The 2015 Jones Criteria for Acute Rheumatic Fever- Need for a Critical Reappraisal.

Abstract

Acute rheumatic fever (ARF), a non-suppurative complication of group A beta hemolytic streptococcus (GAS), continues to be an important cause of acquired heart diseases in children [1, 2]. Whilst the burden of rheumatic heart disease (RHD) has significantly reduced in developed countries, it still continues to be a major health problem in developing countries [2]. Prevalence of RHD in India is estimated to be 0.67/1000 children in a recent school based survey [2, 3]. Over past 50 y, significant developments have occurred in diagnosis and management of ARF. One of the major changes noted in the diagnosis of ARF is the utility of Echocardiogram and Doppler (E&D) studies for detection of clinically unrecognizable carditis for the diagnosis of ARF [4]. Subclinical carditis (SC) is a condition where clinical cardiac examination is completely normal and only E&D studies pick up the valvular abnormalities. Diagnostic criteria for ARF was initially put forth by Dr. T. Duckett Jones in the year 1944. The criteria have been revised and updated several times, and the most recent update of the Jones Criteria have been released by the American Heart Association in May 2015 [5, 6]. Main aim of these guidelines has been to have a uniform diagnostic criteria across the globe and to prevent over-diagnosis. However, even the most recent version has several shortcomings for clinical application in developing countries where the vast majority of patients with ARF are likely to be diagnosed and managed (Table 1). Recent revision of Jones Criteria for diagnosis of ARF has suggested that echocardiography be performed in all cases of suspected ARF [6]. Subclinical carditis is now considered one of the major criteria for diagnosis of ARF. The addition of SC as the major criteria is based on large numbers of good quality evidence from both developed and developing countries around the globe, which suggested that E&D based screening is more sensitive than clinical examination for detection of carditis [6]. However, it is prudent to note that long term outcome of subclinical carditis is not clearly known and it may well represent only a transient phenomenon [7]. Robust data on long term follow-up of patients with subclinical carditis is lacking. This recommendation in the 2015 criteria is, therefore, open to debate and controversy. Existing data on follow-up studies indicate that subclinical carditis may worsen to RHD, may remain unchanged, or may also improve over time [2, 4, 7]. Moreover, facilities for E&D based screening for carditis in patients with suspected ARFwould not be easily available at the point of care in most developing countries. Interpretation of the E&D studies would also need an experienced cardiologist/echocardiographer, who may not be easily available in all centres. If the new criteria have to be accepted and implemented, then a seemingly large number of patients may need referral to higher centres where experts in cardiology are likely to be available. This is likely to put additional burden on the scarce health care resources available in these countries. Though the criteria for pathological valve regurgitation are very clear in the guidelines [6], the line between physiological and pathological abnormalities of cardiac valves appears thin and nebulous when it comes to clinical practice. And unless echocardiography has been performed by an experienced pediatric cardiologist/echocardiographer who is familiar with the finer nuances of cardiac involvement in ARF, it may be difficult for the attending physician to interpret the * Pandiarajan Vignesh vigimmc@gmail.com