Definite Rheumatic Heart Disease Research Articles

Screening-detected rheumatic heart disease can progress to severe disease

ObjectivesEchocardiography is a sensitive test for rheumatic heart disease (RHD) screening; however the natural history of RHD detected on screening has not been established. We aimed to evaluate the progression...

Prevalence of rheumatic heart disease in patients with recurrent tonsillitis and elevated anti-streptolysin O titers

IntroductionPatients with elevated anti-streptolysin O (ASO) titers (ASOT) and recurrent tonsillitis episodes are known to be at higher risk for rheumatic heart disease (RHD). However, there is no data regarding prevalence of RHD in this high risk population. In this study, we aimed to screen ambulatory patients with elevated ASOT and recurrent tonsillitis episodes using echocardiography for identification of RHD. We hypothesized that prevalence of RHD is higher in this patient group compared to general population. Methods102 patients (10.33 ± 4.01 years, 50.98% female) who were diagnosed with recurrent tonsillitis and had elevated ASOT were included this study. Echocardiographic evaluation was performed by an experienced cardiologist. ResultsEchocardiographic examination revealed definite RHD in 2/102 (1.96%) patients and borderline RHD in 3/102 (2.94%) patients. ConclusionOur study demonstrates a high prevalence of RHD in patients with recurrent tonsillitis episodes and high ASOT. Screening with echocardiography is beneficial to improve the detection rates of subclinical RHD in such high-risk populations.

Prevalence of rheumatic heart disease among school children in Ethiopia: A multisite echocardiography-based screening

BackgroundAuscultation-based surveys in Ethiopia conducted in the late 1990's reported a rural prevalence of 4.6/1000 and an urban prevalence of 6.4/1000 of rheumatic heart disease (RHD). With echo-based screening, we aimed to estimate the national prevalence of RHD in school children by taking school-based samples from six regions across the country using the 2012 World Heart Federation echocardiographic criteria. Patients and methodsWe conducted a cross-sectional echocardiographic screening of RHD in school children aged 6–18years from 28 randomly selected primary and secondary schools found in six different geographic regions of Ethiopia. We used the standardized WHF echocardiographic criteria. ResultsA total of 3238 children (48.5% females) were screened. The mean age was 13.2±3.2years. Of these, 44 patients (1.4%) met the WHF criteria for definite RHD, while 15 (0.5%) met the criteria for borderline disease, yielding a prevalence of 19 [13.9–23.4, 95% CI] cases per 1000 school children between the ages of 6–18years. The majority of those who tested positive were girls (26/44). The prevalence was lowest in children aged 6–9years and otherwise uniformly distributed across ages 10–18years. Definite RHD involved the mitral valve in 42 subjects, 39 of whom had mitral regurgitation and 3 with mitral stenosis. The aortic valve was affected in 6 children. The ratio of definite to borderline cases was 2.9. ConclusionThis study demonstrated a consistent pattern of high prevalence of asymptomatic RHD with definite disease predominating over borderline involvement across six regions of Ethiopia.

OC02_09 Next Generation Data Collection and Organizing System to Support Population-Based Screening for Rheumatic Heart Disease

Introduction: Different echocardiographic definitions of Rheumatic Heart Disease (RHD) have been used for screening for RHD. This led to development of the 2012 evidence-based World Heart Federation (WHF) echocardiographic criteria for RHD. Objectives: To determine if the WHF criteria allow for consistent and reproducible differentiation of normal echocardiographic findings from mild RHD. Methods: Participants were 16 international cardiologists. A standard set of 200 echocardiograms was collated from population-based surveys of school-aged children in regions of high RHD prevalence in Australia and New Zealand. Echocardiograms were uploaded for blinded web-based reporting. Inter-observer variability in categorizing echocardiograms as normal, borderline or definite RHD, as per WHF criteria, was measured by comparing individual readings with a reference reading (majority reading if greater than 2/3 consensus, external panel consensus reading otherwise). Agreement in diagnosis of pathologic mitral and aortic regurgitation and morphologic features of RHD were assessed. One hundred echocardiograms were re-reported blindly for intra-observer assessment. Results: 3112 reports were analysed. Based on the reference readings, distribution of cases were: 67 (33.5%) borderline RHD, 53 (26.5%) definite RHD and 80 (40%) no RHD. Overall agreement in categorising echocardiograms as normal, borderline and definite RHD (primary end-point) was good, kappa 0.68 (95%CI 0.66-0.70; SE 0.0152, p-value <0.0001). Fig 1 shows inter/intra-observer agreement, sensitivity and specificity of individual readers. Agreement for pathologic mitral regurgitation was excellent, kappa 0.87 (95%CI 0.85-0.89), Fig 2. Agreement for subtle morphologic changes of RHD was variable ranging from fair to good.

An epidemiological study to assess the true incidence and prevalence of rheumatic heart disease and acute rheumatic fever in New Caledonian school children.

To provide in New Caledonian school children (i) the prevalence of rheumatic heart disease (RHD) detected by annual screening program using new World Heart Federation diagnostic criteria; (ii) the point prevalence of acute rheumatic fever (ARF); and (iii) to investigate socio-demographic risk factors associated with RHD. This study linked data from national ARF/RHD programs by combining ARF incidence data from the register with RHD prevalence data from echocardiographic screening data for a single age year of the population for overall point prevalence ARF/RHD rates. For the analysis, cases of echocardiographic detection of RHD are presumed to be synonymous with undiagnosed ARF. All results were weighted to minimise the bias introduced from absent pupils of each annual screening program. Incidence and prevalence were age-standardised to the WHO World Standard Population. Each 2013 cumulative prevalence of definite and borderline RHD was studied using a multivariate logistic regression adjusted for socio-demographic factors. The overall age-standardised incidence of clinical and undiagnosed ARF (i.e. echocardiographic-detected RHD) was combined as point prevalence and estimated to be 99/10 000 cases in 2012 and 114/10 000 cases in 2013. This included 40/10 000 prevalent cases of asymptomatic RHD detected by screening each year. Being Melanesian, OR 23.2 (95% CI: 3.4-157.3), or Polynesian, OR 21.5 (95% CI: 2.9-157.7), was associated with a higher prevalence of having definite RHD compared with being Caucasian. Being a girl was associated with a higher risk of having borderline RHD, OR 1.9 (95% CI: 1.03-3.3). Without echocardiographic screening, ARF/RHD burden is substantially underestimated.

Prevalence of Subclinical Rheumatic Heart Disease in Eastern Nepal: A School-Based Cross-sectional Study.

Although rheumatic heart disease has been nearly eradicated in high-income countries, 3 in 4 children grow up in parts of the world where it is still endemic. To determine the prevalence of clinically silent and manifest rheumatic heart disease as a function of age, sex, and socioeconomic status and to estimate age-specific incidence. In this school-based cross-sectional study with cluster sampling, 26 schools in the Sunsari district in Eastern Nepal with 5467 eligible children 5 to 15 years of age were randomly selected from 595 registered schools. After exclusion of 289 children, 5178 children were enrolled in the present study from December 12, 2012, through September 12, 2014. Data analysis was performed from October 1, 2014, to April 15, 2015. Demographic and socioeconomic characteristics were acquired in a standardized interview by means of a questionnaire customized to the age of the children. A focused medical history was followed by a brief physical examination. Cardiac auscultation and transthoracic echocardiography were performed by 2 independent physicians. Rheumatic heart disease according to the World Heart Federation criteria. The median age of the 5178 children enrolled in the study was 10 years (interquartile range, 8-13 years), and 2503 (48.3%) were female. The prevalence of borderline or definite rheumatic heart disease was 10.2 (95% CI, 7.5-13.0) per 1000 children and increased with advancing age from 5.5 (95% CI, 3.5-7.5) per 1000 children 5 years of age to 16.0 (95% CI, 14.9-17.0) in children 15 years of age, whereas the mean incidence remained stable at 1.1 per 1000 children per year. Children with rheumatic heart disease were older than children without rheumatic heart disease (median age [interquartile range], 11 [9-14] years vs 10 [8-13] years; P = .03), more commonly female (34 [64.2%] vs 2469 [48.2%]; P = .02), and more frequently went to governmental schools (40 [75.5%] vs 2792 [54.5%]; P = .002). Silent disease (n = 44) was 5 times more common than manifest disease (n = 9). Rheumatic heart disease affects 1 in 100 schoolchildren in Eastern Nepal, is primarily clinically silent, and may be more common among girls. The overall prevalence and the ratio of manifest to subclinical disease increase with advancing age, whereas the incidence remains stable at 1.1 per 1000 children per year. Early detection of silent disease may help prevent progression to severe valvular damage.

School and Community Screening Shows Malawi, Africa, to Have a High Prevalence of Latent Rheumatic Heart Disease.

Determine the prevalence of latent RHD among children ages 5-16 in Lilongwe, Malawi. This is a cross-sectional study in which children ages 5 through 16 were screened for RHD using echocardiography. Screening was conducted in 3 schools and surrounding communities in the Lilongwe district of Malawi between February and April 2014. Children were diagnosed as having no, borderline, or definite RHD as defined by World Heart Federation criteria. The primary reader completed offline reads of all studies. A second reader reviewed all of the studies diagnosed as RHD, plus a selection of normal studies. A third reader served as tiebreaker for discordant diagnoses. The distribution of results was compared between gender, location, and age categories using Fisher's exact test. The prevalence of latent RHD was 3.4% (95% CI = 2.45, 4.31), with 0.7% definite RHD and 2.7% borderline RHD. There was no significant differences in prevalence between gender (P = .44), site (P = .6), urban vs. peri-urban (P = .75), or age (P = .79). Of those with definite RHD, all were diagnosed because of pathologic mitral regurgitation (MR) and 2 morphologic features of the mitral valve. Of those with borderline RHD, most met the criteria by having pathological MR (92.3%). Malawi has a high rate of latent RHD, which is consistent with other results from sub-Saharan Africa. This study strongly supports the need for a RHD prevention and control program in Malawi.

Efficacy of a Standardized Computer-Based Training Curriculum to Teach Echocardiographic Identification of Rheumatic Heart Disease to Nonexpert Users

The ability to integrate echocardiographic for rheumatic heart disease (RHD) into RHD prevention programs is limited because of lack of financial and expert human resources in endemic areas. Task shifting to nonexperts is promising; but investigations into workforce composition and training schemes are needed. The objective of this study was to test nonexperts' ability to interpret RHD screening echocardiograms after a brief, standardized, computer-based training course. Six nonexperts completed a 3-week curriculum on image interpretation. Participant performance was tested in a school-screening environment in comparison to the reference approach (cardiologists, standard portable echocardiography machines, and 2012 World Heart Federation criteria). All participants successfully completed the curriculum, and feedback was universally positive. Screening was performed in 1,381 children (5 to 18years, 60% female), with 397 (47 borderline RHD, 6 definite RHD, 336 normal, and 8 other) referred for handheld echo. Overall sensitivity of the simplified approach was 83% (95% CI 76% to 89%), with an overall specificity of 85% (95% CI 82% to 87%). The most common reasons for false-negative screens (n= 16) were missed mitral regurgitation (MR; 44%) and MR ≤1.5cm (29%). The most common reasons for false-positive screens (n= 179) included identification of erroneous color jets (25%), incorrect MR measurement (24%), and appropriate application of simplified guidelines (39.4%). In conclusion, a short, independent computer-based curriculum can be successfully used to train a heterogeneous group of nonexperts to interpret RHD screening echocardiograms. This approach helps address prohibitive financial and workforce barriers to widespread RHD screening.

The natural history of latent rheumatic heart disease in a 5 year follow-up study: a prospective observational study.

BackgroundLatent rheumatic heart disease (RHD) occurs in asymptomatic individuals with echocardiographic evidence of RHD and no history of acute rheumatic fever. The natural history of latent RHD is unclear but has important clinical and economic implications about whether these children should receive penicillin prophylaxis or not. We performed a 5-year prospective study of this question.MethodsIn August 2013 through September 2014, we conducted a follow-up study of latent RHD among school pupils using the World Heart Federation (WHF) echocardiographic criteria. Contingency tables were used to assess progression, persistence or regression of latent RHD.ResultsForty two borderline and 13 definite cases of RHD (n 55) were identified, 44 (80 %; mean age 13.8 ± 4.0 years; 29 (65.9 %) female) of whom were available for echocardiographic examination at a median follow-up of 60.8 months (interquartile range 51.3-63.5). Over the follow-up period, half the participants (n = 23; 52.3 %) improved to normal or better WHF category (regressors), a third (n = 14, 31.8 %) remained in the same category (persistors), while seven others (15.9 %) progressed from borderline to definite RHD (progressors). In total, 21 subjects (47.7 %) reverted to a normal status, nine (20.4 %) either improved from definite to borderline or remained in the borderline category, and 14 (31.8 %) either remained definite or progressed from borderline to a definite status. Two cases (20 %) progressed to symptomatic disease.ConclusionsLatent RHD has a variable natural history that ranges from regression to normal in nearly half of cases, to persistence, progression or development of symptoms in the remainder of subjects.

Using a Low-Risk Population to Estimate the Specificity of the World Heart Federation Criteria for the Diagnosis of Rheumatic Heart Disease

The 2012 World Heart Federation (WHF) criteria set the minimum standards for echocardiographic diagnosis of rheumatic heart disease (RHD) in a high-risk population without history of acute rheumatic fever. The high sensitivity of the 2012 WHF criteria is well accepted, but the specificity cannot be directly assessed without a confirmatory test. The objective of this study was to estimate the false-positive rate of the WHF criteria through their application in a population at very low risk for RHD. The Children's National Health System echocardiography database was searched for patients (6-15years of age) with an International Classification of Diseases, Ninth Revision, code for "chest pain." Chart review was performed; children with congenital heart disease or systemic disease were excluded. Patients were classified according to WHF criteria as having normal, borderline, or definite RHD on the basis of mitral and aortic valve morphology and the presence of pathologic mitral and/or aortic regurgitation. A total of 1,251 studies were identified, and 152 were excluded. Fifty studies were randomly chosen from each age, with equal gender distribution, for a total of 500 echocardiograms. No patients met the criteria for definite RHD and four (0.8%) for borderline RHD, both by pathologic mitral regurgitation. No patients met the criteria for borderline RHD on the basis of mitral valve morphology or pathologic aortic regurgitation. In a US pediatric population, no children had findings of definite RHD, and 0.8% had findings of borderline RHD, most likely representing false-positive results. Although there appears to be some overlap between the findings of borderline RHD and those in the normal pediatric population, our data suggest acceptable specificity for all RHD, with excellent specificity for definite RHD.

Abstract 19428: Evaluating the Risk of Rheumatic Heart Disease Among Family Members of Children Identified With Latent RHD in School-based Echocardiographic Screening

Background: Poorly understood genetic susceptibility factors influence who develops acute rheumatic fever (ARF) and who develops the long-term complication, rheumatic heart disease (RHD). Risk of RHD in family members - and thus the need for screening of first degree relatives - once an index case has been identified, is not known. Methods: Sixty RHD positive children (30 borderline 30 definite RHD) and 67 age &amp; gender matched controls were recruited from previous school-based echocardiographic screening. All first-degree relatives ≥ 5 years were invited for echocardiographic screening (2012 World Heart Federation Criteria). Absent family members were recorded with reason for absence including death. Continuous variables were compared using 2-tailed independent samples t-test, categorical variables by Fisher’s Exact Test, and relative risk was used to compare cases and controls. Results: A total of 454/733 (62%) family members were screened (106 mothers, 48 fathers &amp; 300 siblings). Definite RHD was more common in childhood siblings of cases than controls (p=0.05), and children with RHD were 4.5 times as likely to have a sibling with RHD compared to controls. Mothers had more RHD than fathers without regard to child’s screening status. Conclusions: Siblings of children identified with latent RHD are at greater risk of having RHD and screening of these children should be considered. While no adult RHD screening data exists from sub-Saharan Africa, this study suggests that the prevalence of occult RHD in adult women is quite high (9.4%). Genotyping studies are needed to fully understand individual and family susceptibility to RHD.

Abstract 18811: Improving the Practicality of Echocardiographic Screening for Rheumatic Heart Disease: Performance of Non-expert Users Following Completion of a Standardized Computer-based Training Curriculum

Background: Echocardiography (echo) is the most sensitive tool for rheumatic heart disease (RHD) detection. However, widespread screening programs are non-existent due to lack of financial and expert human resources in endemic areas. Task-shifting to non-experts to perform RHD screening is promising; however, investigations into workforce composition and replicable training schemes are needed. Objective: Test non-experts’ ability to conduct RHD screening following a brief, standardized, computer-based training course. Methods: Six non-experts with a variety of backgrounds (nurses, health technicians, medical students) and echo experience (6 wks-1 yr) completed a 3-module computer-based curriculum focusing on simplified criteria for RHD screening (mitral regurgitation (MR) ≥1.5cm and/or any aortic regurgitation). Following training, two teams of 3 non-experts were placed in school screening environments. Gold-standard diagnoses of RHD (2012, World Heart Federation criteria) were made by cardiologists using standard portable echo equipment. Children diagnosed with RHD and 25% of the general screening population was blindly evaluated by each non-expert using the simplified criteria with handheld echo. Results: Screening was performed in 1,381 children, with 397 (47 borderline RHD, 6 definite RHD, 336 normal &amp; 8 other) referred for handheld echo (209 Team 1 &amp; 188 Team 2). Age ranged from 5-18 years (mean 13.6); 59% were female. Overall sensitivity of the simplified approach was 90.8% (95% CI 85.4-94.6%; range 75-100%), with an overall specificity of 82.4% (95% CI 79.9-84.7%; range 75-89%). The most common reasons for false-negative screens (n=16) were missed MR (44%) and MR ≤1.5cm (29%), and for false-positive screens (n=179) included identification of erroneous color jets (25%), incorrect MR measurement (24%), and appropriate application of simplified guidelines (MR between 1.5 and 2.0 cm, 39.4%). Conclusions: A short, computer-based curriculum can be successfully used to train a heterogeneous group of non-experts to preform large-scale RHD screening. This simplified approach addresses prohibitive financial and workforce barriers to widespread RHD screening and holds the potential to significantly reduce the global burden of RHD.

Abstract 18614: Rheumatic Heart Disease Screening in Schools Through Portable Echocardiography: Data From the PROVAR Study

Introduction: The accuracy of clinical examination is limited for early diagnosis of Rheumatic Heart Disease (RHD). The 2012 World Heart Federation (WHF) Criteria provides standardized echocardiographic (echo) guidelines for diagnosis of RHD. There is sparse data on echo prevalence of RHD in Brazil. Objective: Assess the prevalence of RHD in students (6-18 years) from public schools in low-income areas in Belo Horizonte, Brazil. Methods: Over 4-days, experts used standard portable echo machines (GE, Vivid-Q) and the 2012 WHF Criteria to determine RHD prevalence. All consented and present children at the visited schools were eligible for participation. Studies identified as abnormal were blindly read by a second cardiologist, with non-agreement adjudicated by a third. RHD prevalence by gender and age (5-11 &amp; 12-18) were compared using Fisher’s Exact Test. Results: A total of 1381 students were screened across four schools in urban Belo Horizonte, Brazil. The mean age was 13.6±2.8 years, range 5-18 years; 59.3% were female. The prevalence of RHD was 3.8% (53/1381): 3.4% borderline RHD (n=47) and 0.4% definite RHD (n=6). Of these cases, 46 (86.8%) had pathologic mitral regurgitation (≥2cm, seen in 2-views, pan-systolic, and velocity ≥3m/sec) and 7 had pathologic aortic regurgitation (≥1cm, seen in 2-views, pan-diastolic, and velocity ≥3m/sec). One child had mixed mitral and aortic valve disease. There were no cases of mitral or aortic stenosis. There was no difference in RHD prevalence between males and females (p=0.57), but older children had a higher prevalence rate (5-11 years 1.3% vs. 12-18 years 4.5%, p=0.01). Minor congenital heart disease was detected in 8 additional children (5.8%), including one large ASD that was referred for closure. Conclusions: WHF Criteria make it possible to obtain and accurately compare echo prevalence of RHD among different regions of the world. The PROVAR study shows that, among children living in low-socioeconomic conditions in urban Brazil, RHD remains a significant health burden, comparable to that in other low-resource communities. Screening older children has higher yield. Contemporary data such as these provide justification for investing in comprehensive RHD control programs both in Brazil, and around the globe.

Prevalence of rheumatic heart disease in Senegalese school children: a clinical and echocardiographic screening

ObjectiveTo study the prevalence of rheumatic heart disease (RHD) in schools (locally referred to as ‘daaras’) located in the city of Dakar and its suburbs using both clinical examination and...

Handheld echocardiographic screening for rheumatic heart disease by non-experts

ObjectivesHandheld echocardiography (HAND) has good sensitivity and specificity for rheumatic heart disease (RHD) when performed by cardiologists. However, physician shortages in RHD-endemic areas demand less-skilled users to make RHD screening...

Rheumatic heart disease in Indigenous children in northern Australia: differences in prevalence and the challenges of screening.

To compare regional differences in the prevalence of rheumatic heart disease (RHD) detected by echocardiographic screening in high-risk Indigenous Australian children, and to describe the logistical and other practical challenges of RHD screening. Cross-sectional screening survey performed between September 2008 and November 2010. Thirty-two remote communities in four regions of northern and central Australia. 3946 Aboriginal or Torres Strait Islander children aged 5-15 years. Portable echocardiography was performed by cardiac sonographers. Echocardiograms were recorded and reported offsite by a pool of cardiologists. RHD was diagnosed according to 2012 World Heart Federation criteria. The prevalence of definite RHD differed between regions, from 4.7/1000 in Far North Queensland to 15.0/1000 in the Top End of the Northern Territory. The prevalence of definite RHD was greater in the Top End than in other regions (odds ratio, 2.3; 95% CI, 1.2-4.6, P = 0.01). Fifty-three per cent of detected cases of definite RHD were new cases; the prevalence of new cases of definite RHD was 4.6/1000 for the entire sample and 7.0/1000 in the Top End. Evaluation of socioeconomic data suggests that the Top End group was the most disadvantaged in our study population. The prevalence of definite RHD in remote Indigenous Australian children is significant, with a substantial level of undetected disease. Important differences were noted between regions, with the Top End having the highest prevalence of definite RHD, perhaps explained by socioeconomic factors. Regional differences must be considered when evaluating the potential benefit of widespread echocardiographic screening in Australia.

Screening for Rheumatic Heart Disease among Peruvian Children: A Two-Stage Sampling Observational Study.

BackgroundThe objective of the study was to evaluate the implications of different classifications of rheumatic heart disease on estimated prevalence, and to systematically assess the importance of incidental findings from echocardiographic screening among schoolchildren in Peru.MethodsWe performed a cluster randomized observational survey using portable echocardiography among schoolchildren aged 5 to 16 years from randomly selected public and private schools in Arequipa, Peru. Rheumatic heart disease was defined according to the modified World Health Organization (WHO) criteria and the World Heart Federation (WHF) criteria.FindingsAmong 1395 eligible students from 40 classes and 20 schools, 1023 (73%) participated in the present survey. The median age of the children was 11 years (interquartile range [IQR] 8–13 years) and 50% were girls. Prevalence of possible, probable and definite rheumatic heart disease according to the modified WHO criteria amounted to 19.7/1000 children and ranged from 10.2/1000 among children 5 to 8 years of age to 39.8/1000 among children 13 to 16 years of age; the prevalence of borderline/definite rheumatic heart disease according to the WHF criteria was 3.9/1000 children. 21 children (2.1%) were found to have congenital heart disease, 8 of which were referred for percutaneous or surgical intervention.ConclusionsPrevalence of RHD in Peru was considerably lower compared to endemic regions in sub-Saharan Africa, southeast Asia, and Oceania; and paralleled by a comparable number of undetected congenital heart disease. Strategies to address collateral findings from echocardiographic screening are necessary in the setup of active surveillance programs for RHD.Trial RegistrationClinicalTrials.gov identifier: NCT02353663

Rheumatic heart disease screening in resource limited settings: is hand held device the answer?

I would like to thank Drs. Godown and Beaton for their letter in response to the recent editorial published in this journal (1). I entirely agree with their view that early diagnosis of rheumatic heart disease (RHD) provides the opportunity for initiating secondary prophylaxis. It is also established that progression of valvular damage can be arrested by effective secondary prophylaxis, as it prevents recurrent streptococcal infections. The moot question is how we effectively identify patients with RHD, early. This question assumes further importance in resource poor settings where the burden of RHD is likely to be high. Auscultation has been shown to be ineffective due to its poor sensitivity and specificity for mild or very mild cases of RHD. A number of studies published in the last decade have established the role of echocardiography in early RHD diagnosis. Data from all these studies has shown a much higher prevalence of RHD than the clinical estimates, based on auscultation. There was no uniformity in diagnostic criteria in many of these studies, making their interpretation difficult. To avoid this, World Heart Federation came up with specific criteria for diagnosing definite and borderline RHD by echo-Doppler. These criteria were developed for conventional and portable echocardiographic equipment.

Are minor echocardiographic changes associated with an increased risk of acute rheumatic fever or progression to rheumatic heart disease?

BackgroundThe World Heart Federation criteria for the echocardiographic diagnosis of rheumatic heart disease (RHD) include a category “Borderline” RHD which may represent the earliest evidence of RHD. We aimed to determine the significance of minor heart valve abnormalities, including Borderline RHD, in predicting the future risk of acute rheumatic fever (ARF) or RHD. MethodsA prospective cohort study of Aboriginal and Torres Strait Islander children aged 8 to 18years was conducted. Cases comprised children with Borderline RHD or other minor non-specific valvular abnormalities (NSVAs) detected on prior echocardiography. Controls were children with a prior normal echocardiogram. Participants underwent a follow-up echocardiogram 2.5 to 5years later to assess for progression of valvular changes and development of Definite RHD. Interval diagnoses of ARF were ascertained. ResultsThere were 442 participants. Cases with Borderline RHD were at significantly greater risk of ARF (incidence rate ratio 8.8, 95% CI 1.4–53.8) and any echocardiographic progression of valve lesions (relative risk 8.19, 95% CI 2.43–27.53) than their Matched Controls. Cases with Borderline RHD were at increased risk of progression to Definite RHD (1 in 6 progressed) as were Cases with NSVAs (1 in 10 progressed). ConclusionsChildren with Borderline RHD had an increased risk of ARF, progression of valvular lesions, and development of Definite RHD. These findings provide support for considering secondary antibiotic prophylaxis or ongoing surveillance echocardiography in high-risk children with Borderline RHD.

Prevalence of rheumatic heart disease in 4720 asymptomatic scholars from South Africa and Ethiopia

BackgroundIn Africa, screening for asymptomatic rheumatic heart disease (RHD) has been conducted in single communities using non-standardised echocardiographic criteria. The use of different diagnostic criteria has led to widely variable...