==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 1805912010.5144/0256-4947.2007.442asm-6-442Brief ReportSymptomatic congenital heart disease in the Saudi Children and Adolescents Project Alqurashi Mansour *El Mouzan Mohammad †Al Herbish Abdullah †Al Salloum Abdullaha †Al Omer Ahmad ‡ * Department of Pediatrics, Al-Yamamah Hospital, Riyadh, Saudi Arabia † Department of Pediatrics, The College of Medicine, King Saud University, Saudi Arabia ‡ The Children’s Hospital, Riyadh Medical Complex, Saudi ArabiaCorrespondence and reprint requests: Mansour Al Qurashi, FRCP, Al-Yamamah Hospital, PO Box 60989, Riyadh 11555, Saudi Arabia, T: +966-1-491-4444 Ext: 1147/4030, F:+966-1-208-3060, m2_qurashi@hotmail.comNov-Dec 2007 27 6 442 444 01 5 2007 Copyright © 2007, Annals of Saudi Medicine2007This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. ==== Body The word ‘prevalence’ of congenital heart disease (CHD) usually means the estimated population of people with CHD at any given time. The term ‘incidence’ of CHD means the annual diagnosis rate or the number of new cases of CHD diagnosed each year. Most of the recent studies in the Gulf region measured the incidence of CHD in children.1,2 There are various local studies on the pattern of CHD,3,4 and these studies are descriptive analyses of a selected sample. Our study is the first community-based national prevalence study of symptomatic CHD in children and adolescents in Saudi Arabia, and includes CHD presenting with symptoms or clinical signs. Excluded are asymptomatic patent ductus arteriosus in the first 3 months of life; simple bicuspid aortic valves; isolated peripheral pulmonary artery stenosis with no clinical significance; and minor atrial shunts across defects measuring less than 5 mm. METHODS Our study was part of the Health Profile of the Saudi Children and Adolescents Project. The sample was 45 682 children and adolescents of ages from birth to 19 years selected by multistage probability random sampling of Saudi households from a stratified listing based on the population census of the 13 regions of the country including major cities, small towns and villages. A house-to-house visit by the field team, which included a physician, was made to all the households in the sample. A questionnaire that included age, gender, medical history and physical examination was completed. The results of the interview and clinical examination allowed classification of the children into one of the following categories: Children with a known diagnosis of CHD, confirmed with medical reports and echocardiography results from the concerned hospitals. These children were classified according to diagnosis into 4 groups (Table 1). Children with a known diagnosis of CHD but without supporting medical reports from concerned hospitals. The diagnosis was based on what the families were told about echocardiography results by treating doctors. These children were labeled as unspecified congenital heart disease (Table 1). Children with a history and clinical signs suggesting cardiac disease that were not diagnosed before, who were referred to hospitals. The hospital diagnosis was based on clinical examination and echocardiography. These children were included in the study after the diagnosis was provided by local hospitals and classified as category (A) into 4 groups. RESULTS During the period 2004–2005, of a total of 45 682 children and adolescents, 95 had CHD for a prevalence of 21 per 10 000. The types of diseases are shown in Table 1. Ventricular septal defect (VSD) was the commonest diagnosis, occurring in 44 of the 95 (46.3%) children with CHD with the highest prevalence of 10 per 10 000. The next most common group was unspecified CHD in 26 of 95 (27.4%) for a prevalence of 6 per 10 000. The remainder of the cases, such as cyanotic CHD, atrial septal defects (ASD), and other non-cyanotic CHD occurred much less commonly with a prevalence of about 2 per 10 000 each. The distribution of CHD according to sex of patients showed a slight predominance in females, with 53 girls and 42 boys, for a female to male ratio of 1.3:1 (Table 1). VSD was slightly more common in females with a female to male ratio of 1.4:1. ASD was seen more in girls with a female to male ratio of 3:1. Cyanotic CHD was equal in both sexes. The regional distribution of CHD showed that the Central Region had the highest prevalence of 27 per 10 000, followed by the Northern and the Eastern Regions, with a prevalence of 25 per 10 000 each and the Southwestern Region prevalence of 21 per 10 000. The prevalence was less common in the northwestern region, with 10 children only (prevalence 9 per 10 000). To assess the prevalence of CHD more accurately, the results were related to sample size in each region: North Western Region (Makkah and Madinah regions)=10 711, Central Region (Riyadh and Qassim regions)=11 194, Eastern Region (Damam region)=4420, Northern Region ( Jouf, Northern Border, Hail and Tabuk regions)= 8 959, and the Southwestern Region (Assir, Gizan, Najran and Al Baha regions)=10 398. DISCUSSION The prevalence of CHD in Saudi children is compared with other studies in Table 2. The prevalence in our study was lower than in hospital-based studies due to variations in methods and age differences,5–7 whereas the prevalence was higher than in school-based studies due to age differences.8–10 The prevalence of CHD is related to the relative frequency of VSD,11 the most common type of CHD.12–13 The majority of VSD are closed spontaneously in early childhood,8,9,14 so the prevalence of CHD in this community-based study (which includes a wide age range) was expected to be lower than in hospital-based studies, which are done usually in infants or newborns.5–7,13 The prevalence of CHD also depends on the diagnosis of minor cardiac defects such as small atrial septal defect, small patent ductus arteriosus, and mild pulmonary valve stenosis. 11,15–17 These minor lesions were not diagnosed in this community study due to subtle clinical signs. Most newborns with severe types of complex cardiac lesions die before 1 year of age, which also reduces the prevalence of CHD in older children.5,7,9,14 These factors explain the low prevalence of CHD in this study in comparison with hospital-based studies.6,7 Our study showed a low prevalence of CHD compared with similar community-based studies in other countries such as China and India, which is either due to actual low prevalence in Saudi Arabia or under-reporting of cases during the survey (Table 2). The prevalence was 42 per 10 000 in Indian children younger than 15 years18 and 50 per 10 000 in Chinese children (aged 3–18 year),19 which are higher than the prevalence of 21 per 10000 in Saudi Arabia. According to the KFSH study,20 the southwestern egion of Saudi Arabia near the border with Yemen and the northern part of the Eastern Region appear to exhibit a higher burden of CHD. Our study demonstrates a Central Region dominance followed by the Eastern Region and the Northern Region, with the last being the Southwestern Region. The KFSH study was hospital-based using data on admitted patients, while our study was community based, which explains the difference between the two studies. A limitation of our study is that the group of children with unspecified CHD is a large group (27% of total children with CHD). These children were diagnosed as having CHD, but without supporting medical reports from concerned hospitals and thus our diagnosis is based on history and clinical examination only. These children were kept in a separate group to avoid bias and included in the total prevalence of CHD in the Kingdom, but their significance in the prevalence of various types of CHD cannot be ignored. This nationwide community-based study for CHD has revealed a relatively low frequency of CHD, the commonest being VSD, with the frequency lower than reported from other populations. We still need supportive community-based studies to measure the prevalence of CHD in different regions of the country. In addition, we need a multicentric study on the epidemiology of CHD to assess the pattern of CHD in Saudi Arabia, and the survival and outcome of affected babies. Acknowledgment This study was supported by a research grant from King Abdulaziz City for Science and Technology in Riyadh. (No AR-20-63). Table 1 Prevalence of congenital heart diseases in Saudi children. Diseases Number of cases Prevalence per 10 000 Males Females Total (%) Ventricular septal defect 18 26 44 (46) 10 Atrial septal defect 2 6 8 (8.5) 2 Other non-cyanotic CHD* 3 4 7 (7.5) 2 Cyanotic CHD† 5 5 10 (11) 2 Unspecified CHD 14 12 26 (27) 6 Total CHD 42 53 95 (100) 21 * Patent ductus arteriosus 1, coarctation of the aorta 1, aortic stenosis 2, pulmonary stenosis 2 and Ebstein’s anomaly 1. † Tetralogy of Fallot 3, transposition of great arteries 2, complex cyanotic heart disease 5. Table 2 Prevalence of congenital heart disease in children and adolescents worldwide. Study description Prevalence per 10 000 population Children Number Year Age Place Of Study Community-based study 21 45 682 2005 Birth - 18 yrs Saudi Arabia (present study) Population-based study 37 4390 1993 0–1 year USA: Baltimore-Washington Infant Study7 Population-based study 47 330 017 2003 Live and still births Italy: Emilia-Romagna Registry, Calzolari E6 Population-based study 61 815 569 1999 0–15 years Czech Republic: Bohemia Survival Study, Samanek M5 School-based study 10 1788 2000 5–15 years Egypt: Alexandria, Zaki9 School-based study 20 13 322 1997 5–15 years Sudan: Sahafa Town, Khalil10 School-based study 13 9420 2003 5–18 years Nepal: Kathmandu, Bahadur8 Community-based study 42 11 833 2001 0–15 years India: New Delhi, Chadha SL18 Community-based study 50 48 638 2005 3–18 years China: Yunnan Province, Jiang19 ==== Refs REFERENCES 1 Subramanyan R Joy J Venugopalan P Sapru A al Khusaiby SM Incidence and spectrum of congenital heart disease in Oman Ann Trop Pediatric 2000 12 20 4 337 41 2 Robida A Folger GM Hajar HA Incidence of congenital heart disease in Qatari children Int J Cardiol 1997 6 27 60 1 19 22 9209935 3 Alabdulgader AA Congenital heart disease in 740 subjects: epidemiological aspects Ann Trop Pediatric 2001 6 21 2 111 8 4 Fuad Abbag FRCPC Pattern of congenital heart disease in the Southwestern region of Saudi Arabia Ann Saudi Med 1998 18 5 393 395 17344707 5 Samanek M Voriskova M Congenital heart disease among 815,569 children born between 1980 and 1990 and their 15-year survival: a prospective Bohemia survival study Pediatr Cardiol 1999 11 20 6 411 417 10556387 6 Calzolari E Garani G Cocchi G Magnani C Congenital heart defects: 15 years of experience of Emilia-Romagna registry (Italy) Eur J Epidemiol 2003 18 8 773 80 12974553 7 Kuehl K Loffredo CA Ferencz C Failure to diagnose congenital heart disease in infancy Pediatrics 4 1999 103 743 7 10103296 8 Bahadur KC Sharma D Shrestha MP Gurung S Rajbhandari S Malla R Prevalence of Rheumatic and Congenital heart disease in Schoolchildren of Kathmandu Valley in Nepal Indian Heart J 2003 55 615 618 14989511 9 Bassili A Mokhtar SA Dabous NI Zaher SR Mokhtar MM Zaki A Congenital heart disease among school children in Alexandria, Egypt: an overview on prevalence and relative frequencies J Trop Pediatr 2000 12 46 6 357 62 11191148 10 Khalil Siddiq I Gharieb Khalid El Haj Mohammed Khalil Mohammed Hakiem Suzan Prevalence of congenital heart disease among schoolchildren of Sahafa Town, Sudan Eastern Mediterranean Health J 1997 3 1 24 28 11 Hoffmann JIE Kaplan S The incidence of congenital heart disease J Am Coll Cardiol 2002 6 19 39 12 1890 900 12084585 12 Miyague NI Cardoso SM Meyer F Araujo FH Rozkowisk I Toschi AP Epidemiological study of congenital heart defects in children and adolescents. 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