulfilled for acute cases.
All patients underwent echocardiographic examination
before starting anti-inflammatory treatment. The Vivid 7 Pro
Ultrasound System (GE Medical Systems, NE) was used for
two-dimensional, M-mode and colour-flow Doppler imaging.
A paediatric cardiologist experienced in rheumatic heart disease
performed all echocardiographic examinations following the
guidelines of the American Society of Echocardiography and
European Society of Cardiology.
16
The severity of mitral and
aortic regurgitation detected by colour Doppler was defined
as mild, moderate and severe when the length of the jet was
>
1.5, 1.5–2.9 and
>
3 cm, respectively.
17
The patient group was
further divided into two subgroups according to the degree of
regurgitation, which included those with severe and those with
mild-to-moderate regurgitation.
Patients who had taken non-steroidal anti-inflammatory
drugs within the last four weeks before blood sampling, and those
with abnormal renal function or liver tests and malignancies
were excluded.
Arthritis and mild-to-moderate carditis were treated with
salicylate, whereas patients with severe carditis were treated
with oral prednisolone. Also, oral steroid therapy was started
in patients without discriminating between moderate and severe
carditis. Initially prednisolone (2 mg/kg/d) was given for two
weeks, which was then tapered off, and aspirin was started at
75–100 mg/kg/d (maximum dose 3.5 g/d) to prevent rebound.
Fifty age- and gender-matched healthy children were recruited
from the local population. They were referred to our hospital
because of cardiac murmur and underwent electrocardiography.
They had a negative medical history and no signs or symptoms
of acute or chronic disease. All participants in the control group
were examined by the same paediatrician and the results of the
physical examination were normal.
Full blood count parameters, anti-streptolysin-O (ASO),
erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)
titres and echocardiographic examinations of all subjects were
recorded from the same computerised database. Blood samples
were drawn from the peripheral veins and collected in plastic
tubes (Vacutainer-Becton, Dickinson and Co, USA), containing
dipotassium ethylene diamine tetra-acetic acid (EDTA-K2).
The full blood count analysis was done by flow cytometry
using the Abxpentra model 120 DX analyser in the laboratory
of our institution. NLR was calculated using the absolute count
method. ESR was determined with the Westergren method. ASO
(Rapitex ASL) and CRP titres were determined using standard
reagents on the Beckman-Coulter DXC 800 systems analyser in
the same laboratory.
Statistical analysis
Data are reported as mean ± standard deviation. If not normally
distributed, parameters are presented as median (range). The
distribution pattern of data was assessed with the Shapiro–
Wilks test. Differences between quantitative groups with normal
distribution were evaluated with the Student’s
t
-test. The Mann–
Whitney
U
-test was used for abnormally distributed data. The
associations between parameters were assessed using Pearson’s or
Spearman’s correlation tests. Statistical Package for Social Sciences
(SPSS) version 22.0 (SPSS Inc, Chicago, IL, USA) was used for all
statistical calculations. Beta- and
p
-values were assessed for each
independent factor in multiple linear regression analysis;
p
-values
<
0.05 were considered to be statistically significant.
Results
One hundred and twenty patients (72 female), who were
diagnosed with ARC, and 50 age- and gender-matched healthy
children were included in this study. The mean age of the patients
was 12.25 ± 2.89 (range: 7–18) years. Baseline clinical and
laboratory characteristics of patients and control subjects are
shown in Table 1.
Compared with the controls, ASO, CRP, ESR, haemoglobin,
white blood cell count (WBC), neutrophil count, MPV and NLR
values were significantly higher in patients with acute carditis
compared with the controls (
p
<
0.001) (Table 1). Also, platelet
counts (
p
=
0.002) and MPV (
p
=
0,049) values were significantly
higher in the patients. NLR was found to have a significantly
positive correlation with CRP (
r
=
0.177,
p
=
0.001), ESR (
r
=
Table 1. Demographic and laboratory characteristics
of the patient and control groups
Characteristics
Control (
n
=
50) ARF (
n
=
120)
p
-value
Age (years)
12.96 ± 2.55
12.25 ± 2.89
0.48
Males,
n
(%)
12
48
0.86
WBC count (× 10
3
cells/mm
3
)
7.02 ± 1.86
10.58 ± 3.76
<
0.01
Haemoglobin (g/dl)
13.60 ± 1.09
12.35 ± 1.03
<
0.01
ESR (mm/hour)
3.83 ± 2.57
37.12 ± 27.63
<
0.001
CRP (mg/l)
3.34 ± 0.54
46.37 ± 48.78
<
0.001
ASO (U/ml)
244.91 ± 239.62 995.24 ± 1023.69
<
0.001
Platelet count (× 10
3
cells/mm
3
) 291.30 ± 67.80
355.22 ± 103.3
0.002
MPV (fl)
10.21 ± 1.25
9.01 ± 1.35
<
0.003
RDW (%)
13.65 ± 1.30
12.88 ± 0.89
0.26
Neutrophil count
(× 10
3
cells/mm
3
)
3.64 ± 1.20
7.21 ± 3.56
<
0.001
Lymphocyte count
(× 10
3
cells/mm
3
)
2.64 ± 0.84
2.55 ± 0.84
0.67
NLR
a
1.35 (1.02–1.94) 3.73 (2.02–4.07)
<
0.001
MCV (fl)
82.95 ± 5.04
80.15 ± 6.01
0.06
ARF: acute rheumatic fever, ASO: anti-streptolysin-O, CRP: C-reactive protein,
ESR: erythrocyte sedimentation rate, MPV: mean platelet volume, WBC:
white blood cell, RDW: red blood cell distribution width, NLR: neutrophil-to-
lymphocyte ratio, MCV: mean corpuscular volume (fl).
Parametric values are expressed as means with standard deviation. Significance
is determined by
p
<
0.05 and shown in bold.
a
If not normally distributed,
values are presented as median and range in parentheses.