Rheumatic fever and rheumatic heart disease continue to be a major cause of mortality and morbidity even now in many parts of the globe and particularly so with poorer sections of societies. In 2005, it was estimated that the global burden of group A streptococcal diseases was still high with a prevalence of at least 20 million cases with around 3,00,000 new cases each year and as many deaths (Lancet Infec Dis 5:685-94). Reappearance of rheumatic fever in parts of the Western world, points out the need for continued vigilance and attention to this problem. The WHO has brought out several technical reports and as recently as 2009 the American Heart Association has updated their scientific statement on the prevention of rheumatic fever and the diagnosis and treatment of acute streptococcal pharyngitis (Circulation, Vol: 119).

It is, therefore, right and proper that an updated book on Acute Rheumatic Fever and Chronic Rheumatic Heart Disease is being published from the Indian subcontinent. Most of the contribution in the newer sections like the role of echocardiography in the diagnosis of acute rheumatic carditis and nonsurgical treatment of rheumatic vascular heart disease has been given by the Indian workers.

Professor I B Vijayalakshmi, Head of Pediatric Cardiology at one of India's major institutions with the Sri Jayadeva Institute of Cardiovascular Sciences and Research is ideally placed to edit such a book. She has had a major interest in rheumatic fever and rheumatic heart disease and has made a notable contribution particularly in the area of echocardiographic criteria for the diagnosis of acute rheumatic carditis. She also has the distinction of being a member of the World Heart Federation Group for standardizing echocardiography in rheumatic heart disease. The book with a galaxy of distinguished contributors, I am sure will be a valuable reference resource for the years to come.

This monogram, in both its concept and design, is aimed at giving a comprehensive and complete knowledge about ARF and RHD to the pediatricians, physicians and all the medical students dealing with health problems in the socioeconomically poor community. I have not made an exhaustive or a complicated report. Instead, I have concentrated on the detailed description, practical successful approach to control the menace of ARF and RHD in the 21st century, which is the need of the hour.

The book begins with Lessons Learnt from the History of Rheumatic Heart Disease, because if I do not learn from the past, I cannot build the future. The doctors have learnt a lot from the pioneering work done by many great clinicians in the past. Rheumatic Fever and Rheumatic Heart Disease: A 4 Century Review with Special Reference to India is written by a doyen, S Padmavati, who herself was in the forefront in the fight against this dreaded disease for decades. Notwithstanding the brilliant achievements of medical fraternity, ARF and RHD remains a major public health problem, throughout the developing countries of the world, that is to say, in most of the world's population. Therefore, the third chapter is Epidemiology of Group A Streptococcal Infections, Rheumatic Fever, Rheumatic Heart Disease and Role of WHO. Today, this disease is not seen much in the West. But, India is in the phase of epidemiological transition. On one hand there is a substantial burden due to RHD, on the other hand resources are scarce to treat and prevent the disease. Hence, the fourth chapter is, Can We Change the Epidemiological Trend of RHD in India?

The ARF has not yet been completely eradicated, as prevention will be less than optimal until the pathogenesis of the disease has been totally elucidated. ARF is caused by a group A beta hemolytic streptococcal (GABHS). The process is triggered by an inadequate immunological response, both humoral and cellular, therefore, the Etiopathogenesis and Management of Streptococcal Infection is a very important and a basic chapter. The Laboratory Diagnosis of Group A Beta Hemolytic Streptococcal Infections is meant for educating all the practitioners about laboratory investigations and their usefulness. Saroja and Sarasa Bharati both pioneers in cardiac pathology have contributed Etiopathogenesis and Pathology of Carditis in Rheumatic Fever. Pathology of Chronic Rheumatic Heart Disease written by Pradeep Vaideeswar has brilliant photos of specimens by him, which will go a long way in the understanding of pathology of carditis in ARF and RHD.

Acute rheumatic fever is an acute, diffuse, nonsuppurative inflammatory disease that occurs in susceptible individuals as a late complication after an untreated Streptococcus pharyngotonsillitis. The infection itself sometimes being asymptomatic. The initial streptococcal pharyngotonsillitis is followed by latent period and then by the acute and chronic phases. There are four distinct phases characterizing the disease. The disease has the potential to involve the heart, joints, brain and subcutaneous and cutaneous tissues. Cardiac injury is the most important manifestation and it is the injuries to the heart which produce its clinical, social and economic impact. Hence, the third part consists of important chapters like Etiopathogenesis, Clinical Manifestation and Diagnosis of Acute Rheumatic Fever and Clinical Profile of 12Rheumatic Heart Disease written by none other than a veteran teacher, AS Chandrasekhara Rao. Probably, this is the first book on rheumatic fever, to dedicate one whole chapter to Role of Echocardiography in Diagnosis of Carditis in Acute Rheumatic Fever written personally by me. The new Echo criteria given for diagnosis of carditis in ARF is very unique and will prove useful in future to the modern clinicians. The degree of cardiac involvement is quite variable, ranging from mild, asymptomatic valvulitis to severe carditis with significant acute mitral and/or aortic regurgitation resulting in heart failure. Many a times, subclinical valvulitis and indolent carditis is missed by best of the clinicians; more so because the auscultation is becoming the dying art among the younger clinicians, who fail to recognize the mild valvular lesions. Therefore, Role of Echocardiography in Diagnosis of Carditis in ARF and Echocardiography and Transesophageal Echo in Rheumatic Heart Disease is added to this book and a DVD of echocardiographic videos is given along with the book to assist the clinicians to improve their skill to detect the disease more accurately. It will certainly help in making an early and precise diagnosis of carditis and this modern modality, ECHO when added to Jones criteria can certainly change the epidemiological face of ARF.

Both ARF and chronic RHD continue to pose serious concerns with regard to health, in many parts of the world and present a significant challenge for those involved in providing health care. In developed countries, although its incidence has been markedly reduced since the 1950s, ARF remains a risk because of its potential risk in many countries. There is consensus in some of the management strategies, but there are some issues in the management which are controversial. In some management strategies there is consensus and the guidelines are laid. But many of the treatment methods are old aged and not evidence based. Hence, there is confusion among the treating physicians. Therefore, the chapter Diagnosis, Consensus and Controversies in the Management of Acute Rheumatic Fever is useful to know the appropriate management and avoid mismanagement. Medical Management of Rheumatic Heart Disease and Management during Pregnancy, Noncardiac Surgery and Infective Endocarditis and How Important is the Echocardiographic Screening for Rheumatic Heart Disease? by Bogarka (Bo) Remenyi and Nigel Wilson is an added attraction to this book. This is aimed at making the clinicians to bring more children with RHD into the net of penicillin prophylaxis and prevent the further damage to the heart.

The 20th century was distinguished by the identification of GABHS pharyngitis as the cause of ARF and by the demonstration that the first attack of ARF and recurrence are preventable by the appropriate use of penicillin to treat and prevent these infections. Prevention and Vaccine for Rheumatic Fever: How Far are We? are extremely important and will go a long way in controlling ARF and RHD.

The disease is seen in its virgin condition undetected and untreated in many poor and backward areas. Therefore, chapters on Natural History of Rheumatic Fever and Rheumatic Heart Disease and Cardiac Complications of Acute Rheumatic Fever are added to caution the clinicians about the dreaded complications and to impress the importance of timely detection and management of consequences.

The repercussions of the disease involve patients of all ages, since the valvular sequelae can be carried throughout life. The children and adolescents, who are most frequently admitted to hospital with acute episodes, are the same group of patients who, after the fourth decade of life, form the largest group when analysis is focused on invasive intervention and death. Tremendous progress is made in interventional cardiology and cardiac surgery, the benefit of which should reach the patients of RHD in advance stage. Therefore, chapters on Non-Surgical Management of Rheumatic Heart Disease written by most experienced, Ramesh Arora who has the highest number of PTMCs to her credit in the world. Juvenile rheumatic heart disease is peculiar to Indian subcontinent, hence, special emphasis is on Challenges of Management of Mitral Stenosis in the Pediatric Age Group. There is an all important chapter Surgical Management of Rheumatic Heart Disease, which contains care of native and prosthetic valve and anticoagulation. RHD, besides being considered the most frequent condition necessitating 13valvular surgery in adults, even the non-surgeons should know about the prosthetic valve complications. The economic impact must also be considered, not only with regard to the financial cost of clinical and surgical treatments but also relative to the loss of productivity as the result of disability acquired at an early age. The last but not least, the book ends with the positive note with the last chapter Rheumatic Fever, Rheumatic Heart Disease Registry and Control Program. This chapter consists of proforma and protocols for ARF control program to be conducted from the remotest place to nationwide. This special chapter is meant for motivating the youngsters to take up preventive and epidemiological projects rather than sit in the clinic and treat the terminal cases. If the morbidity and mortality due to ARF and RHD is reduced in the children and they lead hale and healthy life then the purpose of writing this book is fulfilled.

The book could not have been written without the help of many other individuals whose names do not appear in the list of contributors. I thank all my contributors for their efforts in contribution towards making this book possible. I am now able to include color illustrations throughout the book. The influence of this is likely to be truely spectacular and special.

My grateful thanks to Chitra Narasimhan, who labored beyond the call of duty in her efforts to obtain all the chapters on time and to complete some of the chapters. I am also indebted to Usha Anand, who co-authored a chapter and made the corrections of the proofs a pleasurable task rather than a chore. I also express my thanks to my various colleagues who permitted me to use illustrations from various previous collaborative ventures. I have cited their contributions in the legends to the specific figures, hoping that I have not made any omissions. I hope that this book will be of some value to not only to those involved in the practice of cardiology but also to the medical students and clinicians practicing in the periphery. Most of all, I sincerely hope that the lessons learnt from this book will benefit the helpless patients and reduce the disease burden on patients and economical burden on the society.

My heart goes out to the children suffering from ARF and RHD. The present scenario of ARF and RHD in poor children is pathetic. It makes me feel sad and say:

But I am sure with determined effort at controlling the menace of ARF and with the proper understanding of the disease, utilizing ECHO criteria for early and precise diagnosis and appropriate preventive measures, I can definitely succeed in eradicating ARF from the surface of the globe. So my sincere prayer is:

I have the fond hope that this honest effort of mine, will go a long way in changing the epidemiological trend of ARF and eventually succeed in eradicating RHD worldwide.