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The prevalence of congenital heart disease in United States college freshmen, 1956–1965
876
Brief clinical and laboratory observations
The prevalence of congenital heart disease in United States college freshmen, 1956-1965 Lowell W. Perry, M.D. * Leo M. Henikoff, M.D., and Clare Findlan ~,VASHINGTON,
D. C .
I N 1956 the Heart Disease and Stroke Control Program and the American College Health Association began a cooperative study to determine the prevalence of rheumatic fever in United States college freshmen. 1,2 The students participating were asked to complete a questionnaire especially designed to elicit a history of rheumatic fever. Each student was then examined by a private or school physician. T h e examining physician validated the history and, after physical examination, noted the presence of rheumatic or congenital heart disease. The purpose of this report is to present data relative to the prevalence of congenital heart disease noted in the study between 1956 and 1965. METHODOLOGY T h e history and physical examination were recorded on a questionnaire precoded for automatic data processing?, 2 Data were transferred to punch cards and processed by the data processing facilities of the National Center for Chronic Disease Control. RESULTS
Between 1956 and 1965, 767,600 matriculating college freshmen from 50 states and From the Children's Hospital of D. C. and Heart Disease and Stroke Control Program, United States Public Health Service. *Address: Children's Hospital of D. C., 2125 13th St., N.W., Washington, D. G. 20009.
The Journal of Pediatrics November 1969
Table I. Prevalence of congenital heart disease in United States college freshmen 1956-1965
Year
No. in survey
Cases of CHD*/ 1,000 students examined
1956 1957 1958 1959 1960 1961 1962 1963 1964 1965
86,939 95,083 t13,538 110,317 111,252 18,385 51,275 67,062 62,414 51,335
0.1 0.7 1.0 1.0 0.9 0.3 0.4 0.6 0.7 0.9
~ C H D = congenital heart disease.
the District of Columbia completed the questionaire and were interviewed and examined by physicians. The study population represented 7.8 per cent of the total college freshmen enrollment during the decade of the study. Of the 767,600 students participating, 550, or approximately 0.7 per 1,000 students examined, were identified as having congenital heart disease by the examining physicians. The prevalence of congenital heart disease for each year of the study is shown in Table I. These data indicate no specific trend ill the prevalence of congenital heart disease. Statistically the 95 per cent confidence limits for the mean prevalence are 0.47 to 0.85 cases per 1,000 students examined. Table I I contains the types of heart disease reported during the decade of the study. The examining physicians did not make a specific diagnosis in 212 or 38.5 per cent of the 550 students with congenital heart disease. Of the 338 cases in which the physician made a specific diagnosis, ventricular septal defect was the most common lesion, being found in 41 per cent of the cases. Atrial septal defect was present in 18 per cent. Pulmonary stenosis was the diagnosis in 12 per cent. Patent ductus arteriosus was present in 11 per cent, and aortic stenosis was noted in 7 per cent. Three per cent had tetralogy of Fallot, and the remaining 8 per
Volume 75 Number 5
Brie[ clinical and laboratory observations
87 7
Table II. Types of congenital heart disease noted in United States college freshmen, 1956-1965 Type
Congenital heart disease, type not specified Ventrieular septal defect Atrial septal defect Pulmonary stenosis Patent ductus arteriosus Aortic stenosis Coarctation of aorta Tetralogy of Fallot Congenital aortic insufficiency Complete heart block Other specific lesions Total ~'One h a d
documented
corrected
transportation
of great
Total
No. without surgery
No. with surgery
212 137 61 39 36 24 13 9 4 3~ 12 550
204 131 58 35 18 23 6 4 4 3 12 498
8 6 3 4 18 1 7 5 0 0 0 52
vessels.
Table I l L Prevalence of congenital heart disease in United States military inductees
Year
No. in survey
Age range
Cases of CHDe/ I ,O00 students examined
1943 1950-1953 1953-1958 1958-1960
100,000 3,812,189 1,921,253 552,355
18-38 18-26 18-26 18-26
1.8 1.2 1.8 1.5
Re[erence
e C H D = congenital heart disease.
cent had various other types of lesions. The examining physicians reported that surgical treatment had been performed on 52 or 9.5 per cent of the total group with heart disease. Coarctation of the aorta, patent ductus arteriosus, and tetralogy of Fallot were the lesions most frequently reported as having required surgical treatment prior to college. Less than 5 per cent of the students with a diagnosis of ventricular or atrial septal defect had undergone surgical treatment. Approximately 10 per cent of those with pulmonary stenosis had had surgical treatment prior to enrolling in college. DISCUSSION It is impossible to ascertain the accuracy of the diagnos!s made by the examining physicians. However, the constancy of the prevalence rates noted from year to year and the narrow 95 per cent confidence limits suggest some precision in the ability of a large group of physicians to detect congenital heart disease. During the decade of this
study when the prevalence of congenital heart disease was relatively constant, the total prevalence of both rheumatic fever and rheumatic heart disease decreased by about 36 per cent from 16.6 to 10.6 per 1,000 students examined. The prevalence of rheumatic heart disease alone declined by about 75 per cent from 7.9 to 2.1 per 1,000 students examinedY Studies of several million military inductees between 1943 and 1960 a-5 also indicate no significant trend in the prevalence of congenital heart disease in young adults (Table I I I ) . These data suggest that congenital heart disease is at least twice as prevalent in military inductees as in college freshmen. The lower prevalence rates in college freshmen than in military inductees may also be related to different sensitivities of the screening examination, to selectivity in the population studied (e.g., smaller percentage of children with congenital heart disease subsequently attend college), or to other factors. All epidemiologic studies probably
8 78
Brie[ clinical and laboratory observations
yield a prevalence rate that is lower than might be obtained if each patient were examined carefully by a trained cardiologist, a, 7 CONCLUSIONS Between 1956 and 1965, 767,600 United States college freshmen were examined for the presence of congenital heart disease. Congenital heart disease was identified in approximately 0.7 per 1,000 students examined. Cardiac surgical treatment had been performed in less than 10 per cent of the students with heart disease.
The Journal o/ Pediatrics November 1969
2.
3.
4. 5.
6.
REFERENCES 1. Marienfeld, C. J., Robins, M., Sandidge, R. P., and Findlan, C.: Rheumatic fever and rheumarie heart disease among U. S. college fresh-
The simultaneous occurrence of bistidinemia and congenital hypoplastic anemia Priscilla A. Gilman, M.D., ~" and R. Rodney Howell, M.D. BALTIN$ORE, 1VID.
M o r t ~ . T H A N 75 cases of congenital hypoplastic anemia (Diamond-Blackfan syndrome) have been reported since the description of the disease by Diamond and From the Department o/Pediatrics o[ the J,ohns Hopkins University School of Medicine and the Harriet Lane Service of the Johns Hopkins Children's Medical and Surgical Center. Supported by United States Public Health Service Graduate Training Grant No. T1-AM 5260 and The Pediatric Clinical Research Unit Grant No. 2-MO1-FR 00052. ~Un~ted States Public Health Service Postdoctoral.Fellow.
7.
men, 1956-1960, Public Health Rep. 79: 789, 1964. Perry, L. W., Poltras, J. M., and Findlan, C.: Rheumatic fever and rheumatic heart disease among U. S. college freshmen, 1956-1965, Pub. Health Reports 83: 919, 1968. Levy, R. L., Stroud, W. D., and White, P. D.: Report of reexamination of 4,994 men disqualified for general military service, J. A. M. A. 15: 937, 1943. Karpinos, B. D.: Fitness of American youths for military service, Milbank Mere. Fund Quart. 38: 213, 1960. Karpinos, B. D.: Qualification of American youths for military service, Monograph Medical Statistics Division, Office of Surgeon General, Dept. of the Army, 1962. Shearer, M. C., Sikkema, S. N., and Holden, L. W.: Prevalence of heart disease in university students, J. Am. Pub. Health A. 9: 1103, 1952. Henikoff, L. M., Stevens, W. A., and Perry, L. W.: Detection of heart disease in children, 1919-1967, Circulation 38: 375, 1968.
Blackfan 1 in 1938.1-3 The disease is characterized by onset in early infancy of severe hypoplasia of the erythroid elements of the bone marrow and a profound recurrent normochromic, normocytic anemia. Thrombocytopenia and significant leukopenia usually do not occur. Some patients exhibit short stature and delayed skeletal maturation. A variety of other congenital anomalies have been described in individual patients. Therapy has consisted of repeated blood transfusions or corticosteroid therapy. Spontaneous remissions occur in some children, but others die of secondary hemachromatosis. The etiology of the erythroid hypoplasia is unknown. An abnormality of tryptophan metabolism was suggested by Altman and Miller. 4 Later Pearson and Cone 5 found abnormal concentrations of anthranilic acid in the urine of several patients. Administration of riboflavin effected a reduction of the anthranilic acid excretion without improving the anemia. Smith and co-workers 6 could not confirm the finding of anthranilic acid in the urine of 7 patients with congenital hypoplastic anemia, although 2 of their patients showed elevated urinary concentra-
Brief clinical and laboratory observations
The prevalence of congenital heart disease in United States college freshmen, 1956-1965 Lowell W. Perry, M.D. * Leo M. Henikoff, M.D., and Clare Findlan ~,VASHINGTON,
D. C .
I N 1956 the Heart Disease and Stroke Control Program and the American College Health Association began a cooperative study to determine the prevalence of rheumatic fever in United States college freshmen. 1,2 The students participating were asked to complete a questionnaire especially designed to elicit a history of rheumatic fever. Each student was then examined by a private or school physician. T h e examining physician validated the history and, after physical examination, noted the presence of rheumatic or congenital heart disease. The purpose of this report is to present data relative to the prevalence of congenital heart disease noted in the study between 1956 and 1965. METHODOLOGY T h e history and physical examination were recorded on a questionnaire precoded for automatic data processing?, 2 Data were transferred to punch cards and processed by the data processing facilities of the National Center for Chronic Disease Control. RESULTS
Between 1956 and 1965, 767,600 matriculating college freshmen from 50 states and From the Children's Hospital of D. C. and Heart Disease and Stroke Control Program, United States Public Health Service. *Address: Children's Hospital of D. C., 2125 13th St., N.W., Washington, D. G. 20009.
The Journal of Pediatrics November 1969
Table I. Prevalence of congenital heart disease in United States college freshmen 1956-1965
Year
No. in survey
Cases of CHD*/ 1,000 students examined
1956 1957 1958 1959 1960 1961 1962 1963 1964 1965
86,939 95,083 t13,538 110,317 111,252 18,385 51,275 67,062 62,414 51,335
0.1 0.7 1.0 1.0 0.9 0.3 0.4 0.6 0.7 0.9
~ C H D = congenital heart disease.
the District of Columbia completed the questionaire and were interviewed and examined by physicians. The study population represented 7.8 per cent of the total college freshmen enrollment during the decade of the study. Of the 767,600 students participating, 550, or approximately 0.7 per 1,000 students examined, were identified as having congenital heart disease by the examining physicians. The prevalence of congenital heart disease for each year of the study is shown in Table I. These data indicate no specific trend ill the prevalence of congenital heart disease. Statistically the 95 per cent confidence limits for the mean prevalence are 0.47 to 0.85 cases per 1,000 students examined. Table I I contains the types of heart disease reported during the decade of the study. The examining physicians did not make a specific diagnosis in 212 or 38.5 per cent of the 550 students with congenital heart disease. Of the 338 cases in which the physician made a specific diagnosis, ventricular septal defect was the most common lesion, being found in 41 per cent of the cases. Atrial septal defect was present in 18 per cent. Pulmonary stenosis was the diagnosis in 12 per cent. Patent ductus arteriosus was present in 11 per cent, and aortic stenosis was noted in 7 per cent. Three per cent had tetralogy of Fallot, and the remaining 8 per
Volume 75 Number 5
Brie[ clinical and laboratory observations
87 7
Table II. Types of congenital heart disease noted in United States college freshmen, 1956-1965 Type
Congenital heart disease, type not specified Ventrieular septal defect Atrial septal defect Pulmonary stenosis Patent ductus arteriosus Aortic stenosis Coarctation of aorta Tetralogy of Fallot Congenital aortic insufficiency Complete heart block Other specific lesions Total ~'One h a d
documented
corrected
transportation
of great
Total
No. without surgery
No. with surgery
212 137 61 39 36 24 13 9 4 3~ 12 550
204 131 58 35 18 23 6 4 4 3 12 498
8 6 3 4 18 1 7 5 0 0 0 52
vessels.
Table I l L Prevalence of congenital heart disease in United States military inductees
Year
No. in survey
Age range
Cases of CHDe/ I ,O00 students examined
1943 1950-1953 1953-1958 1958-1960
100,000 3,812,189 1,921,253 552,355
18-38 18-26 18-26 18-26
1.8 1.2 1.8 1.5
Re[erence
e C H D = congenital heart disease.
cent had various other types of lesions. The examining physicians reported that surgical treatment had been performed on 52 or 9.5 per cent of the total group with heart disease. Coarctation of the aorta, patent ductus arteriosus, and tetralogy of Fallot were the lesions most frequently reported as having required surgical treatment prior to college. Less than 5 per cent of the students with a diagnosis of ventricular or atrial septal defect had undergone surgical treatment. Approximately 10 per cent of those with pulmonary stenosis had had surgical treatment prior to enrolling in college. DISCUSSION It is impossible to ascertain the accuracy of the diagnos!s made by the examining physicians. However, the constancy of the prevalence rates noted from year to year and the narrow 95 per cent confidence limits suggest some precision in the ability of a large group of physicians to detect congenital heart disease. During the decade of this
study when the prevalence of congenital heart disease was relatively constant, the total prevalence of both rheumatic fever and rheumatic heart disease decreased by about 36 per cent from 16.6 to 10.6 per 1,000 students examined. The prevalence of rheumatic heart disease alone declined by about 75 per cent from 7.9 to 2.1 per 1,000 students examinedY Studies of several million military inductees between 1943 and 1960 a-5 also indicate no significant trend in the prevalence of congenital heart disease in young adults (Table I I I ) . These data suggest that congenital heart disease is at least twice as prevalent in military inductees as in college freshmen. The lower prevalence rates in college freshmen than in military inductees may also be related to different sensitivities of the screening examination, to selectivity in the population studied (e.g., smaller percentage of children with congenital heart disease subsequently attend college), or to other factors. All epidemiologic studies probably
8 78
Brie[ clinical and laboratory observations
yield a prevalence rate that is lower than might be obtained if each patient were examined carefully by a trained cardiologist, a, 7 CONCLUSIONS Between 1956 and 1965, 767,600 United States college freshmen were examined for the presence of congenital heart disease. Congenital heart disease was identified in approximately 0.7 per 1,000 students examined. Cardiac surgical treatment had been performed in less than 10 per cent of the students with heart disease.
The Journal o/ Pediatrics November 1969
2.
3.
4. 5.
6.
REFERENCES 1. Marienfeld, C. J., Robins, M., Sandidge, R. P., and Findlan, C.: Rheumatic fever and rheumarie heart disease among U. S. college fresh-
The simultaneous occurrence of bistidinemia and congenital hypoplastic anemia Priscilla A. Gilman, M.D., ~" and R. Rodney Howell, M.D. BALTIN$ORE, 1VID.
M o r t ~ . T H A N 75 cases of congenital hypoplastic anemia (Diamond-Blackfan syndrome) have been reported since the description of the disease by Diamond and From the Department o/Pediatrics o[ the J,ohns Hopkins University School of Medicine and the Harriet Lane Service of the Johns Hopkins Children's Medical and Surgical Center. Supported by United States Public Health Service Graduate Training Grant No. T1-AM 5260 and The Pediatric Clinical Research Unit Grant No. 2-MO1-FR 00052. ~Un~ted States Public Health Service Postdoctoral.Fellow.
7.
men, 1956-1960, Public Health Rep. 79: 789, 1964. Perry, L. W., Poltras, J. M., and Findlan, C.: Rheumatic fever and rheumatic heart disease among U. S. college freshmen, 1956-1965, Pub. Health Reports 83: 919, 1968. Levy, R. L., Stroud, W. D., and White, P. D.: Report of reexamination of 4,994 men disqualified for general military service, J. A. M. A. 15: 937, 1943. Karpinos, B. D.: Fitness of American youths for military service, Milbank Mere. Fund Quart. 38: 213, 1960. Karpinos, B. D.: Qualification of American youths for military service, Monograph Medical Statistics Division, Office of Surgeon General, Dept. of the Army, 1962. Shearer, M. C., Sikkema, S. N., and Holden, L. W.: Prevalence of heart disease in university students, J. Am. Pub. Health A. 9: 1103, 1952. Henikoff, L. M., Stevens, W. A., and Perry, L. W.: Detection of heart disease in children, 1919-1967, Circulation 38: 375, 1968.
Blackfan 1 in 1938.1-3 The disease is characterized by onset in early infancy of severe hypoplasia of the erythroid elements of the bone marrow and a profound recurrent normochromic, normocytic anemia. Thrombocytopenia and significant leukopenia usually do not occur. Some patients exhibit short stature and delayed skeletal maturation. A variety of other congenital anomalies have been described in individual patients. Therapy has consisted of repeated blood transfusions or corticosteroid therapy. Spontaneous remissions occur in some children, but others die of secondary hemachromatosis. The etiology of the erythroid hypoplasia is unknown. An abnormality of tryptophan metabolism was suggested by Altman and Miller. 4 Later Pearson and Cone 5 found abnormal concentrations of anthranilic acid in the urine of several patients. Administration of riboflavin effected a reduction of the anthranilic acid excretion without improving the anemia. Smith and co-workers 6 could not confirm the finding of anthranilic acid in the urine of 7 patients with congenital hypoplastic anemia, although 2 of their patients showed elevated urinary concentra-