Rheumatic heart disease screening by echocardiography: the inadequacy of World Health Organization criteria for optimizing the diagnosis of subclinical disease.
ABSTRACT Early case detection is vital in rheumatic heart disease (RHD) in children to minimize the risk of advanced valvular heart disease by preventive measures. The currently utilized World Health Organization (WHO) criteria for echocardiographic diagnosis of subclinical RHD emphasize the presence of pathological valve regurgitation but do not include valves with morphological features of RHD without pathological regurgitation. We hypothesized that adding morphological features to diagnostic criteria might have significant consequences in terms of case detection rates.
We screened 2170 randomly selected school children aged 6 to 17 years in Maputo, Mozambique, clinically and by a portable ultrasound system. Two different echocardiographic sets of criteria for RHD were assessed: "WHO" (exclusively Doppler-based) and "combined" (Doppler and morphology-based) criteria. Independent investigators reviewed all suspected RHD cases using a higher-resolution, nonportable ultrasound system. On-site echocardiography identified 18 and 124 children with suspected RHD according to WHO and combined criteria, respectively. After consensus review, 17 were finally considered to have definite RHD according to WHO criteria, and 66 had definite RHD according to combined criteria, giving prevalence rates of 7.8 (95% confidence interval, 4.6 to 12.5) and 30.4 (95% confidence interval, 23.6 to 38.5) per 1000 children, respectively (P<0.0001, exact McNemar test).
Important consideration should be given to echocardiographic criteria for detecting subclinical RHD because the number of cases detected may differ importantly according to the diagnostic criteria utilized. Currently recommended WHO criteria risk missing up to three quarters of cases of subclinically affected and therefore potentially treatable children with RHD.
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ABSTRACT: Background: Previous studies indicate that compared with physical examination, Doppler echocardiography identifies a larger number of cases of rheumatic heart disease in apparently healthy individuals. Objectives: To determine the prevalence of rheumatic heart disease among students in a public school of Belo Horizonte by clinical evaluation and Doppler echocardiography. Methods: This was a cross-sectional study conducted with 267 randomly selected school students aged between 6 and 16 years. students underwent anamnesis and physical examination with the purpose of establishing criteria for the diagnosis of rheumatic fever. They were all subjected to Doppler echocardiography using a portable machine. Those who exhibited nonphysiological mitral regurgitation (MR) and/or aortic regurgitation (AR) were referred to the Doppler echocardiography laboratory of the Hospital das Clínicas of the Universidade Federal of Minas Gerais (HC-UFMG) to undergo a second Doppler echocardiography examination. According to the findings, the cases of rheumatic heart disease were classified as definitive, probable, or possible. Results: Of the 267 students, 1 (0.37%) had a clinical history compatible with the diagnosis of acute rheumatic fever (ARF) and portable Doppler echocardiography indicated nonphysiological MR and/or AR in 25 (9.4%). Of these, 16 (6%) underwent Doppler echocardiography at HC-UFMG. The results showed definitive rheumatic heart disease in 1 student, probable rheumatic heart disease in 3 students, and possible rheumatic heart disease in 1 student. Conclusion: In the population under study, the prevalence of cases compatible with rheumatic involvement was 5 times higher on Doppler echocardiography (18.7/1000; 95% CI 6.9/1000-41.0/1000) than on clinical evaluation (3.7/1000-95% CI).Arquivos Brasileiros de Cardiologia 08/2014; 103(2):89-97. · 1.12 Impact Factor
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ABSTRACT: Rheumatic heart disease (RHD) is estimated to affect over 20 million people worldwide, the vast majority being in developing countries. Screening for RHD has been recommended by the WHO since 2004. Conventionally, auscultation has been used for diagnosing RHD. Auscultation has its limitation and may not detect mild cases. A large number of studies have reported echocardiographic screening for RHD over the last several years. Most of these studies report an almost 10-fold higher prevalence of RHD by echocardiography as compared to conventional method of auscultation. Early diagnosis of such mild cases may be important as instituting secondary prophylaxis in such cases may reduce the burden of the disease. However, several concerns remain about the significance and natural history of these minor valvular changes detected by echocardiography. Whether secondary prophylaxis will reverse these abnormalities is also unclear. Long term follow up studies are required to answer some of these concerns.Expert Review of Medical Devices 06/2014; · 1.78 Impact Factor
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ABSTRACT: Cardiovascular disease (CVD) is the leading cause of mortality worldwide and also exerts a significant economic burden, especially in low- and middle-income countries (LMICs). Detection of subclinical CVD, before an individual experiences a major event, may therefore offer the potential to prevent or delay morbidity and mortality, if combined with an appropriate care response. In this review, we discuss imaging technologies that can be used to detect subclinical atherosclerotic CVD (carotid ultrasound, coronary artery calcification) and nonatherosclerotic CVD (echocardiography). We review these imaging modalities, including aspects such as rationale, relevance, feasibility, utilization, and access in LMICs. The potential gains in detecting subclinical CVD may be substantial in LMICs, if earlier detection leads to earlier engagement with the health care system to prevent or delay cardiac events, morbidity, and premature mortality. Thus, dedicated studies examining the feasibility, utility, and cost-effectiveness of detecting subclinical CVD in LMICs are warranted.Journal of Cardiovascular Translational Research 09/2014; · 3.06 Impact Factor
Rajesh Beniwal and Maneesha Bhaya
Optimizing the Diagnosis of Subclinical Disease''
Echocardiography: The Inadequacy of World Health Organization Criteria for
Letter by Beniwal and Bhaya Regarding Article, ''Rheumatic Heart Disease Screening by
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Letter by Beniwal and Bhaya Regarding Article,
“Rheumatic Heart Disease Screening by
Echocardiography: The Inadequacy of World
Health Organization Criteria for Optimizing the
Diagnosis of Subclinical Disease”
To the Editor:
Marijon and colleagues1base their arguments on a phenomenon
not observed by them during their study on rheumatic heart disease
(RHD). They assume that “pathophysiologically, repeated rheumatic
carditis can result in subvalvular or valvular thickening before the
development of leaflet retraction and thereby regurgitation.” They
further state, “In adding the diagnostic criterion of morphological
valve changes, otherwise well defined in more advanced rheumatic
valve lesions, we have detected many children with subclinical RHD
but without significant valve regurgitation who would not be eligible
for secondary RHD prophylaxis under current international
A phenomenon of dissociation between mild- to moderate-grade
RHD-like valve abnormalities and significant regurgitation in about
a fifth of the cases has been reported recently by Bhaya et al.2They
had adopted a strategy of universal definitive echocardiography for
all of the enrolled schoolchildren without any intervening screening
round of auscultation or echocardiography to remove any chance of
selection bias while attempting to evaluate and improvise on the
World Health Organization criteria for probable RHD.
Marijon et al had adopted a strategy of an initial screening round
of echocardiography to identify cases with any regurgitation (phys-
iological/significant) of mitral and/or aortic valves followed by a
round of definitive echocardiography. Thus, they would have missed
a large fraction of cases having valvular abnormalities like coexisting
valve thickening without regurgitation during the screening round.
This, we think, was an inadvertent methodological error.
In our experience, mitral valve prolapse is diagnosed in ?1% to
4% of children screened for RHD by echocardiography.2,3For mitral
valve prolapse, significant regurgitation is a late feature, but it is not
unusual to find thickened valves quite early in the course of disease.
Thus, thickened valve leaflets in a child without significant regurgi-
tation is more likely to be of nonrheumatic origin in our opinion.
This fact is also corroborated by an autopsy study.4
In areas of low prevalence, the presentation of subclinical RHD
may be different,2and presentation and progression of the disease
process leading to RHD in a given age group can be variable in
different geographic areas because of differing environmental deter-
minants.5Consequently, the criteria proposed by Marijon et al may
be important for the surveyed population of schoolchildren in
Mozambique, but these criteria are difficult to adopt universally. If a
diagnosis of RHD were to be based on the combined criteria
proposed by Marijon et al, many cases with only significant
regurgitation as evidence of disease would be missed. Such cases
might be much greater in number as reported by Bhaya et al.2
Once acute rheumatic fever has been diagnosed, antibiotic therapy
is offered to prevent recurrences, but it is unlikely that antibiotic
therapy prevents the progression of the immune processes leading to
RHD.6The recent addition of statins to the possible options for
pharmacotherapy of RHD necessitates that a diagnostic criterion for
subclinical RHD should identify the patients in the state when
significant regurgitation is due to softening of valves secondary to
the disease process and well before the time when repeated rheu-
matic carditis results in chronicity of significant regurgitation due to
scarring and retraction of leaflets.
We feel that focusing on significant regurgitation and not valve
deformities would make echocardiographic criteria for diagnosis of
subclinical RHD more sensitive and universally applicable.
Rajesh Beniwal, MBBS, MD
National Institute of Occupational Health
Maneesha Bhaya, MBBS, MD
Sardar Patel Medical College
1. Marijon E, Celermajer DS, Tafflet M, El-Haou S, Jani DN, Ferreira B,
Mocumbi A, Paquet C, Sidi D, Jouven X. Rheumatic heart disease
screening by echocardiography: the inadequacy of World Health
Organization criteria for optimizing the diagnosis of subclinical
disease. Circulation. 2009;120:663–668.
2. Bhaya M, Panwar RB, Beniwal R, Panwar S. Echocardiographic evidence
of significant regurgitation can be the sole criterion for diagnosis of
probable rheumatic heart disease: experience from a large cross-sectional
survey. J Am Coll Cardiol. 2009;53:A409. Abstract.
3. Periwal KL, Gupta BK, Panwar RB, Khatri PC, Raja S, Gupta R. Prev-
alence of rheumatic heart disease in school children in Bikaner: an
echocardiographic study. J Assoc Physicians India. 2006;54:279–282.
4. Roberts WC, Ko JM. Some observations on mitral and aortic valve
disease. Proc (Bayl Univ Med Cent). 2008;21:282–299.
5. Carapetis JR, Currie BJ, Mathews JD. Cumulative incidence of rheumatic
fever in an endemic region: a guide to the susceptibility of the population?
Epidemiol Infect. 2000;124:239–244.
6. Ben-Yehuda O, DeMaria AN. Statins in rheumatic heart disease: taking
the bite out? J Am Coll Cardiol. 2009;53:1880–1882.
© 2010 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.109.908129
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