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Implementation of Early Detection of Congenital Heart Disease in Elementary School Children

Lucia Kris Dinarti

On behalf of COHARD-PH team

Faculty of Medicine, Nursing and Public Health�UNIVERSITAS GADJAH MADA / SARDJITO GENERAL HOSPITAL�YOGYAKARTA, INDONESIA

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BACKGROUND

CHD occurs in 0.8% (8/1000) of children in North America and Europe.

The most common congenital disorder

In general, based on heart flow, they are divided into types: Acyanotic: Flow from the left heart to the right heart

Cyanotic: Flow from the right heart to the left heart

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Indonesian Demographic and PH Profile

Total population: 261.115.456

Total island: 14.574

State Universities with assoc hospital: 13

No NATIONAL DATA

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COHARD PH REGISTRY

SARDJITO HOSPITAL, YOGYAKARTA, INDONESIA

TOTAL 2204

ASD 1448

VSD 331

PDA 150

TOF 52

Others CHD 74

PHp 149

JULY 2012 – 21 MAY 2024

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MATERNAL HEART DISEASE Dr Sardjito Hospital Yogyakarta INDONESIA

Feb 2015 – 26 Juni 2023 (719 pts)

53%

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The Most Common Congenital Heart Disease In Adults

ASD

VSD

PDA

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77%

67%

Dinarti et al. BMC Cardiovascular Disorders (2020) 20:163 https://doi.org/10.1186/s12872-020-01434-z

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Delayed detection of congenital heart disease in Indonesia has serious complications: Pulmonary Hypertension

WITH COMPLICATION

Lifetime medication

WITHOUT COMPLICATION

Defect closure

Early Detection

High Cost

(>60 Millions/months)

Screening programme in Children

PROGRES PJB

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SCREENING PROGRAM

Newborn, child,

familial, pregnant women

RAISE AWARENESS TO CARDIOLOGIST

about gold standard

of PAH diagnosis

APPROACH TO GOVERNMENT 🡪

MINISTRY OF HEALTH

to provide PAH drugs in national formularies

ROUTINE CHECK

NTproBNP and

6MWT as a marker, prognostic, and risk stratification

DIAGNOSIS OF PH

- RHC as gold standard

- VQ scan to exclude CTEPH

LACK OF AWARENESS ABOUT PH 🡪

undiagnosed CHD 🡪 complication

RISK STRATIFICATION AND EVALUATION

not routinely use of NTproBNP

and 6MWT

AVAILABILITY OF PAH SPESIFIC DRUGS

​

CHALLENGE

and

HOW TO MANAGE

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Worldwide : 12 types of PAH drugs

Indonesia : 4

Covered by National Insurance

Not Covered by National Insurance

European Respiratory Journal 2015 46: 903-975; DOI: 10.1183/13993003.01032-2015

Drugs Available in Indonesia

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Diagnosis

Chest X-ray

Electrocardiography (ECG)

Echocardiography

Right Heart Catheterization (RHC)

Gold standard

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12-Lead ECG Examination

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CHEST X-RAY

​

Findings on examination:

  • The proximal part of the pulmonary artery is enlarged and the peripheral part is sharp (pruning)
  • Cardiomegaly due to enlargement of the RA and RV
  • Pleural effusion is rare

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SCREENING PROGRAM FOR CHD, �WHERE ARE WE NOW?

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YEAR

COUNTRY

SAMPLE NUMBER

AGE RANGE

METHODS

FINDINGS (CONFIRMED CHD)

2000

Egypt

869.434

School age

Echo

881

2009

Taiwan

25.816

1st and 4th grade

questionnaire, phonocardiography, ECG

292

2010

Thailand

144.293

elementary school

Xray, echo, ECG

87

2011

Japan

2.067

Newborn

Echo

104

2012

China

540.574

6–13 years old

auscultation and echo

1.157

2012

India

4.213

5-16 years old

auscultation and echo

33

2013

Thailand

138.529

elementary school

physical examination, ECG, echo

102

2014

China

122.378

Newborn

SaO2, echo

1.071

2014

Nigeria

23.124

0-15 yeas old

Echo, ECG

332

2015

Japan

8.819

0-6 years old

Echo

137

2015

China

14,530

0-18 years old

auscultation, ECG and echo

240

2017

Shanghai

167.19

Newborn

SaO2, auscultation, echo

203

2020

Indonesia

6.116

elementary school

SaO2, auscultation, ECG

18 (on going)

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SCREENING PROGRAM IN JAPAN

Medical Check-up Through Echo

Medical Examination

Medical check up

Medical check up

Medical check up

Medical check up

Pregnancy

Newborn

Infant

Year 1

Year 2

Year 3

Physical Examination, Early detection of Heart Murmur using Stetoscope

First year of school (Medical check up) – 6th

Medical check up – 9th

Medical check up

Medical check up

ELEMENTARY SCHOOL

MIDDLE SCHOOL

HIGH SCHOOL

Primary screening: ECG

Secondary and Tertiary screening

Program screening in Japan from Pregnancy to High School

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PERGUB DIY (GOVERNOR`s regulation)

  • Peraturan Gubernur sudah terbit (PERGUB DIY no 103 tahun 2021)

The Concept of Legislation that has been approved through PERATURAN GUBERNUR DIY 2021

Gambar 1. Peraturan Gubernur Daerah Istimewa Yogyakarta Nomor 103 Tahun 2021.

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SCREENING METHOD

PRIMARY SCREENING

    • ECG
    • Physical examination (auscultation)
    • Saturasi O2

SECONDARY SCREENING

    • ECHOCARDIOGRAPHY

FOLLOW UP

GENERAL PRACTITIONER WORKSHOP

CARDIOLOGIST CONFIRMED

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General Practitioner Workshop

  • Training for PHC doctors on early detection of congenital heart disease using heart recording and heart sound devices
  • The team also conducted a refresher course on EKG interpretation for PHC doctors.

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SCREENING FOR CONGENITAL HEART DISEASE IN ELEMENTARY SCHOOL

2018-2019

( N : 6116 )

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TOOLS USED FOR SCRENING

PULSE OXYMETER

STETOSCOPE

6-LEADS ECG

12-LEADS ECG

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6-Leads �ECG

Cost-effective

Simple

More affordable

Easier to interpret the results

More expensive

Complicated

Limited availability

More complex to interpret

12-Leads ECG

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ECG PORTABLE 6 LEAD

AliveCor Kardia Mobile©

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Example of 6-Lead EKG Recording Results

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Summary of Primary School Student Screening Data 12-leads ECG in Yogyakarta Province for 2020

Total of Primary School

130 PS

Total of Children

6367

Children underwent screening

6116

Children who were not screened

251

Electrocardiography abnormalities

278

Murmur (+)

45

Murmur (+), RAD (+)

6

AV block and WPW syndrome

20

Diagnosed as Congenital Septal Defect

7 (5 ASD, 1 AVSD, 1 PFO)

Valve Abnormalities

11

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Summary of Primary School Student Screening Data in Yogyakarta City for 2022

Total of Primary School

18 PS

Total of Children

625

Children underwent screening

523

Children who were not screened

102

RAD

78

Murmur (+)

2

Murmur (+), RAD (+)

1

LAD

2

Diagnosed as Secundum ASD

1

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Summary of Primary School Student Screening Data in Bantul for 2023

Total of Primary School

2 PS

Total of Children

111

Children underwent screening

103

Children who were not screened

8

RAD

19

LAD

5

Arrythmia

12

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Normal

No further test

PRIMARY SCREENING

School Health Teacher

6-Leads ECG

PHC doctors

6-Leads ECG interpretation

Abnormal

PHC Doctors

Auscultation, Pulse Oximetry, and 12-Leads ECG interpretation

(JAMKESOS SCHEEME)

Normal

Abnormal

Referred to Secondary Hospital

Physical examination and Echocardiography

(BPJS SCHEEME)

SECONDARY SCREENING

Elementary School Children

Referred to Tertiary Hospital

Definitive diagnosis and Treatment (BPJS SCHEEME)

TERTIARY SCREENING

Abnormal

Normal

No further test

No further test

Step by step of screening

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RS H. Adam Malik = 235 pts

RS M. Djamil = 200 pts

RS Hasan Sadikin = 123 pts

RSUP Dr. Sardjito = 2000 pts

RS Dr. Kariadi = 0 pts

RS Saiful Anwar = 84 pts

RS Prof. Ngoerah = 12 pts

RS Wahidin

= 123 pts

RS Siloam Kebon Jeruk = 2 pts

RS UI = 70 pts

PJN HK = 795 pts

RS Dr. Moewardi = 10 pts

RS Dr. Soetomo = 0 pts

RS Kandou

= 0 pts

Total population: 261.115.456

Total island: 14.574

Total National Registry: 3654 patients

  • PH Group 1= 2925 pts
    • PAH-CHD = 2739 pts
    • IPAH = 186 pts
  • PH group 3 = 39 pts
  • PH group 4 = 12 pts
  • PH group 5 = 678 pts
  • Other types = 676 pts

Start to create national registry of PH

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Nama SD

TOTAL SISWA DIPERIKSA

EKG 6 LEAD / Murmur

EKG 12 LEAD

ECHOCARDIOGRAPHY

SD Terbansari 1

12

1 RAD

1 RBBB

Normal

SDN Baciro

15

3 RAD

1 Rujuk

2 Belum

1 Ditemukan Small ASD Sekundum

SD Muh Purwo

39

8 RAD

2 Slightly RBBB

2 RAD

4 Normal

3 Rujuk

1 BPJS Non-aktif

SD K Wirobrajan

101

19 RAD, 1 LAD

Rotary Club

-

SDN Kintelan I

10

-

-

-

Follow Up Hasil