The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease

Sydenham's chorea: from pathophysiology to therapeutics

Sydenham's chorea is an autoimmune chorea emerging after a group A beta-hemolytic streptococcal (GABHS) infection, i.e. a rheumatic chorea with or without the presence of carditis or arthritis. The disorder, defined by the presence of chorea, is also associated with cognitive and behavioral symptoms, including emotional lability, anxiety, depressive and obsessive-compulsive symptoms. The authors review the pathophysiology, clinical characteristics, and available evidence on therapeutic strategies, the latter including the secondary prevention of GABHS infections, reduction of chorea, and immune modulation. Sydenham's chorea has been regarded as a model for pediatric autoimmune neuropsychiatric disorders, however, the field is marked by conflicting results and controversies. Regarding therapeutics, there are limited high-quality interventional studies and the selection of treatment strategy often relies on the clinician's experience. A serial treatment algorithm is presented based upon the severity of clinical presentation and response to symptomatic pharmacotherapy.

Concomitant Acute Rheumatic Fever and Acute Post Streptococcal Glomerulonephritis

Acute rheumatic fever (RF) and acute post Streptococcal glomerulonephritis (APSGN) are non-suppurative complications of a Group A Streptococcus (GAS) infection. The concomitant incidence of both complications in a patient is rare because nephritogenic and rheumatogenic strains belong to different serotypes of Group A beta-hemolytic Streptococcus (GABHS). We present a case of a 47-year-old female who had concomitant acute RF and APSGN from a Streptococcus pyogenes infection. It is important to have a high clinical suspicion for the sequela of GABHS infection in the setting of cardiac and renal disease following upper respiratory infection (URI) symptoms even in adults and in geographic locations with the nearly undetectable burden of acute RF because of the importance of secondary prophylaxis with an antibiotic.

Rheumatic Heart Disease in the United States: Forgotten But Not Gone: Results of a 10 Year Multicenter Review

Background

Recent evaluation of rheumatic heart disease (RHD) mortality demonstrates disproportionate disease burden within the United States. However, there are few contemporary data on US children living with acute rheumatic fever (ARF) and RHD.

Methods and Results

Twenty‐two US pediatric institutions participated in a 10‐year review (2008–2018) of electronic medical records and echocardiographic databases of children 4 to 17 years diagnosed with ARF/RHD to determine demographics, diagnosis, and management. Geocoding was used to determine a census tract‐based socioeconomic deprivation index. Descriptive statistics of patient characteristics and regression analysis of RHD classification, disease severity, and initial antibiotic prescription according to community deprivation were obtained. Data for 947 cases showed median age at diagnosis of 9 years; 51% and 56% identified as male and non‐White, respectively. Most (89%) had health insurance and were first diagnosed in the United States (82%). Only 13% reported travel to an endemic region before diagnosis. Although 96% of patients were prescribed secondary prophylaxis, only 58% were prescribed intramuscular benzathine penicillin G. Higher deprivation was associated with increasing disease severity (odds ratio, 1.25; 95% CI, 1.08–1.46).

Conclusions

The majority of recent US cases of ARF and RHD are endemic rather than the result of foreign exposure. Children who live in more deprived communities are at risk for more severe disease. This study demonstrates a need to improve guideline‐based treatment for ARF/RHD with respect to secondary prophylaxis and to increase research efforts to better understand ARF and RHD in the United States.

Left Ventricular Remodeling Following Balloon Mitral Valvuloplasty in Rheumatic Mitral Stenosis: Magnetic Resonance Imaging Study

Background: Rheumatic heart disease affects primarily cardiac valves, it could involve the myocardium either primarily or secondary to heart valve affection. The influence of balloon mitral valvuloplasty (BMV) on left ventricular function has not been sufficiently studied.

Aim: To determine the influence of balloon mitral valvuloplasty (BMV) on both global and regional left ventricular (LV) function.

Methods: Thirty patients with isolated rheumatic mitral stenosis (MS) were studied. All patients had cardiac magnetic resonance imaging (CMR) before, 6 months and 1 year after successful BMV. LV volumes, ejection fraction (EF), regional and global LV deformation, and LV late gadolinium enhancement were evaluated.

Results: At baseline, patients had median EF of 57 (range: 45–69) %, LVEDVI of 74 (44–111) ml/m² and LVESVI of 31 (14–57) ml/m² with absence of late gadolinium enhancement in all myocardial segments. Six months following BMV, there was a significant increase in LV peak systolic global longitudinal strain (GLS) (−16.4 vs. −13.8, p < 0.001) and global circumferential strain (GCS) (−17.8 vs. −15.6, p = 0.002). At 1 year, there was a trend towards decrease in LVESVI (29 ml/m², p = 0.079) with a significant increase in LV EF (62%, p < 0.001). A further significant increase, compared to 6 months follow up studies, was noticed in GLS (−17.9 vs. −16.4, p = 0.008) and GCS (−19.4 vs. −17.8 p = 0.03).

Conclusions: Successful BMV is associated with improvement in global and regional LV systolic strain which continues for up to 1 year after the procedure.

Junctional Tachycardia as a Diagnostic Criterion in Acute Rheumatic Fever

Acute rheumatic fever (ARF) is an acute inflammatory process resulting in rheumatic carditis, one of the most common acquired heart diseases in youth. Among the clinical manifestations of carditis, pathologic valve regurgitation and atrioventricular block are included in the criteria for the diagnosis of ARF. Besides atrioventricular block, ARF may often present with other arrhythmias, such as junctional tachycardia (JT). However, JT is currently not recognized as a criterion for the diagnosis of ARF. Three adolescents presented in our hospital with JT, polyarthralgia, and laboratory signs of inflammation with evidence of preceding group A Streptococcus infection. None of the patients fulfilled the diagnostic criteria of ARF. On the basis of the presumed diagnosis of ARF, all 3 patients were treated with intravenous steroids. Steroid therapy was given, and JT converted to sinus rhythm within an average of 62 hours. Subsequent electrocardiograms revealed variable degree of atrioventricular block in all 3 patients, providing clinical evidence and fulfilling the diagnostic criteria of ARF. Patients were monitored for a total 2 to 8 days before discharge on standard antiinflammatory treatment. Follow-up electrocardiograms and Holter monitoring revealed resolution of the atrioventricular block and lack of JT recurrence in all patients. On the basis of these sentinel cases, we propose that JT should be included as a diagnostic criterion for the diagnosis of ARF.

Q Fever Endocarditis: A Review of Local and all Reported Cases in the Literature

BACKGROUND

Q fever endocarditis by Coxiella burnetii is rare and presents a diagnostic challenge. With limited data available, the aim of this study was to review all reported cases together with unpublished local cases to understand risk factor profiles, diagnostic methods, clinical features, treatments and outcomes.

METHODS

A search of the PubMed database using the term 'Q fever endocarditis' identified cases between 1950-2019. Included cases had positive polymerase chain reaction testing, valve culture or serology. Separately, to identify local cases meeting our criteria we queried the Western Australian Health Open Patient Administration System at two local hospitals for the ICD-10-AM diagnosis code A78 between 2013-2019.

RESULTS

We identified 181 cases from 31 publications and four local cases to create a combined series of 185 cases. The majority 141 (76%) were male and only 11% had normal cardiac valves. Most (72%) of patients had a history of contact with animals or travel. Nearly all (98%) cases had positive serology and over half (56%) had surgery performed. Overall mortality was 17%, and mortality for native valve endocarditis and prosthetic valve endocarditis was 12% and 3% respectively. No patients treated with doxycycline and hydroxychloroquine died. Mortality prior to 1999 was 28%, compared with 5% for more recent cases.

CONCLUSION

Serological diagnosis is key in Q fever endocarditis and possible risk factors exist such as male gender, pre-existing valvular conditions and contact with animals or travel. Native valve endocarditis and treatment with drugs other than doxycycline and hydroxychloroquine increase the risk of death.

Worldwide comparison of treatment guidelines for sore throat

Introduction

Sore throat (acute pharyngitis) is globally one of the most frequent reasons for seeking healthcare. Its etiology is mostly viral. In 15%‐30% of cases, group A streptococci (GAS) are detected, which may cause acute rheumatic fever. We have done a worldwide systematic review to compare diagnostic and therapeutic guidelines across countries and regions. Previous reviews of sore throat guidelines were limited to specific regions and/or language; this is the first global review.

Materials and Methods

Searches were performed in MEDLINE, EMBASE and COCHRANE (key words: sore throat, pharyngitis, tonsillitis or pharyngotonsillitis, and management, guidance, guideline or recommendation) and on the web sites of major health authorities and associated institutions from Africa, Asia, Europe, Middle East, North America, Oceania and South America.

Results

Thirty‐six guidelines were identified from 26 countries. Most common are recommendations relying on the symptom‐ and age‐based Centor or McIsaac scores. However, antibiotic treatment may be based on other symptomatic criteria; in the most extreme approach just sore throat in children. The recommendation of GAS‐specific diagnostic tests is mainly limited to countries where such tests are readily available, although some countries choose not to use them. Penicillins are consistently recommended as first‐line antibiotics. By contrast, guidance for symptomatic treatment is variable and mostly sparse or missing. African countries without sore throat guidelines and Asian countries bypassing them are afflicted by rising antibiotic resistance.

Conclusion

The availability of sore throat guidelines varies considerably by region and country. Moreover, important divergence is found among the guidelines regarding diagnostic and treatment criteria. This may be explained by the historical background or adoption of external guidelines, rather than local incidences of GAS infections or acute rheumatic fever. Absence of recommendations on symptomatic treatment in many guidelines is concerning, and raises issues about antimicrobial stewardship, as this should be the mainstay of sore throat management, rather than antibiotics.

Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease

Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.

Relationship between patient understanding and timeliness of penicillin prophylaxis in rheumatic heart disease prevention programmes in American Samoa

AIM

While mostly eradicated in developed nations, rheumatic heart disease (RHD) is still the leading cause of preventable cardiovascular disease in children. RHD and its antecedent acute rheumatic fever remain endemic in many low to middle income countries, as well as in vulnerable communities in wealthy ones. Evidence-based interventions are particularly important in resource-poor settings. We sought to determine if efforts directed at patient and family education impact degree of participation in community-based prevention measures, and with short-term disease progression.

METHODS

We performed an observational, cross-sectional study of children with RHD aged 5-19 years, along with their parents, in American Samoa. A survey was administered in November 2016 to assess patient and parent knowledge of RHD. Scores were compared to percent timeliness of penicillin prophylaxis via chart review.

RESULTS

We collected a total of 70 surveys of child-parent dyads with a patient mean age of 14.28 years ±2.71. An increased knowledge score was predictive of increased penicillin compliance for both children (12.70% increase in compliance per 1-unit increase in score (P = 0.0004)) and parents (10.10% increase in compliance per 1-unit increase in score (P = 0.0012)).

CONCLUSIONS

A clear relationship exists between patient and parent knowledge of RHD and timeliness of penicillin prophylaxis doses. This study was the first to link patient understanding of RHD to engagement with preventative measures.

Transcatheter Aortic Valve Replacement in Rheumatic Aortic Stenosis: A Comprehensive Review

Rheumatic heart disease (RHD) mainly affects people in developing, low-income countries. However, due to globalization and migration, developed countries are now seeing more cases of RHD. In RHD patients who develop severe symptomatic aortic stenosis, surgical aortic valve replacement remains the treatment of choice. In the past decade, there has been an extension of transcatheter aortic valve replacement (TAVR) to intermediate-risk and lower-risk patients with aortic stenosis. This review suggests the possible utility of TAVR for the treatment of rheumatic aortic stenosis. Rheumatic aortic stenosis has been excluded from major TAVR studies due to the predominantly noncalcific pathology of the rheumatic aortic valve. However, there have been case reports and case series showing successful implantation of the valve even in patients with and without significant leaflet calcification. In this review article, we summarize the latest evidence of severe rheumatic aortic stenosis treated with TAVR and discuss the procedure's impact on patient care, safety, and efficacy.

Epidemiological characteristics, management, and outcomes of atrial fibrillation in TUNISIA: Results from the National Tunisian Registry of Atrial Fibrillation (NATURE-AF)

BACKGROUND

Contemporary registries on atrial fibrillation (AF) are scare in North African countries.

HYPOTHESIS

In the context of the epidemiological transition, prevalence of valvular AF in Tunisia has decreased and the quality of management is still suboptimal.

METHODS

NATURE-AF is a prospective Tunisian registry, involving consecutive patients with AF from March 1, 2017 to May 31, 2017, with a one-year follow-up period. All the patients with an Electrocardiogram-documented AF, confirmed in the year prior to enrolment were eligible. The epidemiological characteristics and outcomes were described.

RESULTS

A total of 915 patients were included in this study, with a mean age of 64.3 ± 22 years and a male/female sex ratio of 0.93. Valvular AF was identified in 22.4% of the patients. The mean CHA₂ DS₂ VASC score in nonvalvular AF was 2.4 ± 1.6. Monotherapy with antiplatelet agents was prescribed for 13.8% of the patients. However, 21.7% of the subjects did not receive any antithrombotic agent. Oral anticoagulants were prescribed for half of the patients with a low embolic risk score. In 341 patients, the mean time in therapeutic range was 48.87 ± 28.69%. Amiodarone was the most common antiarrhythmic agent used (52.6%). During a 12-month follow-up period, 15 patients (1.64%) had thromboembolism, 53 patients (5.8%) had major hemorrhage, and 52 patients (5.7%) died.

CONCLUSIONS

NATURE-AF has provided systematic collection of contemporary data regarding the epidemiological and clinical characteristics as well as the management of AF by cardiologists in Tunisia. Valvular AF is still prevalent and the quality of anticoagulation was suboptimal.

Prevalence of rheumatic heart disease among school children in East Africa: a systematic review and meta-analysis

Introduction

conducting researches and estimating the prevalence of rheumatic heart disease in school children is crucial to develop school-based strategies targeted to decrease the prevalence of this disease. Therefore, this systematic review and meta-analysis were aimed to estimate the overall prevalence of rheumatic heart disease (RHD) among school children in East Africa.

Methods

PubMed/MEDLINE, Google Scholar, Cochrane review, African Journals Online and African Index Medicus databases were searched to identify relevant research articles. The overall prevalence of rheumatic heart disease was pooled based on the weighted inverse variance random-effects model at a 95% confidence interval. The presence of heterogeneity, sensitivity analysis and presence of publication bias was tested. Results were presented with narrative synthesis, tables and forest plots.

Results

a total of thirteen research articles were included in the final analysis. The pooled prevalence of rheumatic heart disease in East African school children was 1.79% (17.9 cases per 1000 children (95% CI=11.6, 24.2; I²=95.1%; p<0.001)). From the subgroup analysis conducted by publication year, a lower prevalence of RHD in school children was reported among studies published after 2015 (six studies; overall prevalence=1.17% (11.7 cases per 1000 school children); with 95% CI=0.60, 1.73%; I²=88.8%; p<0.001). Additionally, the horn of Africa was found to have the lowest prevalence of RHD in school children among East African countries (six studies; overall prevalence=1.59% (15.9 cases per 1000 school children); with 95% CI=0.68, 2.51%; I²=94.2%; p<0.001).

Conclusion

the prevalence of rheumatic heart disease (RHD) among school children in East Africa was considerably higher than the results from high-income countries. Therefore, community education on strep throat and its complications should be implemented through mass media. Rheumatic heart disease preventive strategies should be integrated with schools to reduce the prevalence of RHD among school children.

A multivalent T-antigen-based vaccine for Group A Streptococcus

Pili of Group A Streptococcus (GAS) are surface-exposed structures involved in adhesion and colonisation of the host during infection. The major protein component of the GAS pilus is the T-antigen, which multimerises to form the pilus shaft. There are currently no licenced vaccines against GAS infections and the T-antigen represents an attractive target for vaccination. We have generated a multivalent vaccine called TeeVax1, a recombinant protein that consists of a fusion of six T-antigen domains. Vaccination with TeeVax1 produces opsonophagocytic antibodies in rabbits and confers protective efficacy in mice against invasive disease. Two further recombinant proteins, TeeVax2 and TeeVax3 were constructed to cover 12 additional T-antigens. Combining TeeVax1–3 produced a robust antibody response in rabbits that was cross-reactive to a full panel of 21 T-antigens, expected to provide over 95% vaccine coverage. These results demonstrate the potential for a T-antigen-based vaccine to prevent GAS infections.

A case report of isolated rheumatic tricuspid regurgitation and pericarditis

Rheumatic fever (RF) is a complex syndrome in which the human body develops antibodies against β-haemolytic streptococcus, and triggers inflammation in various organs. RF valvulitis mostly affects the mitral valve (MV) and, to a lesser extent, the aortic valve (AV). Isolated rheumatic tricuspid valve (TV) disease and pericarditis is extremely rare and is not well described in the RF guidelines. The current case demonstrates the echocardiographic findings of TV valvulitis of RF and describes the presentation and electrocardiogram (ECG) changes in pericarditis. We present the case of a 16-year-old male patient who developed upper respiratory tract infection followed by typical pericarditis chest pain. The patient had no history of joint pain or swelling, but was found to have a tricuspid regurgitation (TR) murmur upon examination. Laboratory investigations revealed an elevated erythrocyte sedimentation rate, and elevated C-reactive protein and antistreptolysin O titres. ECG showed a wide-spread 1.5 mm upward concave ST-segment elevation. In echocardiography, the TV opened well with markedly thickened leaflets and severe TR, while the MV and AV were normal in both structure and function. The diagnosis of RF was established and treatment with high-dose aspirin and antibiotics was initiated. The treatment led to resolution of the chest pain. Our case highlights that the physical and lab findings of rheumatic TR are similar to those of rheumatic mitral regurgitation, with the exception of a high-velocity jet. Similarly, the presentations of rheumatic pericarditis are similar to other types and may also respond to high-dose aspirin. Finally, physicians should be familiar with both the common and rare complications of RF because the guidelines have placed Middle East region among the high-risk countries.

Prevalence of rheumatic heart disease in a major referral cardiology clinic in Ethiopia: A retrospective cross-sectional study

Background

Rheumatic Heart Disease (RHD) remains one of the major causes of death and disability in developing countries. This preventable, treatable but not curable form of cardiovascular disease is needlessly killing scores of children and youth mainly due to the misunderstanding of the burden of the disease in these countries. We sought to describe the prevalence of RHD at one of the major referral cardiology clinics in Ethiopia.

Methods

This was a retrospective cross-sectional chart review of all patients referred for a cardiopathy at the Tikur Anbessa Referral Cardiac Clinic from June 2015 to August 2018. We excluded records of patients with a non-cardiac diagnosis and those without a clear diagnosis. A predesigned and tested EXCEL form was used to collect the data. The data was encoded directly from the patient record files. MATLAB’s statistics toolbox (MATLAB2019b) was used for statistical analysis.

Results

Among the total 7576 records analyzed 59.5% of the patients were women. 83.1% of the data belonged to adult patients with the largest concentration reported in the 18 to 27 age group. 69.7% of the patients were from urban areas. The median age of the study population was 30 (interquartile range = 21–50). 4151 cases were caused by RHD which showed that RHD constituted 54.8% of the cases. The median age for RHD patients was 25 (interquartile range = 19–34). The second most prevalent disease was hypertensive heart disease which constituted 13.6% that was followed by congenital heart disease with 9% prevalence rate.

Conclusion

The results of this study indicated the extent of the RHD prevalence in Ethiopia’s cardiac hospital was 54.8%. What was more critical was that almost 70% of the RHD patients were mainly the working-age group(19 to 34 years).

Prevalence of Rheumatic Heart Disease and Other Cardiac Conditions in Low-Risk Pregnancies in Kenya: A Prospective Echocardiography Screening Study

Background:

Rheumatic heart disease (RHD) in sub-Saharan Africa contributes to significant cardiac morbidity and mortality, yet prevalence estimates of RHD lesions in pregnancy are lacking.

Objectives:

Our first aim was to evaluate women using echocardiography to estimate the prevalence of RHD and other cardiac lesions in low-risk pregnancies. Our second aim was to assess the feasibility of screening echocardiography and its acceptability to patients.

Methods:

We prospectively recruited 601 pregnant women from a low-risk antenatal clinic at a tertiary care maternity centre in Western Kenya. Women completed a questionnaire about past medical history and cardiac symptoms. They underwent standardized screening echocardiography to evaluate RHD and non-RHD associated cardiac lesions. Our primary outcome was RHD-associated cardiac lesions and our secondary outcome was a composite of any clinically-relevant cardiac lesion or echocardiography finding. We also recorded duration of screening echocardiography and its acceptability among pregnant women in this sample.

Results:

The point prevalence of RHD-associated cardiac lesions was 5.0/1,000 (95% confidence interval: 1.0–14.5), and the point prevalence of all clinically significant lesions/findings was 21.6/1,000 (11.6–36.7). Mean screening time was seven minutes (SD 1.7, range: 4–17) for women without cardiac abnormalities and 13 minutes (SD 4.6, range: 6–23) for women with abnormal findings. Echocardiography was acceptable to women with 74.2% agreeing to participate.

Conclusions:

The prevalence of clinically-relevant cardiac lesions was moderately high in a low-risk population of pregnant women in Western Kenya.

Risk Factors and Patient Profile of Infective Endocarditis due to Gemella spp

BACKGROUND

The diagnosis of infective endocarditis is difficult, especially when it involves atypical organisms. Therefore, our study identified risk factors of infective endocarditis caused by rare pathogen, Gemella spp.

METHODS

A systematic review was conducted to investigate characteristics of endocarditis patients infected with Gemella spp. using the search term "Gemella" and "endocarditis." Case reports were gathered by searching Medline/Pubmed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science databases. 83 articles were selected for review.

RESULTS

Five species of Gemella were identified. Typical patients were males between 31 and 45 years of age. On admission, patients had fever, tachycardia, and normal blood pressure. Common clinical manifestation other than fever included fatigue and weakness, chills and sweating, and nausea, vomiting, diarrhea, and weight changes. One in four reported a history of congenital heart disease, and a recent oral cavity infection. Laboratory tests reveal anemia, leukocytosis, and elevated erythrocyte sedimentation in all age groups, elevated C-reactive protein is observed among adult and geriatric populations only. Mitral and aortic valves were most commonly infected by Gemella spp.. The most common Gemella spp.-susceptible antibiotics were penicillin, vancomycin, cephalosporin, macrolide, and aminoglycosides. However, antibiotic resistance was observed against penicillin, aminoglycoside, and fluoroquinolone. Antibiotic course of at least six weeks resulted in superior clinical improvements than durations under six weeks. Finally, one in two patients underwent valve replacement or repair, with common complications affecting the cardiovascular, neurological, and renal systems. Finally, death occurred in 1 in 8 patients, half of which occurred post-surgical procedure, and the majority occurring equal to or greater than 1 week from admission.

CONCLUSION

Our systematic review highlights the importance of considering rare pathogens, particularly in the presence of predisposing risk factors.

Rising Ethnic Inequalities in Acute Rheumatic Fever and Rheumatic Heart Disease, New Zealand, 2000-2018

We describe trends in acute rheumatic fever (ARF), rheumatic heart disease (RHD), and RHD deaths among population groups in New Zealand. We analyzed initial primary ARF and RHD hospitalizations during 2000-2018 and RHD mortality rates during 2000-2016. We found elevated rates of initial ARF hospitalizations for persons of Māori (adjusted rate ratio [aRR] 11.8, 95% CI 10.0-14.0) and Pacific Islander (aRR 23.6, 95% CI 19.9-27.9) ethnicity compared with persons of European/other ethnicity. We also noted higher rates of initial RHD hospitalization for Māori (aRR 3.2, 95% CI 2.9-3.5) and Pacific Islander (aRR 4.6, 95% CI 4.2-5.1) groups and RHD deaths among these groups (Māori aRR 12.3, 95% CI 10.3-14.6, and Pacific Islanders aRR 11.2, 95% CI 9.1-13.8). Rates also were higher in socioeconomically disadvantaged neighborhoods. To curb high rates of ARF and RHD, New Zealand must address increasing social and ethnic inequalities.

The quest for the optimal surgical management of tricuspid valve endocarditis in the current era: a narrative review

Tricuspid valve endocarditis (TVE) is a growing concern with increasing rates and mortality burden. The currently changing etiology, the antibiotic resistance and the raise in iatrogenic causes as with implantable cardiac devices [cardiac implantable electronic device (CIED)], represent a challenge for the management of these patients. The progressively widespread use of CIEDs is adding to the more commonly known intravenous (IV) drug abuse in the list of causes. Treatment strategies include medical therapy alone or surgery. From the surgical standpoint tricuspid valve repair, replacement or the staged procedure of valvectomy as bridge to replacement are available options. Treatment of endocarditis related to implantable device is another expanding field which requires a coordinated action with microbiologists in consideration of the microorganism antibiotic resistance. This review summarizes the currently available evidences on TVE including surgical indications, timing of interventions and technical considerations. The conflicting results of the available observational evidences and the non-unanimous consensus on many aspects of TVE impede to reach a definitive conclusion regarding the best management strategy and demands for randomized studies in this field.

Screening and evaluation of newly diagnosed cardiovascular diseases in first-trimester asymptomatic pregnant women in a tertiary antenatal care center in Turkey

OBJECTIVE

Cardiovascular disease (CVD) is the leading cause of death during pregnancy. Therefore, its detection early in pregnancy is of great importance. In this study, we aimed to investigate the rate and spectrum of CVD among healthy women in the first trimester of pregnancy.

METHODS

A total of 900 women in the first trimester of pregnancy, who attended the antenatal outpatient clinic of a tertiary care center in Ankara, Turkey, for a routine pregnancy examination, were recruited into this prospective study. Patients with a history of chronic systemic diseases, CVD, and/or a family history of an early onset CVD, and multiple pregnancies were excluded. Patients who were included in the study underwent electrocardiography and transthoracic echocardiography by the same cardiologist.

RESULTS

The rate of newly diagnosed CVD cases among asymptomatic pregnant women without any cardiac or clinical risk factors was 5.2% (n=47). The following CVDs were detected: rheumatic heart disease (n=26; 55.3%), congenital heart disease (n=13; 27.6%), and isolated valve disease (moderate and severe) (n=8; 17%). The mitral valve prolapse was detected in 32 women (3.5%) and atrial septal aneurysm in 51 women (5.67%). Thirty women (3.3%) had arrhythmia.

CONCLUSION

The CVD rate of 5.2% among healthy women in the first trimester of pregnancy shows that the clinicians must keep in mind that during pregnancy, physiological changes in the cardiovascular system may aggravate an undiagnosed disease, and they should be alert even in case of mild cardiac symptoms that may interfere with pregnancy complaints.

Efficacy of levetiracetam in the treatment of Sydenham chorea

BACKGROUND

To study the effect of levetiracetam in treating Sydenham chorea.

METHODS

We retrospectively collected the data of 140 patients diagnosed with Sydenham chorea in the pediatric neurology and pediatric cardiology outpatient clinics of Van Training and Research Hospital between January 2010 and December 2018.

RESULTS

There were 140 patients, 102 (70%) of whom were girls, with mean age of onset 11.8 ± 2.7 years. Symptomatic treatment was initiated in all patients at the time of diagnosis; this medication was changed during follow up in 15 patients. The most frequently prescribed drugs were haloperidol and sodium (Na) valproate, and the most frequently discontinued one was haloperidol, due to side effects. The second-choice drug was most often levetiracetam. Clinical response often began within the first 2 weeks, with Na valproate (P = 0.002), within 4 weeks with carbamazepine (P = 0.037) but 1-6 months with haloperidol (P = 0.018) and levetiracetam (P = 0.008). Time to full remission was similar with Na valproate, carbamazepine, haloperidol, and levetiracetam (P = 0.276). Our study indicated that levetiracetam was as effective as the other commonly used drugs in the symptomatic treatment of Sydenham chorea.

CONCLUSION

Levetiracetam might be an option in the treatment of Sydenham chorea because of its acceptable effect and safety profile. This observation needs further support with evidence obtained through controlled and blinded trials.

Infective endocarditis is associated with worse outcomes in stroke: A Thailand National Database Study

BACKGROUND

There is lack of data on the association between infective endocarditis (IE) and outcomes of mortality and complications in stroke. We aimed to compare characteristics and outcomes of stroke patients with and without IE.

METHODS

We retrospectively examined the above association using data obtained from an insurance database which covers ~75% of the Thai population. All hospitalised strokes between 8 January 2003 and 31 December 2013 were included in the current study. Characteristics and outcomes were compared between stroke patients with or without IE, and then between two main stroke types. Multiple logistic regression models including propensity score-matched analyses were constructed to assess study outcomes controlling for age, sex, stroke type and comorbidities.

RESULTS

A total of 590 115 stroke patients (mean (SD) age = 64.2 ± 13.7 years; ischaemic = 51.7%; haemorrhagic = 32.6%; undetermined = 15.7%) were included, of whom 2129 (0.36%) had stroke associated with IE. After adjustment, we found that IE was significantly associated with the following complications: arrhythmias (adjusted odds ratio (95% CI) 6.94 (6.29-7.66)), sepsis (1.24 (1.01-1.52)), pneumonia (1.34 (1.17-1.53)), respiratory failure (1.43 (1.24-1.66)) and in-hospital mortality (1.29 (1.13-1.47)) (P for all <.001). Patients with haemorrhagic stroke with IE had poorer outcomes for in-hospital mortality and respiratory failure compared with their counterparts with ischaemic stroke. Propensity score-matched analysis showed similar results.

CONCLUSIONS

Our results suggest that stroke patients with IE differ from that of the general stroke population and these patients have worse outcomes. Future studies are needed to determine the best treatment strategies for stroke patients with IE.

Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: a systematic review and meta-analysis of diagnostic accuracy

OBJECTIVE

To summarise the accuracy of handheld echocardiography (HAND) which, if shown to be sufficiently similar to that of standard echocardiography (STAND), could usher in a new age of rheumatic heart disease (RHD) screening in endemic areas.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Scopus, EBSCOHost and ISI Web of Science were initially searched on 27 September 2017 and again on 3 March 2020 for studies published from 2012 onwards.

ELIGIBILITY CRITERIA

Studies assessing the accuracy of HAND compared with STAND when performed by an experienced cardiologist in conjunction with the 2012 World Heart Federation criteria among populations of children and adolescents living in endemic areas were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and assessed the methodological quality of included studies against review-specific Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 criteria. A meta-analysis using the hierarchical summary receiver operating characteristic model was conducted to produce summary results of sensitivity and specificity. Forest plots and scatter plots in receiver operating characteristic space in combination with subgroup analyses were used to investigate heterogeneity. Publication bias was not investigated.

RESULTS

Six studies (N=4208) were included in the analysis. For any RHD detection, the pooled results from six studies were as follows: sensitivity: 81.56% (95% CI 76.52% to 86.61%) and specificity: 89.75% (84.48% to 95.01%). Meta-analytical results from five of the six included studies were as follows: sensitivity: 91.06% (80.46% to 100%) and specificity: 91.96% (85.57% to 98.36%) for the detection of definite RHD only and sensitivity: 62.01% (31.80% to 92.22%) and specificity: 82.33% (65.15% to 99.52%) for the detection of borderline RHD only.

CONCLUSIONS

HAND displayed good accuracy for detecting definite RHD only and modest accuracy for detecting any RHD but demonstrated poor accuracy for the detection of borderline RHD alone. Findings from this review provide some evidence for the potential of HAND to increase access to echocardiographic screening for RHD in resource-limited and remote settings; however, further research into feasibility and cost-effectiveness of wide-scale screening is still needed.

PROSPERO REGISTRATION NUMBER

CRD42016051261.

Learning From Controversy: Contemporary Surgical Management of Aortic Valve Endocarditis

Aortic valve replacement is the commonest cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies guided by the comprehensive evaluation of the extension of the infection and its microbiological characteristics, clinical profile of the patient, and risk of infection recurrence are currently available. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. However, in cases of complex IE with the involvement of the root or the aortomitral continuity, the use of homograft is suggested according to the surgeon and center experience. Homograft use should be counterbalanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit (mechanical and bioprosthetic) are also potentially suitable alternatives. Further development of preservation techniques enabling longer durability of allogenic substitutes is required. We evaluate the current evidence for the use of valve substitutes in aortic valve endocarditis and propose an evidence-based algorithm to guide the choice of therapy. We performed a systemic review to clarify the contemporary surgical management of aortic valve endocarditis.

Echocardiography Screening for Latent Rheumatic Heart Disease: What Can We Do in Indonesia?

Rheumatic heart disease (RHD), a sequela of acute rheumatic fever (ARF), is a preventable disease but remains a significant health problem, especially in developing countries. It causes disability, poor quality of life, early mortality, and national economic burden. The World Heart Federation (WHF) aimed to achieve a 25% reduction in premature deaths from ARF and RHD among individuals aged <25 years by 2025. Primordial and primary prophylaxis of RHD is aimed to prevent the occurrence of ARF, while the goal of secondary and tertiary prophylaxis is to limit the progression and reduce the consequences of RHD. Early recognition of RHD is important for early prophylaxis strategies to inhibit any progression to advanced stages. In 2012, WHF introduced the latest echocardiographic criteria to recognize the early stage of RHD. This includes the evaluation of pathological regurgitation jet and morphological features of RHD based on 2D, color, and spectral Doppler criteria. In remote areas, portable echocardiography is preferable for RHD screening. Previous portable devices were only capable of producing 2D and color images. Hence, a simplified echocardiographic criterion without spectral Doppler evaluation is needed in selected areas. Indonesia is a developing country, an archipelago with a population of over 250 million. Currently, there are no data on ARF incidence and RHD prevalence nationwide. The only data available are the number of patients in advanced stages who came to referral centers for further management. The screening program has to be introduced in Indonesia as part of national RHD prophylaxis.

Throat Colonization and Antibiotic Susceptibility of Group a β-Hemolytic Streptococci Among Rheumatic Heart Disease Patients Attending a Cardiac Referral Hospital in Tanzania, a Descriptive Cross-Sectional Study

Background: Secondary prophylaxis against repeated attacks of acute rheumatic fever is an important intervention in patients with rheumatic heart disease (RHD), and it aims to prevent throat infection by group A β-hemolytic streptococcus (GAS); however, its implementation faces many challenges. This study aimed to assess throat colonization, antibiotic susceptibility, and factors associated with GAS colonization among patients with RHD attending care at Jakaya Kikwete Cardiac Institute in Dar-es-Salaam, Tanzania.

Methods: A descriptive cross-sectional study of RHD patients attending the Jakaya Kikwete Cardiac Institute was conducted from March to May 2018, where we consecutively enrolled all patients known to have RHD and coming for their regular clinic follow-up. A structured questionnaire was used to obtain patients' sociodemographic information, factors associated with GAS colonization, and status of secondary prophylaxis use and adherence. Throat swabs were taken and cultured to determine the presence of GAS, and isolates of GAS were tested for antibiotic susceptibility using Kirby–Bauer disk diffusion method according to the Clinical and Laboratory Standards Institute version 2015. Antibiotics of interest were chosen according to the Tanzanian Treatment Guidelines.

Results: In total, 194 patients with RHD were enrolled, their mean age was 28.4 ± 16.5 years, and 58.2% were females. Only 58 (29.9%) patients were on regular prophylaxis, 39 (20.1%) had stopped taking prophylaxis, whereas 97 (50.0%) had never been on prophylaxis. Throat cultures were positive for GAS in 25 (12.9%) patients. Patients who stopped prophylaxis were 3.26 times more likely to be colonized by GAS when compared to patients on regular prophylaxis. Majority (96%) of GAS isolates were susceptible to penicillin, ceftriaxone, and ciprofloxacin, whereas the highest resistance (20%) was observed with vancomycin. No GAS resistance was observed against penicillin.

Conclusion: The prevalence of GAS throat colonization is high among this population and is associated with stopping prophylaxis. The proportion of patients on regular secondary prophylaxis is unacceptably low, and interventions should target both patients' and physicians' barriers to effective secondary prophylaxis.

How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018)

Rheumatic heart disease (RHD) as a chronic sequela of repeated episodes of acute rheumatic fever (ARF), remains a cause of cardiac morbidity in Egypt although it is given full attention through a national RHD prevention and control program. The present report reviews our experience with subjects presenting with ARF or its sequelae in a single RHD centre and describes the disease pattern over the last decade. A cross-sectional study was conducted in El-Mahalla RHD centre between 2006 and 2018. A total of 17014 individual were enrolled and evaluated. Diagnosis ARF was based on the 2015 revised Jones criteria and RHD was ruled in by echocardiography. The majority of the screened subjects were female (63.2%), in the age group 5-15 years (64.6%), rural residents (61.2%), had primary education (43.0%), and of low socioeconomic standard (50.2%). The total percentage of cases presenting with ARF sequelae was 29.3% [carditis/RHD (10.8%), rheumatic arthritis (Rh.A) (14.9%), and Sydenham's chorea (0.05%)]. Noticeably, 72% were free of any cardiac insult, of which 37.7% were victims of misdiagnoses made elsewhere by untrained practitioners who prescribed for them long term injectable long-acting penicillin [Benzathine Penicillin G (BPG)] without need. About 54% of the study cohort reported the occurrence of recurrent attacks of tonsillitis of which 65.2% underwent tonsillectomy. Among those who experienced tonsillectomy and/or received BPG in the past, 14.5% and 22.3% respectively had eventually developed RHD. Screening of family members of some RHD cases who needed cardiac surgery revealed 20.7% with undiagnosed ARF sequalae [RHD (56.0%) and Rh.A (52.2%)]. Upon the follow-up of RHD cases, 1.2% had improved, 98.4% were stable and 0.4% had their heart condition deteriorated. Misdiagnosis of ARF or its sequelae and poor compliance with BPG use may affect efforts being exerted to curtail the disease. Updating national guidelines, capacity building, and reliance on appropriate investigations should be emphasized. Since the genetic basis of RHD is literally confirmed, a family history of RHD warrants screening of all family members for early detection of the disease.

Active Case Finding for Rheumatic Fever in an Endemic Country

Background Despite the high burden of rheumatic heart disease in sub-Saharan Africa, diagnosis with acute rheumatic fever (ARF) is exceedingly rare. Here, we report the results of the first prospective epidemiologic survey to diagnose and characterize ARF at the community level in Africa. Methods and Results A cross-sectional study was conducted in Lira, Uganda, to inform the design of a broader epidemiologic survey. Key messages were distributed in the community, and children aged 3 to 17 years were included if they had either (1) fever and joint pain, (2) suspicion of carditis, or (3) suspicion of chorea, with ARF diagnoses made by the 2015 Jones Criteria. Over 6 months, 201 children met criteria for participation, with a median age of 11 years (interquartile range, 6.5) and 103 (51%) female. At final diagnosis, 51 children (25%) had definite ARF, 11 (6%) had possible ARF, 2 (1%) had rheumatic heart disease without evidence of ARF, 78 (39%) had a known alternative diagnosis (10 influenza, 62 malaria, 2 sickle cell crises, 2 typhoid fever, 2 congenital heart disease), and 59 (30%) had an unknown alternative diagnosis. Conclusions ARF persists within rheumatic heart disease-endemic communities in Africa, despite the low rates reported in the literature. Early data collection has enabled refinement of our study design to best capture the incidence of ARF and to answer important questions on community sensitization, healthcare worker and teacher education, and simplified diagnostics for low-resource areas. This study also generated data to support further exploration of the relationship between malaria and ARF diagnosis in rheumatic heart disease/malaria-endemic countries.

Acute rheumatic fever in south-east of Turkey: clinical features and epidemiological evaluation of the patients over the last 25 years

This study evaluates clinical and epidemiological features of acute rheumatic fever using the data of last 25 years in our hospital in south-east of Turkey. The medical records of 377 patients with acute rheumatic fever admitted to Pediatric Cardiology Department of Çukurova University during 1993-2017 were retrospectively analysed. Two hundred and six patients were admitted between 1993 and 2000, 91 between 2001 and 2008, and 80 between 2009 and 2017. The largest age group (52%) were between 9 to 12 years of age and approximately two-thirds of the patients presented in the spring and winter seasons (62.8%). Among the major findings, the most common included carditis 83.6% (n = 315), arthritis at 74% (n = 279), Sydenham's chorea at 13.5% (n = 51), and only two patients (0.5%) had erythema marginatum and two patients (0.5%) had subcutaneous nodule. Carditis was the most common manifestation observed in 315 patients (83.6%). The most commonly affected valve was the mitral valve alone (54.9%), followed by a combined mitral and aortic valves (34%) and aortic valve alone (5.7%). Of the patients with carditis, 48.6% (n = 153) had mild carditis, of which 45 had a subclinical. Sixty-two patients (19.7%) had moderate and 100 patients (31.7%) had severe carditis. At the follow-up, 2 patients died and 16 patients underwent valve surgery. Twenty-eight (7.4%) patients' valve lesions were completely resolved. Conclusion: Although the incidence of acute rheumatic fever decreased, it still is an important disease that can cause serious increases in morbidity and mortality rates in our country.

COVID-19 concomitant with infective endocarditis: A case report and review of management

Coronavirus disease 2019 (COVID-19) has emerged as a pandemic and public health crisis across the world. With its high infectivity and rapid spread, the severity of the disease is escalating in certain populations, especially in patients with pre-existing cardiovascular disease. In developing countries, infective endocarditis remains a problem in patients with rheumatic heart disease. We report the case of a patient with a diagnosis of infective endocarditis concomitant with COVID-19, including the diagnosis, management, and main outcomes.

Role of the physical examination in the determination of etiology of ischemic stroke

The actual investigation of the body of a patient by the clinician in search for the signs of the disease beginning with the primary vital signs and continues with the careful and attentive observation of the patient. This article reviews the key findings in the physical examination of patients with ischemic stroke that have the potential to indicate the etiology of the infarct and to help to choose the use of ancillary tests. Through a systematic search of articles published in English related to the physical examination of patients with stroke, we identified key findings in the vital signs and classic components of the physical exam (appearance of the patient, auscultation, and eye examination) that have shown clinical significance when determining ischemic stroke etiology. We further suggest that the prompt identification of such findings can translate into better use of diagnostic tools and selection of ancillary confirmatory tests, thus, reducing the time to etiology based treatment and secondary prevention of ischemic stroke. in this manuscript, we aim to show that even though nowadays the clinical skills tend to be overlooked due to the overreliance on technology, the physical exam continues to be a valuable tool in the clinician armamentarium when facing the challenge of a patient with ischemic stroke.

Impact of balloon mitral valvuloplasty on left ventricular rotational deformation: Magnetic Resonance Imaging follow up study

In patients with rheumatic mitral stenosis (MS), some previous studies have investigated the influence of balloon mitral valvuloplasty (BMV) on left ventricular (LV) systolic function. However, the impact of BMV on LV twisting motion in this clinical setting has not been studied before yet. To describe changes in LV torsion in patients with rheumatic MS following BMV. Thirty patients (median age 33 years, 22 women) with isolated severe MS were studied. CMR myocardial tissue tagging was used for assessment of LV rotational deformation. LV torsion was calculated as the twist value (the net difference between apical counterclockwise and basal clockwise rotation) normalized to the length of the ventricle and multiplied by the mean radius at the base and apex. All patients had CMR studies before, 6 months and 1 year after successful BMV. At baseline, patients had a mitral valve area of 0.9 (0.6-1.3) cm², mean pressure gradient of 12.5 (8-24) mmHg across the valve as measured by transthoracic echocardiography. Median LV ejection fraction (LVEF) estimated by CMR was 57 (range: 45-69) %. A significant improvement in LV base-apex torsion was shown at 6 months (3.3° vs. 2.5°, p < 0.001) with a further improvement at 1 year (4.1° vs. 3.3°, p = 0.05). Similar pattern of change was seen in LV base-mid torsion with a significant increase at 6 months (3.6° vs. 2.3°, p < 0.001) and a further increase at 1 year (4.7° vs. 3.6°, p = 0.007). These changes were associated with a significant increase in LVEF (62% vs. 57%, p < 0.001) at 1 year following BMV. Successful BMV is associated with a significant improvement in LV torsion that is accompanied by a significant improvement in LVEF.

A glimpse of hope: cardiac surgery in low- and middle-income countries (LMICs)

Currently, more than five times more people live in low- and middle-income countries (LMICs) than in high-income countries (HICs). As such, the downward trend in cardiac surgical needs in HICs reflects only the situation of one sixth of the world population while the vast majority living in LMICs has still no or limited access to life saving heart operations. In these countries, rheumatic heart disease (RHD) still accounts for a significant proportion of cardiac surgical needs. In low- and lower-middle income countries it remains the single most common cardiovascular disease in young adult and adolescent patients in need of heart surgery outweighing other indications such as congenital cardiac defects almost 4-fold. Compared to HICs with their predominance of calcific aortic stenosis in the elderly mitral valve surgery is required in >90% of the largely young patients with RHD in low-income countries (LICs) and still in 70% of the often middle aged patients in middle-income countries (MICs). Although recent government initiatives in LICs led to the establishment of local, independent cardiac surgical services gradually replacing fly-in missions, these centers still only cover less than 2% of the needs of their populations. In MICs, cardiac surgical needs continually grow with the emergence of degenerative diseases. As such, in spite of the concomitant growth of cardiac surgical capacity, significantly less than half the estimated patients in need have access. Capacities in LICs range from 0.5 to 7 cardiac operations/million population; 100-481/million in MICs and >1,200/million in HICs such as the USA and Germany. While a new level of awareness of the scope and magnitude of the problem has begun to emerge in LICs and the establishment of local cardiac surgical capacity has given rise to a glimpse of hope, the challenges of expanding these fledgling services to a significant proportion of the population still seem insurmountable. Challenges in MICs are on the other hand the widening gap between private cardiac medicine for the affluent few and overwhelmed public services for the many and the rural urban divide with the underappreciation of the ongoing dominance of RHD in the rural and indigent population on the other. Overshadowing all LMICs is the low level of valve-repair skills associated with insufficient cardiac surgical capacity and the unavailability of suitable replacement valves which address the young age of the patients and the difficulties of anticoagulation in a socioeconomic environment distinctly different from the elderly patients of HICs.

Environmental and social determinants of acute rheumatic fever: a longitudinal cohort study

Acute rheumatic fever (ARF), an auto-immune response to a group A Streptococcus infection and precursor to rheumatic heart disease (RHD), remains endemic in many socio-economically disadvantaged settings. A Global Resolution on ARF and RHD was recently adopted at the 71st World Health Assembly where governments committed to improving efforts to prevent and control ARF and RHD. To inform these efforts, the objectives of this study were to examine associations between childhood ARF in the UK between 1958 and 1969 and a range of environmental and social factors. Of 17 416 children from the nationally representative birth cohort of the National Child Development Study, ARF was reported in 23 children during early childhood (between birth and the 7-year follow-up) and in 29 additional children during middle childhood (between the 7- and 11-year follow-ups). Risk factors associated with ARF in both early and middle childhood were: a large family size; attendance at a private nursery or class; a history of nephritis, kidney or urinary tract infections; and a history of throat or ear infections. Risk factors for ARF in early childhood alone were families with fathers in a professional or semi-professional occupation and families who moved out of their local neighbourhood. Risk factors in late childhood alone included overcrowding and free school meals. These data suggest that prevention strategies in ARF endemic settings may be enhanced by targeting, for example, new members entering a community and children in environments of close contact, such as a nursery or shared bedrooms.

Rheumatic Mitral Stenosis: Long-Term Follow-Up of Adult Patients with Nonsevere Initial Disease

INTRODUCTION

There is no consensus regarding the natural history of rheumatic mitral stenosis (MS) among adults presenting with nonsevere disease. This study aims to describe the progression of stenosis among adult rheumatic MS patients, to identify predictive factors for progression, and to assess the incidence of complications.

METHODS

A retrospective cohort analysis was performed among patients with rheumatic MS treated at a single center. Eighty-five patients were included with mild to moderate MS, ≥30 years old on initial echocardiography. Demographics, medical history, echocardiographic reports over at least 10 years, and related complications were obtained from a computerized database.

RESULTS

Over a period of 13.1 ± 2.38 years, 75 patients (88%) had no significant progression in stenosis severity. The final echocardiographic assessment demonstrated 2 groups with a significant difference between them regarding the mitral valve area (1.58 ± 0.44 vs. 1.1 ± 0.26 cm2, p = 0.001) and mean valvular pressure gradient (6.27 ± 2.52 vs. 8.5 ± 2.69 mm Hg, p = 0.01). Patients with indolent MS (group A) were compared to patients with progressive disease (group B), and a higher percent of Bedouin patients were found in group B (OR 8.036, p = 0.015). No significant differences were found in other parameters. Complications including atrial fibrillation, cerebral ischemic events, and impaired right ventricle function, although frequent, were not statistically different between the groups.

CONCLUSIONS

An indolent natural progression of rheumatic MS was observed in our study. Despite this finding, it still has potentially deleterious effects. Bedouin patients have a higher risk for progressive disease.

Rheumatic Fever in Large Cohort of Adolescents in Israel

Background: Acute rheumatic fever (ARF) remains a major worldwide healthcare problem, despite its progressive decline in developed countries. The aims of our study were to estimate the prevalence of ARF among adolescents in Israel and to investigate risk factors.

Methods: The study population consisted of 113,671 consecutive conscripts 16–19 years old, born during 1971–1993, who completed the medical profiling as part of the recruitment process to the IDF. ARF was diagnosed according to Jones criteria at time of illness, with confirmation relying on medical documentation and cardiologist evaluation including echocardiography.

Results: The general prevalence rate of ARF was 0.12%. A downward trend was observed, from 0.19% among those born during 1971–1980 to 0.07% among those born during 1981–1993. Differences in prevalence of ARF were noted in sub-populations based on country of birth and origin—Israel, Ethiopia and the former soviet union (FUSSR). The prevalence rates of valvar disease among ARF+ and ARF– recruits were 15.7% and 0.95%, respectively. In multivariable logistic regression analyses, 4 variables were negatively associated with ARF: later birth year group, female gender, rural residence, youngest child; and 3 were positively associated with ARF: young parents, above normal BMI and valvar disease.

Conclusion: Our study provides support for the documented decline in ARF prevalence and describes socio-demographic and anthropometric risk factors including the association with valvar disease and novel risk factors including above normal BMI and young parents, both warranting further investigation which might help in developing societal level prevention strategies.

Acute Rheumatic Fever and Kawasaki Disease Occurring in a Single Patient

Kawasaki disease and acute rheumatic fever are two major causes of acquired heart disease in the pediatric population. Although both conditions are well-known entities, the association between them has never been described. We report herein a case of 6-year-old male patient who first presented with Kawasaki shock syndrome, followed by acute rheumatic fever 1 year later. In contrast to the prompt intervention given for atypical Kawasaki disease, in the present case the diagnosis was significantly delayed during the otherwise typical presentation of acute rheumatic fever. Our case highlights the difficulty experienced by many pediatricians in developed nations in diagnosing acute rheumatic fever due to its comparative rarity. To prevent diagnostic errors, all pediatricians should be alert to the possibility of acute rheumatic fever even if they are practicing in areas where it is not endemic.

Adherence to Benzathine Penicillin G Secondary Prophylaxis and Its Determinants in Patients with Rheumatic Heart Disease at a Cardiac Center of an Ethiopian Tertiary Care Teaching Hospital

PURPOSE

Benzathine penicillin G (BPG) monthly administration is the most effective method for secondary prophylaxis against acute rheumatic fever (ARF). BPG's efficacy largely depends on adherence to treatment. This study was aimed at assessing adherence to BPG prophylaxis and its determinants among adult patients with rheumatic heart disease.

PATIENTS AND METHODS

An institutional cross-sectional study design was used. One hundred and forty-five patients receiving monthly BPG at the Adult Cardiac Clinic of Tikur Anbessa Specialized Hospital (TASH) were interviewed. Their 1-year BPG prophylaxis administration record was also reviewed. The rate of adherence to BPG injection was determined by calculating the percentage of the administered drug from the total expected doses. Data were entered and analyzed using Statistical Package for Social Sciences (SPSS) software version 25. Both descriptive and logistic regression analyses were computed to describe different variables and assess factors associated with adherence, respectively. A p-value <0.05 was used to declare association.

RESULTS

Among a total of 145 study participants involved, the majority (76.6%) of them had been receiving BPG for the last 10 years. The average adherence rate to monthly BPG injection was 80.60% with a range of 0% to 100%. However, only 101 (69.7%) of participants were taking ≥80% of their prescribed monthly BPG prophylaxis doses. Study participants with informal education 1.10 (0.023-46.96) and secondary school education 0.89 (0.10-8.11) were more and less likely to adhere to BPG injection, respectively, when compared with those who attended higher education programs. The regression analysis showed patients who were not admitted to the hospital (AOR: 26.22; CI: 2.55-269.70; p=0.006) and once admitted patients (AOR: 50.08; CI: 2.87-873.77; p=0.007) were more likely to adhere to their BPG injections than those admitted twice or more. The study participants who waited until the next appointment were also less adherent (AOR: 0.02; CI: 0.00-0.13; p=0.000) than those who went a few days later for receiving the missed/late dose.

CONCLUSION

The adherence rate to BPG injection among RHD patients was found to be high (80.60%). Patients' admission status and their action on missed and/or late doses were found to be important determinants of adherence in this study.

Iranian Registry of Infective Endocarditis (IRIE): Time to relook at the guideline, regarding to regional differences

Aims

Infective endocarditis (IE) remained a potentially fatal disease with high rate of mortality and morbidity. The epidemiology and global burden of IE are largely different between the countries. We aimed to address the epidemiological aspects of IE in a tertiary hospital in Tehran, Iran.

Methods and Results

Between 2006–2018, all adults patients with diagnosis of IE were enrolled in the Iranian Registry of Infective Endocarditis (IRIE). The data were analyzed using the χ², Kolmogorov–Smirnov, and Mann–Whitney U tests. Overall, 602 patients, 407 (67.6%) men, mean age 46 ± 16 years were recruited. Positive blood culture found in 49%.The most common underlying heart diseases were: Congenital heart diseases (CHD) particularly bicuspid aortic valves (BAV) and ventricular septal defects (VSD) in 37%, followed by degenerative heart diseases :flail and mitral valve prolapse (16.3%), intravenous drug user in 12.6%, prosthetic valves in 11.1%, previous IE (8.9%), rheumatic heart diseases (RHD) in 8.4%. The most causative microorganisms were Staphylococcus aureus, Enterococci, coagulase-negative staphylococci and Streptococcus viridans. Cardiac or extra cardiac complications occurred in 56.6% of the patients.

Conclusions

Based on IRIE, IE occurs in the younger population in Iran with high rates of blood culture-negative IE. RHD are not the main cause of IE in Iran, CHD including BAV and VSDs, followed by prolaptic or flail mitral valve were the most common. These 2 groups can be considered a high-risk group for IE. More than half of the patients with IE had cardiac or extra cardiac complications.

The End Rheumatic Heart Disease in Australia Study of Epidemiology (ERASE) Project: data sources, case ascertainment and cohort profile

PURPOSE

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist as public health issues in developing countries and among disadvantaged communities in high-income countries, with rates in Aboriginal and Torres Strait Islander peoples in Australia among the highest recorded globally. A robust evidence base is critical to support policy recommendations for eliminating RHD, but available data are fragmented and incomplete. The End RHD in Australia: Study of Epidemiology (ERASE) Project aims to provide a comprehensive database of ARF and RHD cases in Australia as a basis for improved monitoring and to assess prevention and treatment strategies. The objective of this paper is to describe the process for case ascertainment and profile of the study cohort.

PATIENTS AND METHODS

The ERASE database has been built using linked administrative data from RHD registers, inpatient hospitalizations, and death registry data from 2001 to 2017 (mid-year). Additional linked datasets are available. The longitudinal nature of the data is harnessed to estimate onset and assess the progression of the disease. To accommodate systematic limitations in diagnostic coding for RHD, hospital-only identified RHD has been determined using a purposefully developed prediction model.

RESULTS

Of 132,053 patients for whom data were received, 42,064 are considered true cases of ARF or RHD in the study period. The patient population under 60 years in the compiled dataset is more than double the number of patients identified in ARF/RHD registers (12,907 versus 5049). Non-registered patients were more likely to be older, non-Indigenous, and at a later disease stage.

CONCLUSION

The ERASE Project has created an unprecedented linked administrative database on ARF and RHD in Australia. These data provide a critical baseline for efforts to end ARF/RHD in Australia. The methodological work conducted to compile this database resulted in significant improvements in the robustness of epidemiological estimates and entails valuable lessons for ARF/RHD research globally.

Infective endocarditis: trends, surgical outcomes, and controversies

The number of hospitalizations and surgical cases of infective endocarditis (IE) are increasing. The aim of this study was to review these trends, surgical outcomes, and controversies related to IE. A search of MEDLINE of studies published between 1960 and 2018 was conducted. Search terms included "infective endocarditis", "history of", "trend", "epidemiology", "outcome", "medical management", "surgery", "indication", and "re-operative surgery", or any combination thereof. The United States has the highest incidence of IE in the world at 15 per 100,000 people, with increases in incidence due to the aging population as well as increasing rates of intravenous drug use (IVDU). National guidelines support early surgical intervention in specific clinical settings in both left and right-sided IE. However, only 11% of the evidence used in formulating guidelines for surgical therapy in IE are based on level A evidence. Ongoing controversies include whether to perform surgery in the setting of continued or recurrent IVDU in a patient with a prior valve operation, timing of surgery after acute stroke due to IE, and general indications for surgery for tricuspid valve IE. IE has a surging incidence and increasing burden on the healthcare system in the United States. Multiple controversies exist, and formulating level A evidence and multidisciplinary collaboration will be essential components to effectively treating this complex patient population.

Youngest documented rheumatic mitral stenosis with regurgitation in a 28-month-old girl

BACKGROUND

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are the leading causes of acquired diseases in children and young adults in developing countries carrying considerable morbidity and mortality. Rheumatic fever (RF) commonly affects children between 5-15 years old and is rarely seen in < 5 years old. Mitral stenosis (MS) is the most common sequela, as it bears maximum onslaught. In India, few patients follow an unusually rapid course in developing severe MS because of its fulminant nature following attack of ARF.

CASE REPORT

Our patient was a 28-month-old girl who had developed severe MS, mitral regurgitation (MR), and pulmonary hypertension (PH) as the sequelae of ARF which she had suffered at the age of 18 months old.

CONCLUSION

To the best of our knowledge, this is the youngest reported case of rheumatic MS following ARF after extensive search in the literature. This case highlights the fact that very young population is not immune to ARF contrary to prior belief and therefore, more stringent preventive measures need to be implemented for it and possibility of ARF should be kept in mind while evaluating carditis in a child.