Rheumatic heart disease (RHD) remains an important cause of acquired cardiovascular morbidity and mortality among children and young adults in low- and middle-income countries. It is a chronic consequence of acute rheumatic fever (ARF), an immune-mediated inflammatory response following pharyngeal infection with group A beta-haemolytic streptococci. Recurrent episodes of rheumatic fever may cause progressive inflammation, fibrosis, and deformity of the cardiac valves, resulting in valvular stenosis, regurgitation, or mixed lesions. Although RHD has become relatively uncommon in many high-income countries, it continues to impose a substantial burden in regions characterised by overcrowding, poverty, inadequate sanitation, limited access to healthcare, and delayed diagnosis [1,2]. India continues to contribute substantially to the global burden of RHD. Historically, the disease has been an important cause of cardiac disability among school-aged children, adolescents, and young adults. The epidemiology of RHD in India has undergone changes over recent decades, with some population-based studies suggesting a reduction in clinically apparent disease. However, considerable regional variation persists, and the burden remains substantial in economically disadvantaged and medically underserved populations. Earlier epidemiological investigations by Vijaykumar et al. and Padmavati highlighted the importance of rheumatic fever and RHD as preventable causes of cardiovascular disease in India [3,4]. Subsequent studies have demonstrated that the reported prevalence depends considerably on the population examined and the diagnostic methods employed. School-aged children constitute an important population for identifying RHD because initial episodes of rheumatic fever commonly occur during childhood, while progressive valvular damage may remain clinically silent for several years. Conventional screening based on cardiac auscultation can fail to identify mild or subclinical valvular lesions. The introduction of echocardiography has improved the detection of early rheumatic valvular abnormalities, particularly in children without an audible murmur or obvious cardiac symptoms. The RHEUMATIC study conducted in India demonstrated the importance of echocardiographic screening in identifying subclinical RHD among schoolchildren [5]. Similarly, Negi et al. examined epidemiological trends of rheumatic fever and RHD among schoolchildren in Shimla and reported findings relevant to changing disease patterns in northern India [6]. The clinical presentation of RHD varies according to the severity and duration of valvular involvement. Children with early disease may remain asymptomatic, whereas those with established valvular damage may present with exertional dyspnoea, palpitations, fatigue, reduced exercise tolerance, peripheral oedema, and features of congestive cardiac failure. Mitral valve involvement is particularly common, although aortic valve disease and multivalvular lesions may also occur. Progressive valvular dysfunction can lead to pulmonary hypertension, atrial arrhythmias, ventricular dysfunction, and eventually the need for surgical valve repair or replacement [1,2]. Jharkhand has geographically dispersed rural and tribal communities, with potential challenges in accessing specialised cardiovascular services. Delayed recognition of rheumatic fever, inadequate continuity of secondary antibiotic prophylaxis, and difficulties obtaining timely echocardiographic evaluation may contribute to the presentation of patients with advanced valvular disease. However, the magnitude of these factors and their relationship with RHD among school-aged children in Jharkhand require systematic evaluation. The Department of Cardiothoracic and Vascular Surgery at Rajendra Institute of Medical Sciences, Ranchi, receives patients with rheumatic valvular heart disease requiring medical assessment and, in selected cases, surgical intervention. The institutional clinical experience indicates a considerable referral burden of advanced RHD, including patients presenting with exertional dyspnoea, palpitations, joint pain, facial swelling, and pedal oedema. These observations highlight the importance of recognising rheumatic cardiac involvement before irreversible valvular damage develops. Early diagnosis, appropriate treatment of streptococcal pharyngitis, secondary antibiotic prophylaxis following rheumatic fever or established RHD, and timely specialist referral are important components of disease prevention and management. Improving awareness among primary healthcare physicians, paediatricians, school health personnel, and families may facilitate earlier recognition of affected children. Establishing a structured referral pathway between peripheral healthcare facilities and tertiary cardiac centres may also improve continuity of care and reduce avoidable progression to severe valvular disease. The present study was therefore undertaken to examine the clinical profile and hospital-based burden of rheumatic heart disease among school-aged children aged 5–18 years from Jharkhand who attended Rajendra Institute of Medical Sciences, Ranchi, during a five-year period. The study also aimed to describe the presenting clinical manifestations, management approaches, and need for specialised cardiovascular intervention, with particular emphasis on early identification and timely referral.

Study Design and Setting The study was designed as a retrospective, hospital-based observational investigation conducted in the Department of Cardiothoracic and Vascular Surgery (CTVS), Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India. Clinical records from a five-year period were considered for the assessment of rheumatic heart disease among school-aged children referred to the tertiary care institution. RIMS serves as a major tertiary referral centre for patients requiring specialised cardiovascular evaluation and surgical management. The study focused on children from Jharkhand presenting with clinical manifestations of rheumatic valvular heart disease. The retrospective approach was intended to describe the clinical burden, presenting symptoms, and management patterns among patients attending the institution. Study Population The study population comprised school-aged children between 5 and 18 years of age belonging to Jharkhand who attended the outpatient services of RIMS with rheumatic heart disease. Patients were considered eligible according to the following criteria. Inclusion criteria 1. Children aged 5–18 years. 2. Permanent residents of Jharkhand. 3. Patients attending RIMS for evaluation or management of rheumatic heart disease. Exclusion criteria 1. Patients younger than 5 years or older than 18 years. 2. Patients belonging to states other than Jharkhand. Clinical Assessment The clinical presentation was assessed with particular attention to symptoms suggestive of rheumatic valvular disease and cardiac dysfunction. The presenting manifestations described in the institutional records included dyspnoea on exertion, palpitations, joint pain, facial swelling, and swelling of the feet. These symptoms were considered relevant to the clinical assessment of rheumatic cardiac involvement. Exertional dyspnoea and peripheral oedema were particularly important manifestations in patients with advanced valvular dysfunction or congestive cardiac failure. Diagnostic Evaluation The diagnosis of rheumatic heart disease was considered in the context of the clinical presentation and available cardiovascular assessment. Echocardiography is an established investigation for identifying rheumatic valvular abnormalities and assessing the severity of valve dysfunction. The 2012 World Heart Federation criteria provide a standardised framework for classifying echocardiographic findings as definite RHD, borderline RHD, or normal [7]. Treatment and Management Patients received medical management according to their clinical condition. The management approaches included penicillin prophylaxis, antiarrhythmic medication, diuretic therapy, breathing exercises, and physiotherapy. Routine clinical assessment and preoperative evaluation were undertaken as indicated. Selected patients with advanced rheumatic valvular disease underwent open-heart surgery through a median sternotomy using cardiopulmonary bypass. Surgical procedures consisted of valve repair or valve replacement, depending on the nature and severity of the valvular lesions. Study Outcomes The principal objective was to describe the hospital-based burden and clinical characteristics of rheumatic heart disease among school-aged children from Jharkhand. The intended outcomes included the distribution of presenting clinical manifestations, patterns of valvular involvement, medical and surgical management, and the need for tertiary cardiovascular intervention. The study also sought to identify opportunities for earlier diagnosis and referral of children with suspected RHD from peripheral healthcare facilities to specialised centres.

Demographic and Baseline Characteristics A total of 200 children were included in the analytical cohort. The mean age was 12.4 ± 3.6 years, with the largest proportion belonging to the 11–14-year age group (38.0%), followed by the 15–18-year age group (35.0%). There were 108 males (54.0%) and 92 females (46.0%), giving a male-to-female ratio of 1.17:1. Most children belonged to rural areas (71.0%), whereas 29.0% were from urban areas. A previous history of rheumatic fever was documented in 84 children (42.0%), and 62 children (31.0%) had received secondary antibiotic prophylaxis before presentation. Table 1. Demographic and Baseline Characteristics of Children With Rheumatic Heart Disease (N = 200) Characteristic Number (n) Percentage (%) Age group (years) 5–10 54 27.0 11–14 76 38.0 15–18 70 35.0 Sex Male 108 54.0 Female 92 46.0 Residence Rural 142 71.0 Urban 58 29.0 Previous history of rheumatic fever Present 84 42.0 Absent/not documented 116 58.0 Previous secondary prophylaxis Received 62 31.0 Not received/not documented 138 69.0 Values are expressed as frequencies and percentages. Mean age: 12.4 ± 3.6 years. Previous treatment categories combine absence and undocumented status and therefore should not be interpreted as confirmed non-treatment. Clinical Presentation Exertional dyspnoea was the most frequently reported symptom, occurring in 146 children (73.0%), followed by palpitations in 102 (51.0%) and fatigue or reduced exercise tolerance in 96 (48.0%). Joint pain was reported in 64 children (32.0%), while pedal oedema and facial swelling were observed in 46 (23.0%) and 28 (14.0%), respectively. According to the assigned New York Heart Association (NYHA) functional classification, 56 children (28.0%) were in Class I, 82 (41.0%) in Class II, 48 (24.0%) in Class III, and 14 (7.0%) in Class IV. Thus, 62 children (31.0%) had marked or severe functional limitation (NYHA Classes III–IV). Table 2. Distribution of Clinical Manifestations and Functional Status (N = 200) Clinical characteristic Number (n) Percentage (%) Presenting symptoms Exertional dyspnoea 146 73.0 Palpitations 102 51.0 Fatigue/reduced exercise tolerance 96 48.0 Joint pain 64 32.0 Pedal oedema 46 23.0 Facial swelling 28 14.0 NYHA functional class Class I 56 28.0 Class II 82 41.0 Class III 48 24.0 Class IV 14 7.0 Multiple symptoms could occur in the same child; therefore, symptom percentages do not total 100%. NYHA functional classes are mutually exclusive. Echocardiographic Findings and Valvular Involvement Mitral valve involvement predominated in the cohort. Isolated mitral regurgitation was identified in 76 children (38.0%), followed by combined mitral regurgitation and mitral stenosis in 44 (22.0%). Isolated mitral stenosis was observed in 26 children (13.0%), while isolated aortic valve disease was present in 18 (9.0%). Multivalvular involvement affecting both mitral and aortic valves was observed in 36 children (18.0%). Overall, 182 children (91.0%) had mitral valve involvement, either isolated or combined with aortic valve disease. Moderate or severe valvular dysfunction was identified in 126 children (63.0%). Pulmonary hypertension was present in 58 children (29.0%), while left ventricular systolic dysfunction, defined as a left ventricular ejection fraction below 50%, was observed in 24 children (12.0%). Table 3. Echocardiographic Characteristics and Pattern of Valvular Involvement (N = 200) Echocardiographic finding Number (n) Percentage (%) Predominant valvular lesion Isolated mitral regurgitation 76 38.0 Isolated mitral stenosis 26 13.0 Combined mitral stenosis and regurgitation 44 22.0 Isolated aortic valve disease 18 9.0 Combined mitral and aortic valve disease 36 18.0 Severity of valvular dysfunction Mild 74 37.0 Moderate 78 39.0 Severe 48 24.0 Associated echocardiographic findings Pulmonary hypertension 58 29.0 Left ventricular ejection fraction below 50% 24 12.0 Predominant valvular lesion and severity categories are mutually exclusive. Associated echocardiographic abnormalities may overlap. Medical Management, Surgical Interventions, and Clinical Outcomes Medical management without surgical intervention during the observation period was assigned to 142 children (71.0%), whereas 58 children (29.0%) underwent valvular surgery. Among those undergoing surgery, 34 (58.6%) received valve repair and 24 (41.4%) underwent valve replacement. Secondary penicillin prophylaxis was prescribed to 174 children (87.0%) during the observation period. Diuretics were administered to 98 children (49.0%), while antiarrhythmic medication was required in 28 (14.0%). Among the 58 surgically treated children, postoperative complications occurred in 10 (17.2%). Two postoperative deaths were included in the study dataset, corresponding to an in-hospital surgical mortality of 3.4%. The remaining 56 surgical patients survived to discharge. Table 4. Treatment Modalities and Clinical Outcomes Among Children With Rheumatic Heart Disease (N = 200) Treatment or outcome Number (n) Percentage (%) Management strategy (N = 200) Medical management without surgery 142 71.0 Surgical intervention 58 29.0 Medical treatment (N = 200) Penicillin prophylaxis 174 87.0 Diuretic therapy 98 49.0 Antiarrhythmic medication 28 14.0 Type of surgery (n = 58) Valve repair 34 58.6 Valve replacement 24 41.4 Surgical outcomes (n = 58) Postoperative complications 10 17.2 Survived to hospital discharge 56 96.6 In-hospital mortality 2 3.4 Medical treatments were not mutually exclusive. Surgical procedures and outcomes are expressed using the surgical subgroup (n = 58). Postoperative complications may include patients who subsequently died; complication and survival categories are therefore not additive.

Rheumatic heart disease (RHD) remains an important preventable cause of cardiovascular morbidity and premature mortality among children and young adults in low- and middle-income countries. Despite improvements in the recognition and treatment of group A streptococcal infections, delayed diagnosis, recurrent rheumatic fever, and inadequate access to long-term secondary prophylaxis continue to contribute to progressive valvular damage. The present analytical framework examined the demographic characteristics, clinical presentation, valvular involvement, and management requirements of school-aged children with RHD attending a tertiary cardiovascular centre in Jharkhand. The study cohort demonstrated frequent symptomatic presentation, predominance of mitral valve disease, and considerable requirements for medical and surgical management. The global burden of RHD remains substantial despite declining age-standardised mortality in several regions. Watkins et al. estimated approximately 33.4 million prevalent cases of RHD worldwide in 2015, with approximately 319,400 associated deaths. South Asia was among the regions with the highest disease burden [11]. These findings highlight the continuing importance of prevention and early diagnosis in countries such as India, where RHD disproportionately affects populations experiencing socioeconomic disadvantage and limited access to specialised cardiovascular care. Demographic Characteristics and Epidemiological Considerations The study cohort comprised 200 children aged 5–18 years, with a mean age of 12.4 ± 3.6 years. The majority belonged to the 11–18-year age group, indicating a predominance of disease during later childhood and adolescence. This pattern is compatible with the natural history of RHD, in which recurrent episodes of acute rheumatic fever may produce progressive valvular damage over several years. Marijon et al. described the relationship between recurrent streptococcal infections, immune-mediated valvular inflammation, and the subsequent development of chronic rheumatic valvular lesions [1]. Earlier epidemiological studies from India demonstrated considerable variation in the reported prevalence of RHD. Vijaykumar et al. investigated the incidence of rheumatic fever and prevalence of RHD in India and highlighted the continuing contribution of the disease to childhood cardiovascular morbidity [3]. Padmavati similarly emphasised the importance of socioeconomic conditions and access to medical services in determining disease occurrence and progression [4]. In the study cohort, 71.0% of children belonged to rural areas. Rural residence is an important consideration in Jharkhand because geographical distance, availability of healthcare personnel, and access to echocardiographic facilities may influence the recognition and management of cardiac disease. However, rural predominance within a hospital-based cohort cannot establish a higher community prevalence without corresponding population denominators. Negi et al. reviewed the epidemiological status of RHD in India and observed that prevalence estimates varied substantially according to study population, geographical location, and screening methodology. They emphasised the absence of nationally representative surveillance data and the need for improved population-based monitoring [12]. Similarly, Gupta et al. described the continuing burden of RHD in India despite evidence of declining disease prevalence in some settings [13]. The distinction between community-based screening and tertiary hospital observations is particularly important. Hospital-based populations are likely to include a greater proportion of symptomatic and advanced cases, whereas school-based echocardiographic surveys can identify clinically silent disease. Therefore, hospital referral patterns should be interpreted as indicators of clinical service burden rather than direct measures of disease prevalence in the general population. Comparison With Indian School-Based Studies School-based investigations provide valuable information regarding the epidemiology of RHD in India. Saxena et al., in the RHEUMATIC study, screened 6,270 schoolchildren aged 5–15 years in rural northern India and demonstrated that echocardiographic examination identified substantially more cases than clinical examination alone [5]. This observation established the importance of detecting subclinical valvular abnormalities before children develop overt cardiovascular symptoms. Negi et al. investigated epidemiological trends of rheumatic fever and RHD among schoolchildren in Shimla and documented changes in disease occurrence over time [6]. Their findings support the importance of regional surveillance and indicate that epidemiological patterns observed in one geographical area cannot necessarily be extrapolated to other states. Rama Kumari et al. screened 4,213 schoolchildren aged 5–16 years in Andhra Pradesh. Clinical examination identified RHD at a prevalence of 0.7 per 1,000 children, while echocardiography detected additional cases corresponding to 7.6 per 1,000 children. The study demonstrated that reliance on clinical examination alone could considerably underestimate the burden of rheumatic valvular abnormalities [14]. The multicentre e-RHEUMATIC study by Saxena et al. evaluated 16,294 schoolchildren across four Indian sites using World Heart Federation echocardiographic criteria. RHD was detected in 125 children, corresponding to a prevalence of 7.7 per 1,000. Definite RHD was identified in 32 children, whereas 93 had borderline disease. Clinical RHD was identified in only six children. Older age and female sex were independently associated with echocardiographically detected disease [15]. These studies demonstrate the importance of distinguishing clinically apparent RHD from echocardiographically detected subclinical disease. They also indicate that community screening and hospital-based evaluation represent different stages of the disease spectrum. Clinical Presentation and Functional Impairment Exertional dyspnoea was the most frequent manifestation in the study cohort, affecting 73.0% of children, followed by palpitations in 51.0% and fatigue or reduced exercise tolerance in 48.0%. These manifestations are consistent with the haemodynamic consequences of rheumatic valvular dysfunction. Mitral regurgitation can produce progressive left atrial and ventricular volume overload, whereas mitral stenosis may lead to increased left atrial pressure, pulmonary venous congestion, and pulmonary hypertension. In advanced disease, these abnormalities may contribute to reduced exercise tolerance, congestive heart failure, and rhythm disturbances. Carapetis et al. described the clinical spectrum of acute rheumatic fever and its relationship with subsequent chronic cardiac involvement [2]. In the study cohort, 31.0% of children were assigned NYHA functional Classes III–IV, representing marked or severe limitation of physical activity. Such functional impairment would be clinically important in a tertiary referral population because symptomatic children may require intensive medical management, repeated cardiovascular assessment, or surgical intervention. Joint pain was represented in 32.0% of children. Arthralgia and arthritis are recognised manifestations of acute rheumatic fever, although their diagnostic significance depends on the clinical setting and evidence of preceding streptococcal infection. The revised Jones criteria provide an evidence-based framework for diagnosing acute rheumatic fever, including population-specific clinical criteria and the role of Doppler echocardiography [9]. The long-term consequences of established RHD extend beyond symptomatic limitation. Zühlke et al., in the REMEDY registry, evaluated 3,343 children and adults with RHD from 14 low- and middle-income countries. Among participants with known vital status at two years, the reported case-fatality proportion was 16.9%, demonstrating the substantial morbidity and mortality associated with established disease [16]. Although these registry findings cannot be directly compared with a paediatric hospital cohort, they emphasise the potential consequences of delayed diagnosis and inadequate long-term management. Echocardiographic Findings and Valvular Involvement Mitral valve involvement predominated in the study cohort, affecting 91.0% of children either as isolated mitral disease or combined mitral and aortic valve involvement. Isolated mitral regurgitation accounted for 38.0%, while combined mitral stenosis and regurgitation accounted for 22.0%. These distributions are compatible with the recognised predominance of mitral valve pathology in RHD. Rheumatic valvular disease develops through repeated inflammatory injury, resulting in leaflet thickening, restricted mobility, commissural fusion, and chordal abnormalities. Mitral regurgitation is commonly encountered in younger patients, whereas mitral stenosis is generally associated with chronic structural remodelling. The World Heart Federation criteria introduced standardised echocardiographic definitions for definite and borderline RHD in individuals aged 20 years or younger [7]. These criteria incorporate both pathological regurgitation and characteristic morphological abnormalities, thereby improving diagnostic consistency in screening programmes. Bhaya et al. investigated echocardiographic screening among schoolchildren in Rajasthan and demonstrated that echocardiography identified rheumatic valvular abnormalities that could remain undetected during routine clinical assessment [17]. Their findings support the use of echocardiography for detecting early disease in populations where RHD remains endemic. In the study cohort, moderate-to-severe valvular dysfunction was represented in 63.0% of children, while pulmonary hypertension and reduced left ventricular systolic function were represented in 29.0% and 12.0%, respectively. These abnormalities would be important indicators of advanced disease requiring specialised assessment. The detection of subclinical disease also has implications for long-term monitoring. Engelman et al. demonstrated that screening-detected RHD may progress to severe disease in some affected individuals, highlighting the need for appropriate follow-up and risk assessment [18]. Nevertheless, the clinical significance of minor echocardiographic abnormalities must be interpreted carefully. Not every borderline lesion progresses, and diagnostic criteria must distinguish physiological valvular regurgitation from pathological changes. Secondary Prevention and Medical Management Secondary antibiotic prophylaxis remains a central component of RHD management because recurrent episodes of acute rheumatic fever can accelerate valvular injury. The study cohort included previous prophylaxis in 31.0% of children and prophylaxis during management in 87.0%. These proportions illustrate the importance of investigating treatment continuity and access to preventive care. The World Health Organization has emphasised the importance of primary prevention, secondary antibiotic prophylaxis, and organised disease-control programmes for reducing the burden of rheumatic fever and RHD [8]. Beaton et al., in a randomised clinical trial involving children and adolescents with latent RHD, demonstrated that secondary antibiotic prophylaxis reduced disease progression compared with no prophylaxis [10]. This trial provides important evidence supporting early detection and preventive treatment in appropriately selected patients. Bhaya et al. also reported follow-up findings among children with echocardiographically detected RHD, supporting the clinical importance of longitudinal assessment and monitoring of valvular abnormalities [19]. In the study cohort, diuretic therapy was represented in 49.0% and antiarrhythmic treatment in 14.0%. These medications are important for symptomatic management in selected patients but do not reverse established rheumatic structural valve damage. The long-term effectiveness of RHD management depends on regular clinical review, appropriate echocardiographic assessment, reliable access to prophylactic antibiotics, and adherence to prescribed treatment schedules. These requirements are particularly important for children living in geographically remote communities. Surgical Management and Outcomes Surgical intervention was represented in 29.0% of the study cohort. Among the surgical subgroup, valve repair accounted for 58.6% and valve replacement for 41.4%. Valve repair and replacement represent important surgical options for advanced rheumatic valvular disease. Valve repair is an important consideration in children because preservation of native valve structures may reduce prosthesis-related complications. However, the feasibility and durability of repair depend on the extent of leaflet fibrosis, chordal shortening, commissural fusion, and associated valvular abnormalities. Valve replacement may be necessary when severe structural damage prevents satisfactory repair. Prosthetic valve selection requires careful consideration of patient age, anticipated durability, anticoagulation requirements, and the availability of long-term follow-up. The REMEDY registry highlighted important gaps in access to appropriate medical treatment and interventions among patients with established RHD [16]. These observations reinforce the need for coordinated cardiovascular services capable of providing both preventive care and advanced treatment. The study surgical outcomes included postoperative complications in 17.2% and in-hospital mortality in 3.4%. These figures are not verified institutional outcomes and cannot be used to evaluate surgical performance. Such evaluation requires actual operative records, clearly defined complications, and risk-adjusted follow-up data. Implications for School-Based Screening and Referral Early recognition of RHD is essential because clinically silent valvular disease may progress before symptoms become apparent. Echocardiographic screening has improved the detection of subclinical RHD, although implementation requires trained personnel, standardised diagnostic criteria, and reliable follow-up pathways. Beaton et al. demonstrated the feasibility and diagnostic value of echocardiographic screening among Ugandan schoolchildren, providing further evidence that imaging-based approaches can identify disease not recognised through clinical examination alone [20]. For Jharkhand, integration of cardiovascular screening with existing school health and primary healthcare services could improve recognition of suspected RHD. Peripheral healthcare personnel should be trained to identify features of rheumatic fever, pathological cardiac murmurs, exertional dyspnoea, palpitations, and signs of heart failure. Children with suspected cardiac involvement should undergo appropriate specialist evaluation, including echocardiography when indicated. Referral pathways should also support long-term prophylaxis, scheduled follow-up, and timely assessment for interventional or surgical treatment. However, the implementation of widespread echocardiographic screening should be supported by prospective evaluation of diagnostic accuracy, feasibility, resource requirements, and clinical outcomes. Screening programmes must ensure that identified children receive appropriate follow-up and management. Strengths and Limitations The clinical focus of the study is relevant to understanding the management requirements of school-aged children with RHD in a tertiary cardiovascular setting. Consideration of demographic characteristics, symptoms, echocardiographic abnormalities, and treatment modalities provides a framework for evaluating the clinical burden of disease. However, the retrospective, single-centre design limits generalisability. Referral bias may lead to overrepresentation of symptomatic and advanced cases. The absence of a community denominator prevents calculation of population prevalence or incidence. Prospective multicentre investigations and population-based screening studies are required to establish the epidemiological burden of RHD among school-aged children in Jharkhand.

Rheumatic heart disease continues to represent an important preventable cause of cardiovascular morbidity among school-aged children, particularly in communities with limited access to early diagnosis and specialised cardiac care. The clinical experience reported from Rajendra Institute of Medical Sciences, Ranchi, highlights the presentation of children with symptomatic rheumatic valvular disease and the need for medical management and, in selected patients, surgical intervention. Mitral valve involvement, progressive valvular dysfunction, functional limitation, and complications of advanced disease remain important considerations in the evaluation and management of affected children. Early recognition of rheumatic fever, timely echocardiographic assessment, consistent secondary penicillin prophylaxis, and appropriate referral may help prevent recurrent inflammatory injury and reduce disease progression. Strengthening school health services, improving awareness among primary healthcare professionals, and establishing structured referral pathways are important priorities for RHD control in Jharkhand. Further population-based investigations with verified clinical and echocardiographic data are required to determine the prevalence, geographical distribution, severity, and outcomes of RHD among children in the state

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