**4.3. Rheumatic heart disease (RHD)**

The RHD, which was the leading cause of IE in the preantibiotics era, is now rare in developed countries. However, it remains a highly prevalent disease in developing countries. More developed areas, such as Hong Kong and Thailand, still have a case of IE in 18 and 12%, respectively.

Chou et al. in their study compared 68,426 adult patients with ESRD in HD with two groups: with IE and without IE. They found that 1.2% without IE and 4.4% with IE, respectively, had the RHD, having a statistical significance *p* < 0.001, relative to RHD and IE in HD patients [16]. The same study shows the differences in incidence among Asian countries and the western countries. However, many western countries, such as in the case of Mexico and parts of South America, are still considered to be endemic for this disease. Simsek-Yavuz et al. in their study in Turkey also noted the difference in incidence among the developed countries and found low incidence of RHD compared with developing countries. They presented their work in 325 patients with IE that 33% had RHD.

Although this study is not specifically for HD patients, it demonstrates a high prevalence of RHD in IE [20].
