With the exception of isolated outbreaks, acute rheumatic fever has all but disappeared from developed nations, and its sequela, chronic rheumatic heart disease (RHD), has become uncommon. Prevalence estimates for RHD vary, from 0.6/1,000 among American school-age children1 to <0.05/1,000 among hospital discharge diagnoses.2 In developing nations, rheumatic fever and RHD continue unabated, with RHD affecting an estimated 5 to 30 million worldwide.3 Documented outbreaks of streptococcal infections in American Indian communities4,5 and retrospective studies of valvular heart disease6,7 suggest that this population may have a high prevalence of RHD. Therefore, the Strong Heart Study (SHS) assessed the prevalence and correlates of RHD in American Indians.