Screening For Valvular Heart Disease Research Articles

Treatments affecting splenic function as a risk factor for valvular heart disease in Childhood Cancer Survivors: A DCCSS-LATER study.

Splenectomy might be a risk factor for valvular heart disease (VHD) in adult Hodgkin lymphoma survivors. As this risk is still unclear for childhood cancer survivors (CCS), the aim of this study is to evaluate the association between treatments affecting splenic function (splenectomy and radiotherapy involving the spleen) and VHD in CCS. CCS were enrolled from the DCCSS-LATER cohort, consisting of 6,165 five-year CCS diagnosed between 1963 and 2002. Symptomatic VHD, defined as symptoms combined with a diagnostic test indicating VHD, was assessed from questionnaires and validated using medical records. Differences in the cumulative incidence of VHD between CCS who received treatments affecting splenic function and CCS who did not were assessed using the Gray test. Risk factors were analyzed in a multivariable Cox proportional hazards model. The study population consisted of 5,286 CCS, with a median follow-up of 22 years (5-50 years), of whom 59 (1.1%) had a splenectomy and 489 (9.2%) radiotherapy involving the spleen. VHD was present in 21 CCS (0.4%). The cumulative incidence of VHD at the age of 40 years was significantly higher in CCS who received treatments affecting splenic function (2.7%, 95% confidence interval (CI) 0.4%-4.9%) compared with CCS without (0.4%, 95% CI 0.1%-0.7%) (Gray's test, p=0.003). Splenectomy was significantly associated with VHD in a multivariable analysis (hazard ratio 8.6, 95% CI 3.1-24.1). Splenectomy was associated with VHD. Future research is needed to determine if CCS who had a splenectomy as part of cancer treatment might benefit from screening for VHD.

Adoptability and accuracy of point-of-care ultrasound in screening for valvular heart disease in the primary care setting.

Despite continued efforts, a majority of patients with valvular heart disease (VHD) remain undiagnosed and untreated. This study aimed to assess the adoptability and accuracy of point-of-care handheld echocardiographic assessments (POCE) in the primary care setting. Eleven previously untrained primary care providers were trained to use the Vscan Extend (GE, WI) POCE to assess VHD, left ventricular function (LVEF), and major extra-cardiac findings. Their assessments were compared to those of three blinded expert readers. A total of 175 patients underwent POCE assessments which were evaluated using Kappa statistics (κ) together with their estimated standard error, p value, and 95% CI bounds. Each patient had a mean of 3.3 ± 1.1 (±SD) assessments performed. Identical or nearly identical agreement between previously untrained primary providers and expert readers was evident for the diagnosis of tricuspid regurgitation, mitral regurgitation, pericardial effusion, and volume status. These agreements were strongest in apical long axis (κ=1, p < 0.001) and parasternal long and short axis views (κ > =0.82 p < 0.001), though agreement remained robust in apical 4-chamber views (κ ≥ 0.76). The agreements in LVEF assessment were identical in the apical long axis view (κ=1, p < 0.001) and robust in the remaining 3 views (κ > =0.66, p < 0.001). The assessments of aortic stenosis (parasternal/long, κ=0.42, and parasternal/short, κ=0.47, both p < 0.001) were weak in their agreement. Compared to expert echocardiography readers, the untrained providers' use of POCE for VHD shows high user adoptability and diagnostic accuracies in the primary care setting.

Screening for aortic stenosis using physical examination and echocardiography.

Most patients with aortic stenosis (AS) can be treated with either traditional surgical aortic valve replacement or newly emerged transcatheter aortic valve implantation. Therefore, the early and appropriate detection of significant AS has become more important for avoiding overlooking patients who require treatment. AS is initially detected by the presence of a systolic ejection murmur (SEM). However, it is time-consuming and expensive for all subjects presenting with SEM to undergo comprehensive standard echocardiography using high-end ultrasound machines since the SEM is audible in a large proportion of elderly patients and is not specific for significant AS. Therefore, further physical examination and/or focused cardiac ultrasound (FoCUS) is required to determine whether patients with a SEM should be referred for standard echocardiography. One or more abnormal physical findings in addition to a SEM can rule out a certain proportion of normal cases without overlooking severe AS. Most of the previous studies suggesting the usefulness of FoCUS in screening for valvular heart disease only used visual impressions in their assessment of AS. By contrast, visual AS and calcification scores are good objective parameters in screening for AS with FoCUS. Patients with severe AS and patients with a high probability of AS-related events are rarely overlooked even if comprehensive standard echocardiography is performed only when either (or both) of the FoCUS scores is 3 or more. The appropriate combination of physical examinations and FoCUS to screen for AS is discussed in this review article.

Increased risk of valvular heart disease in patients with ankylosing spondylitis: a nationwide population-based longitudinal cohort study.

Aims:We aimed to evaluate the risk of valvular heart disease (VHD) among patients with ankylosing spondylitis (AS).Methods:This was a population-based cohort study utilizing the Longitudinal Health Insurance Research Database of the National Health Insurance in Taiwan. Patients with and without coding of newly diagnosed AS from 1999 to 2013 were assigned to the AS and non-AS groups, respectively. Primary outcome was the incidental risk of VHD. Multiple Cox regression was used to estimate the adjusted hazard ratio of VHD. Subgroup analysis and sensitivity tests were also conducted.Results:The AS group included 3780 patients, and 22,680 matched subjects without an AS diagnosis were identified as controls. The AS group had an increased risk of VHD compared with non-AS controls (adjusted hazard ratio: 1.63; 95% confidence interval: 1.43–1.86; p < 0.001). Subgroup analysis also revealed an increased risk of individual types of VHD, including aortic, mitral, and tricuspid valve disease. Patients in the AS group had a higher incidence of valve replacement surgery after the onset of VHD.Conclusion:Patients with AS had a significant risk of VHD compared to non-AS controls in this population-based cohort study. Screening for VHD may be needed in caring patients with AS. We suggest that echocardiography may be performed when patients are diagnosed with AS.

Point-of-care ultrasound: Closing guideline gaps in screening for valvular heart disease.

BackgroundA linear increase in the number of valvular heart disease is expected due to the aging population, yet most patients with severe valvular heart disease remain undiagnosed.HypothesisPOCUS can serve as a screening tool for valvular heart disease.MethodsWe reviewed the literature to assess the strengths and limitations of POCUS in screening and diagnosing valvular heart disease.ResultsPOCUS is an accurate, affordable, accessible, and comprehensive tool. It has a fast learning curve and can prevent unnecessary and more expensive imaging. Challenges include training availability, lack of simplified screening protocols, and reimbursement. Large scale valvular screening data utilizing POCUS is not available.ConclusionPOCUS can serve as a screening tool and guide the management of patients with valvular heart disease. More data is needed about its efficacy and cost‐effectiveness in the screening of patients with valvular heart disease.

Clinical Features and Complications of Coxiella burnetii Infections From the French National Reference Center for Q Fever.

Q fever remains widespread throughout the world; the disease is serious and causes outbreaks and deaths when complications are not detected. The diagnosis of Q fever requires the demonstration of the presence of Coxiella burnetii and the identification of an organic lesion. To describe the hitherto neglected clinical characteristics of Q fever and identifying risk factors for complications and death. This prospective cohort study conducted from January 1, 1991, through December 31, 2016, included patients treated at the French National Reference Center for Q fever with serologic findings positive for C burnetii and clinical data consistent with C burnetii infection. Clinical data were prospectively collected by telephone. Patients with unavailable clinical data or an unidentified infectious focus were excluded. Q fever complications and mortality. Of the 180 483 patients undergoing testing, 2918 had positive findings for C burnetii and 2434 (68.8% men) presented with clinical data consistent with a C burnetii infection. Mean (SD) age was 51.8 (17.4) years, and the ratio of men to women was 2.2. At the time of inclusion, 1806 patients presented with acute Q fever, including 138 with acute Q fever that progressed to persistent C burnetii infection, and 766 had persistent focalized C burnetii infection. Rare and hitherto neglected foci of infections included lymphadenitis (97 [4.0%]), acute Q fever endocarditis (50 [2.1%]), hemophagocytic syndrome (9 [0.4%]), and alithiasic cholecystitis (11 [0.4%]). Vascular infection (hazard ratio [HR], 3.1; 95% CI, 1.7-5.7; P < .001) and endocarditis (HR, 2.4; 95% CI, 1.1-5.1; P = .02) were associated with an increased risk of death. Independent indicators of lymphoma were lymphadenitis (HR, 77.4; 95% CI, 21.2-281.8; P < .001) and hemophagocytic syndrome (HR, 19.1; 95% CI, 3.4-108.6; P < .001). The presence of anticardiolipin antibodies during acute Q fever has been associated with several complications, including hepatitis, cholecystitis, endocarditis, thrombosis, hemophagocytic syndrome, meningitis, and progression to persistent endocarditis. Previously neglected foci of C burnetii infection include the lymphatic system (ie, bone marrow, lymphadenitis) with a risk of lymphoma. Cardiovascular infections were the main fatal complications, highlighting the importance of routine screening for valvular heart disease and vascular anomalies during acute Q fever. Routine screening for anticardiolopin antibodies during acute Q fever can help prevent complications. Positron emission tomographic scanning could be proposed for all patients with suspected persistent focused infection to rapidly diagnose vascular and lymphatic infections associated with death and lymphoma, respectively.

Screening for valve disease in patients with hyperprolactinaemia disorders prescribed cabergoline: a service evaluation and literature review.

The indication for screening for valvular heart disease in patients taking cabergoline is based on evidence from patients with Parkinson's disease on high-dose medication. However, current patients take much lower doses for indications such as hyperprolactinaemia disorders. Contemporary guidelines for echocardiogram monitoring in patients taking cabergoline are conflicting. This study aimed to review current clinical practice in our area regarding echocardiographic screening and to review the literature examining the evidence of valvular heart disease in patients taking lower dose cabergoline. This was a retrospective study of all patients with hyperprolactinaemia disorders prescribed cabergoline in a single UK NHS health board between January 2014 and July 2015. The proportion of patients receiving baseline and follow-up echocardiograms was recorded. A review of the published literature was carried out using the databases EMBASE and Medline to examine the current evidence for the effect cabergoline has on cardiac valves in patients treated for hyperprolactinaemia disorders. The mean age was 51.7 ± 16.5 years with a 64.4% female predominance. The mean duration of therapy was 5.9 years ± 4.1 years. Of the total cohort (n = 45), two (4.4%) patients had an initial baseline echocardiogram and five (13.2%) had follow-up echocardiograms every 24 months. Of the 25 articles identified, 12 showed no clinically significant evidence of valvular dysfunction in the cabergoline group groups. Of the remaining 13 articles, evidence for valvular changes was confined to high cumulative dose cabergoline patients and there was only one confirmed case of 'cabergoline associated valvulopathy' described. Clinically significant valvular dysfunction is uncommon and generally only reported in high cumulative dose treatment groups. We propose that clearer national guidelines are required and that echocardiogram screening be reserved for patients who are high risk, are taking a high weekly dose (≥2 mg cabergoline weekly) or high cumulative dose.

17. Usefulness of portable ultrasounds in screening for valvular heart disease in children

Portable ultrasound machines are becoming increasingly useful in bedside routine exams and field surveys for early detection of heart disease. This is especially important for rheumatic heart disease (RHD) which is an emerging public health problem in developing countries. The aim of this study was to screen primary school children, with a focus on females living in rural settings, for valvular disease.Methods: A total of 465 girls aged 8–12 years were screened using portable vivid-e GE machine. All subjects were exposed to full history and clinical examination as well as a routine echo exam for left ventricular (LV) function assessed by M-Mode for fractional area shortening (FAS) and ejection fraction, assessment of mitral valve morphology, color Doppler and spectral Doppler for all four valves using pulsed and continuous wave spectral Doppler. Suspicious cases were referred to a higher center in Cairo University Children Hospital and followed up in the AFCRHD follow up clinic. Laboratory studies for anti-streptolysin-O (ASO) titer and C-reactive protein was carried out for suspicious cases. Findings: The study detected 24 children with valvular abnormality by echo examination. Mitral regurgitation (MR) was the commonest findings being detected in 21 cases (10 RHD and 11 congenital); one case with mitral stenosis (MS) of rheumatic origin, aortic regurgitation (AR) in 4 cases and stenosis in one case; tricuspid regurgitation in 4 cases and pulmonary regurgitation in one case. The MR detected was in the range of 10–30% i.e. mild to moderate, cases with trivial regurge were excluded from the study. Mitral valve thickening and decreased mobility were evident in the cases diagnosed as RHD. However one case with congenital mitral prolapse also showed valve thickening. Hence the overlap between RHD and congenital prolapse did present a diagnostic dilemma. Overall RHD was diagnosed in 13 cases (6 definite and 7 suspected). Ventricular function assessed by M-mode for FAS and EF as well as spectral Doppler findings were within the normal range for age. Epidemiological assessment showed that most of the cases with positive echo findings came from the rural areas (91.7%) and were characterized by high maternal illiteracy rates of 16.7% compared to 5.2% in the echo free cases. Increasing age, increasing number of children sleeping in one room and poor dietary habits and tendency to underweight increased the prevalence of valvular disorders detected indicating the need for screening populations at risk. We conclude that mitral valve is the most commonly affected valve. RHD is the commonest etiological factor and appears to be on the rise especially in underprivileged populations. Differentiating between rheumatic and non-rheumatic etiology for valve disease still poses a problem. We recommend that every child with suspicious RHD should be followed up carefully and the decision for prophylaxis should be based on multiple factors taking the family history, living conditions and general condition of the child into consideration. Portable echocardiography machines are the state of the art in early detection of RHD and should be recommended as the standard for diagnosis of RHD.

165 The oxvalve study: echocardiographic screening for valvular heart disease in the community setting: methodology, feasibility and preliminary results

<h3>Introduction</h3> Valvular heart disease (VHD) is poorly researched in comparison with other areas of cardiovascular disease. Principle limitations are the diverse nature of patients with VHD, inability to identify individuals at the earliest stages of disease and lack of an appropriate investigational infrastructure. Studies addressing the contemporary epidemiology and natural history of VHD are scarce but demonstrate an increasing prevalence in the elderly, associated with significant morbidity and mortality. Cohort studies in the USA are ongoing but there are no European or UK studies to date. We have developed a large scale, prospective community echocardiographic screening study within the adult Oxfordshire population, to determine the epidemiological characteristics of VHD in the UK for the first time, to assess the acceptability of echocardiographic screening for VHD, and establish cohorts with well-characterised genetic and echocardiographic phenotypes for future study. Herein, we present preliminary data for the first 1050 patients, with enrolment ongoing. <h3>Methods</h3> Patients &gt;65 years, registered with participating general practices (GP) and with no known VHD, were invited to attend their GP surgery where routine demographic and cardiac data were collected and a focused examination undertaken. Participants underwent a standard transthoracic echocardiogram (TTE) according to British Society of Echocardiography guidelines. The threshold for inclusion in the screen positive group was deliberately low to capture all manifestations of VHD. Participants were given preliminary results, before completing a shortened Spielberger STAI questionnaire. <h3>Results</h3> Uptake was 46% (age range 65–96 years; male to female ratio 1:1.1). VHD was detected in 33% of participants and prevalence increased with increasing age (see Abstract 165 figure 1). Mitral regurgitation and aortic regurgitation were the most common lesions detected (present in 17% and 14% respectively). The majority of VHD was graded as mild (84%); only 1% of VHD detected was severe. The majority of participants (99%) described themselves as calm or relaxed at the time of screening; none expressed significant levels of worry or tension. 98% would be prepared to undergo repeat echocardiography as screening for VHD. <h3>Conclusions</h3> The prevalence of VHD in adults aged over 65 in the Oxfordshire population, using a low threshold for detection, is approximately 33% and increases with age. Mitral regurgitation is the most common lesion, and the majority of detected VHD is mild. Echocardiographic screening for VHD is feasible in the primary care setting and acceptable in this group of patients.

Heart valve disease associated with treatment with ergot‐derived dopamine agonists: a clinical and echocardiographic study of patients with Parkinson’s disease

To elucidate the association between treatment with ergot-derived dopamine agonists (EDDA) and valvular abnormalities amongst patients with idiopathic Parkinson's disease (IPD) and secondly, to analyse the yield of clinical screening for valvular heart disease. A cross-sectional controlled study. The cohort of IPD patients treated in the outpatient clinic, Department of Neurology, Aarhus University Hospital, Denmark. A total of 138 IPD patients [median age 64 (39-87) years, 62% men] treated with either EDDA (n = 85) or non-EDDA (n = 53) for at least 6 months. Interventions. Patients were screened for valvular heart disease by clinical means and by examiner-blinded echocardiography. Main outcome measure was valvular regurgitation revealed by echocardiography. Severe aortic regurgitation (n = 4) or moderate aortic (n = 12), mitral (n = 3) or tricuspidal valve regurgitation (n = 5) was found in 22 EDDA patients (25.9%). Two patients had coexistent moderate mitral and tricuspid valvular regurgitation. Two non-EDDA patients had moderate valve insufficiency (3.8%, P < 0.05). The adjusted relative risk for at least moderate valve insufficiency in the EDDA patients was 7.2% (P < 0.05). The sensitivity of detecting at least moderate valvular disease by cardiac murmur, dyspnoea, or the heart failure marker NT-proBNP (natriuretic peptide) was 62% for the neurologists and 93% for the cardiologist but with equally low specificity (30-35%). EDDA was associated with a clinically important and statistically significant risk of at least moderate valve regurgitation. Clinical screening for valve disease was inadequate and it seems advisable to offer EDDA patients control with echocardiography.