Impact of Pharmaceutical Care on Clinical Outcomes in Patients with Rheumatic Heart Disease: A Six-Month Prospective Study in South Punjab

Pakistan Journal of Medical & Cardiological Review https://pakjmcr.com/index.php/1/about Online ISSN Print ISSN 3007-2387 3007-2379 Vol. 4 No. 4 (2025) Pakistan Journal of Medical & Cardiological Review Page 1377 Impact of Pharmaceutical Care on Clinical Outcomes in Patients with Rheumatic Heart Disease: A Six-Month Prospective Study in South Punjab Alveena Rabbani Faculty of Pharmacy, Bahauddin Zakariya University, Multan Syed Nisar Hussain Shah Faculty of Pharmacy, Bahauddin Zakariya University, Multan Quaid-e-Azam College of Pharmacy, Sahiwal 57000, Pakistan Sana Yousof Faculty of Pharmacy, Bahauddin Zakariya University, Multan Rida Nisar Nishtar Hospital, Multan Mughisa Munir Chaudhary Pervaiz Elahi, Institute of Cardiology, Multan Anns Mustafa Nishtar Hospital, Multan Ahmad Mustafa IMS, Bahauddin Zakariya University, Multan Muneeb Ahmad Quaid-e-Azam College of Pharmacy, Sahiwal 57000, Pakistan Aousaf Ahmad* Quaid-e-Azam College of Pharmacy, Sahiwal 57000, Pakistan Shakeel Ijaz* Department of Pharmacy, The University of Lahore, Sargodha Campus, Sargodha, 40100. Pakistan Background: Rheumatic Heart Disease (RHD) remains a significant public health concern in developing countries, including Pakistan. This prospective study was conducted at the Chaudhary Pervaiz Elahi Institute of Cardiology, Multan, from July to December, to assess clinical patterns and evaluate pharmaceutical care in pediatric RHD. Objective: To analyze demographic and clinical characteristics, diagnostic findings, management practices, socioeconomic factors, and hygiene-related risk indicators among pediatric RHD patients, and to design and implement a pharmaceutical care plan to optimize therapy and follow-up. Materials and Methods: Children aged 5–15 years presenting with recurrent Group A β-hemolytic streptococcal (GABHS) pharyngitis and diagnosed with RHD by a pediatric cardiologist-based on clinical signs, echocardiography, and the Modified Jones Criteria were consecutively enrolled and followed for at least three months. Patients with unrelated cardiac or respiratory disorders were excluded. A structured SOAP-based pharmaceutical care form was completed for each patient Abstract Author Details Keywords: Rheumatic Heart Disease (RHD), Pediatric patients (5–15 years), Group A β-hemolytic streptococcal pharyngitis (GABHS), Pharmaceutical care intervention, Mitral regurgitation, Poor hygiene and overcrowding Received on 25 Oct 2025 Accepted on 20 Nov 2025 Published on 01 Dec 2025 Corresponding E-mail & Author*: Aousaf Ahmad* aousaf.3[email protected] Shakeel Ijaz* Shakeelijaz8[email protected] Page 1378 to guide individualized treatment and monitoring. Results: A total of 134 patients were included (rural: 48; urban: 86). Most patients were 11–13 years old (rural: 40.7%; urban: 41.6%). Rural males were more affected (58.3%), while sex distribution was similar in urban patients. Fever and arthritis were the predominant symptoms. Mitral regurgitation was the most common echocardiographic finding (rural: 47.9%; urban: 52.3%). All patients received benzyl penicillin; diuretics and ACE inhibitors were commonly prescribed. Overcrowding and poor hygiene emerged as major risk factors, with most families not meeting acceptable living-condition standards. Conclusion: Recurrent sore throat remains a major precursor to RHD in children. Improving hygiene, reducing overcrowding, and increasing awareness can significantly lower disease risk. Pharmaceutical care interventions may further enhance disease management and follow-up. Introduction Rheumatic Heart Disease (RHD) is caused by the long-term damage to heart muscles or heart valves by Acute Rheumatic Fever (ARF). ARF is an inflammatory disease that occurs after untreated or insufficiently treated upper respiratory tract infection like pharyngitis, caused by Group A Beta Hemolytic Streptococcus bacterium (GABHS). ARF is characterized by high grade fever, pain in joints leading to valvular damage. RHD as the sequelae of ARF is the commonest cause of heart diseases in children between the ages of 5-15 years globally. The complications of GABHS pharyngitis and delayed immune response may result in valvular regurgitation and stenosis. The incidence of rheumatic fever and rheumatic heart disease has decreased significantly in the developed countries. However, there are still significant health problems in under developed, developing countries like Pakistan and in the indigenous population of Australia and New Zealand (Sadiq, et al:2009, Alizzi AM et al: 2010, Wilson N:2010, Remenyl, et al:2012). WHO has estimated that about 1.33 lakh deaths occur from RF/RHD annually in the south east Asia compared to 10,000 deaths in America and 30,000 deaths in Europe. (WHO, 2004) Low socioeconomic status characterized by poverty, overcrowding, unemployment, unhygienic conditions have been associated with RHD. These risk factors have rarely been investigated in Pakistan (Rizvi, et al: 2004). Other risk factors associated with a high risk in the population include poor health care access, remoteness of the affected area from the health care facility, lack of adequate follow-up of the diseased person and lack of knowledge of ARF/RHD among health staff, patients and community. (White, et al: 2011, Carapetis, et al: 2000). Research has proven that the probability of RHD/RF, in developing countries, can be reduced by preventive care and especially through secondary prevention. Diseases prevention is paramount than instead of providing therapies to patients after they got ill. Pharmaceutical Care also called pharmacist care play an important role in this regard. It describes Specific activities and services through which an individual pharmacist cooperates with a patient and other professionals in designing, implementing and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient. (Helper and Strand, 1990) In addition, it also includes assessment of patient physical and psycho-social problems. Pharmacist role is to motivate and educate patient about therapeutic regimens. He can recognize therapeutic problems by interpreting laboratory tests and should manage drug related problems such as ADR and drug-drug interactions, so he must have knowledge about community resources. He has the potential to recognize patient at risk and to apply pharmacokinetic principles for the determination of dose of prescribed drugs. Pharmacist role is to plan and implement pharmaceutical care activities in community pharmacy, ambulatory care services, home health services etc. We designed this study to investigate the prevalence of RHD among the children. The study also had two objectives. One of which was to investigate role of socioeconomic Page 1379 and environmental factors which is considered responsible for the pathogenesis of RHD. The second objective was to design, implement and monitor pharmaceutical care plan for RHD patients. Methods This was a single centered prospective study and Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, the only institute treating cardiac patients in Southern Punjab, was chosen. The study was conducted for a period of 6 months starting from July 2014 to December 2014. The pediatric patients attending one of the two pediatric facilities of the hospital, were entered in the study consecutively after confirmation of RHD by the pediatric cardiologists. The informed consents were taken from parents/guardians of the patients. All the children of either sex with in age of 5-15 years from both urban and rural areas was eligible to participate in this study. Children with diseases other than ARF/RHD like ventricle septal defect, asthma etc., were excluded from the study. Diagnosis of RHD The cardiologists declared the patients suffering from ARF/RHD who fulfill two major or one major and two minor manifestations of Johns criteria (Table). The evidences of GABHS infection based on clinical examination like high grade fever, raised ESR & positive CRP (C-reactive protein) & arthralgia was also evaluated to diagnose. For confirmation of the disease, serological test for quantitative estimation of ASO (anti-streptolysin O antibodies) titer was conducted in CPEIC laboratory. This test is based on principle of agglutination formed due to anti-bodies to streptolysin-O. This method detects presence of anti-bodies to streptolysin-O in the concentration ranging from 200 IU/ml to 4000 IU/ml. The cardiac manifestations were confirmed by M-mode cross-sectional & color flow Doppler echocardiography as AR, MR, MS & other related valvar abnormalities by a specialist in CPEIC, Multan. Treatment In order to eradicate streptococcal throat infections like RHD, we gave injections of Benzathine Penicillin G(BPG) in a dose of 1.2 million IU to all patients. The first injection was given at the time of admission and repeated after 2 weeks, and then at 34 weekly intervals. Inflammation was controlled with Aspirin, which was given in the dose of 100 mg/kg/day in 4 divided doses, being reduced to 75 mg/kg/day after 2 weeks, and continued in the same dose until the erythrocyte sedimentation rate had returned to normal. All patients with carditis were treated with Digoxin. Children with severe carditis complicating recurrent episodes needed more aggressive vasodilator therapy, such as ACE inhibitors. Follow-up Follow-up of all the patients was conducted for a minimum of 3 months from the date of registration in this study, attendance to the hospital occurring at one month interval until the end of the study. Socioeconomic and Environmental Status of RHD patients: Information about the socioeconomic status of the patients were also recorded in a specially designed Performa. This includes the following: Overcrowding: Overcrowding is health problem in human dwellings Dwelling of patients was determined through the information’s gathered about house area, noof rooms and noof persons living in the accommodation. Degree of overcrowding was calculated by modified method of Parke which is as follows: Degree of overcrowding=No-of persons in household / Noof rooms in the dwelling and the accepted criteria was: 1 room 2 persons Page 1380 2 rooms 3 persons 3 rooms 5 persons 4 rooms 7 persons 5 or more rooms 10 persons (additional 2 for further room) Hygienic Conditions Hygienic condition was determined through a questionnaire containing questions about availability of toilet facility with hand washing and without hand washing practice. Counseling of patients and their attendants The patients & their attendants were counseled on the following points in their mother tongue (Punjabi, Saraiki etc.) & were also provided with Urdu translation (Annex) for strict compliance. Patient should get injection after every third week with regularity. Get the injection on the fleshy part of the body. Before getting injection, patient should take allergic test. After getting injection, patient should remain under observation for some time. Take all medicines with regularity according to Doctor or Pharmacist instructions. Parents should not let their children to eat spicy & bitter food to avoid sore throat. Patients should not play with dirt & if they do so, they should properly clean & wash themselves. Patients should wash their hands after using toilet. If patient suffers from sore throat & fever, then parents should immediately take their child to doctor. After operation, patients should take INR (International Normalize Ratio) test every month so that proper dose of medicine can be prescribed. Patients should avoid green leafy vegetables like spinach. Pharmaceutical care plan development It was developed according to SOAP format. A structured approach for questioning to collect objective information from patient was employed. To minimize the risk of missing vital information, a mnemonics SITDOWNSIR was used (Edwards & Kiska, 2004). These mnemonics stand for: S Site or location I Intensity or severity T Type or nature D Duration O Onset W With (other symptoms) N aNnoyed or aggravated by R Relieved by All the information about every patient were gathered in a separate pharmaceutical care Performa which is given in the Annex. Data Analysis: All the data were collected in the form of percentage, means, standard deviation for continuous variables and student t-test were employed for comparative analysis between Urban and Rural RHD patients at 5% significant level. Results The results of this study have been compiled from the Subjective and Objective information of the pharmaceutical care Performa prepared by the researcher under SOAP format for individual RHD patients. Data of the two patients who died during study period is not included. Page 1381 Demographic data of RHD patients Following is the demographic data of RHD patients included in the study, who meet the inclusion criteria. Patients were divided in Rural and Urban patients. There were 48 Rural patients and 86 Urban patients, attending CPEIC, Multan. Age, Sex, and Month wise distribution of RHD patients Patients suffering from RHD were within 5-15 years. Age wise distribution of male and female patients belonging to both Urban and Rural dwelling is shown graphically in Figures 1-3. Overall, 58.30% rural male patients have RHD as compared to 50% male urban patients while 37.50% rural female patients have RHD as compared to 51% urban patients. Fig: 1: Month wise distribution of RHD Urban patients (n=86) between different age groups with sex. Mean and S.D of 5-7 years male and female Urban RHD patients is zero. Means of 810 years of both male and female RHD Urban patients are 1.33 and S.D of both are 1.36 and 1.21. Means of 11-13 years male and female patients are 2.83 and 3 while S.D are 2.85 and 2.38 respectively. Similarly, means of age group greater than 13 years of both sexes are 3 and 2.83 while S.D are 1.41 and 3.54 respectively. Fig: 2: Month wise distribution of RHD Rural patients (n=48) between different age groups with sex. Age with Sex Months 5-7 years 5-7 years 8-10 years 8-10 years 11-13 years 11-13 years Greater than 13 yrs Greater than 13 yrs Age with Sex Months 5-7 years 5-7 years 8-10 years 8-10 years 11-13 years 11-13 years Greater than 13 yrs Greater than 13 yrs Page 1382 Means of 5-7 years male and female rural RHD patients are 0.16 while S.D of both are 0.4. Means of 8-10 years of both male and female RHD rural patients are 0.5 and 0.66 while S.D of both are 0.83 and 0.81 respectively. Means of 11-13 years male and female patients are 1.66 and 1.83 while S.D are 1.36 and 0.98 respectively. Similarly Means of age group greater than 13 years of both sexes are 2.33 and 0.33 while S.D are 2.94 and 0.51 respectively. Fig: 3: Comparison of Age wise distribution of Urban and Rural RHD patients. Figure 3 shows in between 5-7 years age group, 0% rural patients while 4.16% urban patients have RHD disease. In 8-10 years, age group, 18.60% rural while 15% urban patients have RHD disease. In 11-13 years, age group, 40.69% rural while 41.60% urban patients have RHD disease While in greater than 13 years age group, 40.69% Rural while 33.33% Urban have RHD disease. Diagnosis of RHD according to Modified Jones Criteria Manifestations of both minor and major symptoms of RHD according to Modified Jones Criteria are given in Tables 1-3. These Tables depict information about the patients belonging to both Urban and Rural localities. Table: 1: Month wise distribution of Symptoms of Urban RHD patients (n=86) Fever Arthritis Chorea Others July 2 5 0 5 August 8 8 1 8 September 18 19 0 25 October 16 21 0 27 November 14 15 0 19 December 1 3 0 2 Mean 9.83 11.83 0.16 14.67 STDEV 7.27 7.54 0.4 4.5 Table 1 shows means and S.D of fever, arthritis, chorea and others. Mean and S.D of fever is 9.83 and 7.27 respectively. Similarly for arthritis is 11.83 and 7.54, for chorea is 0.16 and 0.4 and for other symptoms are 14.67 and 4.5 respectively. Table: 2: Month wise distribution of Symptoms of Rural RHD patients (n=48) 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 5-7yrs 8-10yrs 11-13yrs )13yrs Percentage % Age groups %age of Rural Patients %age of Urban patients Page 1383 Fever Arthritis Chorea Others July 2 2 0 1 August 5 5 1 3 September 10 8 0 12 October 6 18 0 17 November 2 5 0 5 December 2 4 0 4 Mean 4.5 7 0.16 7 STDEV 3.2 5.72 0.4 3.08 Table 2 shows means and S.D of fever, arthritis, chorea and others. Mean and S.D of fever is 4.5 and 3.2 respectively. Similarly for arthritis is 7 and 5.72, for chorea is 0.16 and 0.4 and for other symptoms are 7 and 3.08 respectively. Table: 3: Comparison of Symptoms of Rural and Urban RHD patients: Symptoms % age of Rural % age of Urban Fever 56.25 68.60 Arthritis 87.50 82.50 Chorea 2.08 1.16 Others 87.50 100 Table 3 shows that 68.60% urban patients show fever as compared to 56.25% rural patients, 82.50% urban patients show arthritis as compared to 87.50% rural patients, 1.16% urban patients show chorea as compared to 2.08% rural patients. Similarly, 100% other symptoms have shown in urban patients as compared to 87.50% in rural patients. Echocardiography of RHD patients RHD was confirmed by detecting abnormalities in different valves caused by GABHS infection by echocardiography techniques and results are tabulated in Tables 4-6. Table 4: Month wise distribution of Echocardiographic manifestations of Rural RHD patients (n=48) Mont hs M R AoR +MR AoR+MR+Pul monary HTN AR+MR+Pul monary HTN AR +M R A R MR+Pulmo nary HTN OTH ERS July 3 0 0 0 0 0 0 0 Augu st 3 2 0 0 0 0 0 1 Septe mber 4 1 3 0 0 1 2 3 Octo ber 9 1 0 2 1 0 1 4 Nove mber 3 0 0 1 0 0 0 0 Dece mber 1 0 0 0 1 1 0 0 Mean 3. 8 3 0.66 0.5 0.5 0.33 0. 3 3 0.5 1.33 STD EV 2. 7 1 0.81 1.22 0.83 0.51 0. 5 1 0.83 1.75 Page 1384 Table 4 shows means and S.D of different echocardiographic manifestations of rural RHD patients. Mean and S.D of MR is 3.83 and 2.71, AoR + MR 0.66 and 0.81, AoR + MR+ Pulmonary HTN 0.5 and 1.22, AR+ MR+ Pulmonary HTN 0.5 and 0.83, AR + MR 0.33 and 0.51, AR 0.33 and 0.51, MR + Pulmonary HTN 0.5 and 0.83 while others are 1.33 and 1.75. Table: 5: Month wise distribution of Echocardiographic manifestations of Urban RHD patients (n=86) Month s M R AoR+ MR AoR+MR+Pu lmonary HTN AR+MR+Pu lmonary HTN AR+ MR A R MR+Pul monary HTN OTH ERS July 5 0 0 0 0 0 0 0 Augus t 4 3 0 0 2 0 2 2 Septe mber 12 3 1 1 2 0 1 2 Octob er 18 1 1 0 3 0 6 3 Nove mber 4 1 0 0 3 0 3 0 Dece mber 2 0 0 0 1 0 0 0 Mean 7. 5 1.33 0.33 0.16 1.83 0 2 1.16 STDE V 6. 18 1.36 0.51 0.4 1.16 1. 16 2.28 1.32 Table 5 shows means and S.D of different echocardiographic manifestations. Mean and S.D of MR is 7.5 and 6.18, AoR + MR 1.33 and 1.36, Aor + MR+ Pulmonary HTN 0.33 and 0.51, AR+ MR+ Pulmonary HTN 0.16 and 0.4, AR + MR 1.83 and 1.16, AR 0 and 1.16, MR + Pulmonary HTN 2 and 2.28 while others are 1.16 and 1.32. Table: 6: Comparison of Echocardiographic manifestations between Rural and Urban RHD patients: Echocardiogra phic manifestation M R Ao R+ MR AoR+MR+P ulmonary HTN AR+MR+P ulmonary HTN AR +M R A R MR+Pul monary HTN OT HE RS % age of Rural 47 .9 1 8.33 6.25 6.25 4.1 6 4. 1 6 6.25 16.6 6 %age of Urban 52 .3 2 9.3 2.32 1.16 12. 79 0 13.95 8.13 Table 6 shows comparison of echocardiographic manifestations between rural and urban RHD patients. 47.91% rural patients show diagnosis of MR as compared to 52.32% in urban patients. Similarly, AoR + MR in 8.33% rural as compared to 9.3% urban patients, AoR + MR + Pulmonary HTN in 6.25% rural as compared to 2.32% urban patients, AR + MR + Pulmonary HTN in 6.25% rural as compared to 1.16% urban patients, AR + MR in 4.16% rural as compared to 12.79% urban patients, AR in 4.16% rural as compared to o% in urban patients, MR + Pulmonary HTN in 6.25% rural as compared to 13.95% urban Patients and others in 16.66% rural as compared Page 1385 to 8.13% urban patients. In both the cases, results show, MR is dominant which is consistent with other studies in Asian countries. (Sriharibabu et al: 2013, Crapetis: 2008) Treatment of RHD patients All the drugs prescribed by the pead cardiologist and dispensed by hospital pharmacist along with proper counseling, are given in Tables 7-9. Table: 7: Month wise distribution of Drugs prescribed to Urban RHD patients (n=86) Months Benzyl Penicillin Cardiac glycosides ACEI Diuretics Beta-blockers Anti-platelet Others July 5 4 4 4 0 1 0 August 9 8 10 10 0 2 4 September 26 16 23 24 3 4 16 October 27 19 20 24 4 3 15 November 15 11 13 13 0 1 5 December 4 2 0 3 0 2 2 Mean 14.33 10 11.66 13 1.16 2.16 7.33 STDEV 10.19 6.66 8.91 9.29 1.83 1.16 6.81 Table 7 shows means and S.D of drugs prescribed to Urban RHD patients. Mean and S.D of Benzyl Penicillin is 14.33 and 10.19, cardiac glycosides 10 and 6.66, ACE 11.66 and 8.91, Diuretics 13 and 9.29, Beta-blockers 1.16 and 1.83, anti-platelet 2.16 and 1.16 while others have 7.33 and 6.81 respectively. Table 8: Month wise distribution of Drugs prescribed to Rural RHD patients (n=48) Months Benzyl Penicillin Cardiac glycosides ACEI Diuretics Beta-blockers Anti-platelet Others July 3 1 1 2 1 1 1 August 5 2 2 4 1 1 3 September 12 10 7 10 0 0 1 October 19 13 17 18 2 2 6 November 5 1 3 4 0 1 0 December 4 4 4 4 0 0 1 Mean 8 5.16 5.66 7 0.66 0.83 2 STDEV 6.26 5.11 5.92 6.03 0.81 0.75 2.19 Table 8 shows means and S.D of drugs prescribed to Rural RHD patients. Mean and S.D of Benzyl Penicillin is 8 and 6.26, cardiac glycosides 5.16 and 5.11, ACE 5.66 and 5.92, Diuretics 7 and 6.03, Beta-blockers 0.66 and 0.81, anti-platelet 0.83 and 0.75 while others have 2 and 2.19 respectively. 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Nanomedicine 2011; 7(2):168-173 ANNEXURES Performa# 1 Pharmaceutical care plan for Rheumatic heart disease patients: An individual dedicated plan to address the drug related problems for RHD patients under SOAP format. Subjective Information: Entry # _____________ CPEIC Reg # _____________ Date: ___/___/______ Patient,s Name: _______________________________ Father,s Name: ___________ ____ Age/Sex: ____ No.of cohabitants:_________ No. of Rooms:________ Income/month: __________ House Area________ Address:___________________________________________ Cell # ____________ History of present/past illness:____________________ Family history (related to the disease)______________________________ Allergies:______________________________ Medication history:_________________________________________________________ Objective Information: (According to mnemonics SITDOWN SIR) Page 1395 Symptoms: Sore throat: Yes/No, if yes: when and for how long? ___________________ Joint pain/Swelling: Yes/No, if yes: Which Joint? ___________________ Fever: Yes/No, if yes: High grade/Low grade. ___________________ Abnormal movement/Behavior: Yes/No SOB/Palpitation: Yes/No Aggravated by: ___________________________________________________________ Relieved by: ____________________________________________________________ Laboratory Examination: Hb___________________ ESR ___________________ ASO Titer___________________ CRP___________________ Echo Cardiography: _____________________________________________________ Conclusion: _________________________________________________________ Final Diagnosis: _________________________________________________________ Prescribed Drugs: Drug Dose Dosage form Rout of Administration Frequency Assessment by Pharmacist: This part of SOAP profile covers therapeutic objectives/goals, drug-related problems and brief description of therapeutic alternatives. If patient shows hypersensitivity to Penicillin, then erythromycin can be given to patient as a therapeutic alternative. Pharmaceutical Care Plan: It includes a plan for improvement of signs/symptoms, early detection of drug-related problems and suggestions for therapeutic alternatives and therapeutic drug monitoring. The usual drug-related problems are: Contra-Indications: ___________________________________________________ Drug-Drug Interactions: Drug-Drug Interaction Onset Severity Documentation Significance level Effects Management Adverse Drug Reactions: This portion includes suggestion for prevention of some and early detection of other ADR, s and reporting of any existed ADR,s due to the prescribed drugs and submission of Yellow Card to the relevant authority. Patient Counseling: 1. Patient should get injection after every third week with regularity. 2. Get the injection on the fleshy part of the body. 3. Before getting injection, patient should take allergic test. 4. After getting injection, patient should remain under observation for sometime. 5. Take all medicines with regularity according to Doctor or Pharmacist instructions. 6. Parents should not let their children to eat spicy and bitter food to avoid sore throat. 7. Patients should not play with dirt and if they do so, they should properly clean and wash themselves. Page 1396 8. Patients should wash their hands after using toilet. 9. If patient suffers from sore throat and fever, then parents should immediately take their child to Doctor. 10. After operation, patients should take INR (International Normalize Ratio) test every month so that proper dose of medicine can be prescribed. 11. Patients should avoid green leafy vegetables like spinach. Follow-up Plan: Patients were said to do visit to the hospital every month and regularly get injection every month. Patients should follow the prescription regularly.