Effectiveness of Systematic Echocardiographic Screening for Rheumatic Heart Disease in Nepalese Schoolchildren: A Cluster Randomized Clinical Trial

Follow-up echocardiographic changes in children and youth aged <25 years with latent rheumatic heart disease: A systematic review and meta-analysis of global data

OBJECTIVES

To estimate progression, regression and persistence rates for borderline and mild-definite latent RHD in children and youth diagnosed at age < 25 years.

METHODS

A review was conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Electronic databases were searched for latent RHD echocardiography follow-up studies which used World Heart Federation diagnostic criteria. A meta-analysis of outcomes was conducted for borderline and mild-definite disease subcategories.

RESULTS

Data for 1618 individuals from 12 studies were included. For borderline cases, 48.51% regressed (95%CI 45.10-51.93), 13.99% progressed (95%CI 9.72-18.25), and 38.61% had persistent (unchanged) disease at follow-up (95%CI 29.68-47.54). For mild-definite cases, 34.01% regressed (95%CI 28.88-39.15), 8.06% progressed (95%CI 3.65-16.90), and 60.23% had persistent disease (95%CI 55.08-67.38).

CONCLUSIONS

Borderline and mild-definite latent RHD show variable evolution following initial diagnosis. While 8% of mild-definite and 14% borderline cases had signs of disease progression at follow-up, a third of mild-definite and half of borderline cases had disease regression, even with sub adequate antibiotic prophylaxis. The significant variability between study cohorts suggests latent RHD natural history is likely variable between different endemic regions globally. Future research is needed to identify those individuals who would most benefit from antibiotic prophylaxis and determine regional natural history of latent RHD.

Valvular heart disease: from mechanisms to management

Valvular heart disease is common and its prevalence is rapidly increasing worldwide. Effective medical therapies are insufficient and treatment was historically limited to the surgical techniques of valve repair or replacement, resulting in systematic underprovision of care to older patients and those with substantial comorbidities, frailty, or left ventricular dysfunction. Advances in imaging and surgical techniques over the past 20 years have transformed the management of valvular heart disease. Better understanding of the mechanisms and causes of disease and an increasingly extensive and robust evidence base provide a platform for the delivery of individualised treatment by multidisciplinary heart teams working within networks of diagnostic facilities and specialist heart valve centres. In this Series paper, we aim to provide an overview of the current and future management of valvular heart disease and propose treatment approaches based on an understanding of the underlying pathophysiology and the application of multidisciplinary treatment strategies to individual patients.

Combination of Tele-Cardiology Tools for Cardiovascular Risk Stratification in Primary Care: Data from the PROVAR+ Study

BACKGROUND

Tele-cardiology tools are valuable strategies to improve risk stratification.

OBJECTIVE

We aimed to evaluate the accuracy of tele-electrocardiography (ECG) to predict abnormalities in screening echocardiography (echo) in primary care (PC).

METHODS

In 17 months, 6 health providers at 16 PC units were trained on simplified handheld echo protocols. Tele-ECGs were recorded for final diagnosis by a cardiologist. Consented patients with major ECG abnormalities by the Minnesota code, and a 1:5 sample of normal individuals underwent clinical questionnaire and screening echo interpreted remotely. Major heart disease was defined as moderate/severe valve disease, ventricular dysfunction/hypertrophy, pericardial effusion, or wall-motion abnormalities. Association between major ECG and echo abnormalities was assessed by logistic regression as follows: 1) unadjusted model; 2) model 1 adjusted for age/sex; 3) model 2 plus risk factors (hypertension/diabetes); 4) model 3 plus history of cardiovascular disease (Chagas/rheumatic heart disease/ischemic heart disease/stroke/heart failure). P-values < 0.05 were considered significant.

RESULTS

A total 1,411 patients underwent echo; 1,149 (81%) had major ECG abnormalities. Median age was 67 (IQR 60 to 74) years, and 51.4% were male. Major ECG abnormalities were associated with a 2.4-fold chance of major heart disease on echo in bivariate analysis (OR = 2.42 [95% CI 1.76 to 3.39]), and remained significant after adjustments in models (p < 0.001) 2 (OR = 2.57 [95% CI 1.84 to 3.65]), model 3 (OR = 2.52 [95% CI 1.80 to3.58]), and model 4 (OR = 2.23 [95%CI 1.59 to 3.19]). Age, male sex, heart failure, and ischemic heart disease were also independent predictors of major heart disease on echo.

CONCLUSIONS

Tele-ECG abnormalities increased the likelihood of major heart disease on screening echo, even after adjustments for demographic and clinical variables.

Outcomes of latent rheumatic heart disease: External validation of a simplified score in patients with and without secondary prophylaxis

BACKGROUND

Secondary antibiotic prophylaxis reduces progression of latent rheumatic heart disease (RHD) but not all children benefit. Improved risk stratification could refine recommendations following positive screening. We aimed to evaluate the performance of a previously developed echocardiographic risk score to predict mid-term outcomes among children with latent RHD.

METHODS

We included children who completed the GOAL, a randomized trial of secondary antibiotic prophylaxis among children with latent RHD in Uganda. Outcomes were determined by a 4-member adjudication panel. We applied the point-based score, consisting of 5 variables (mitral valve (MV) anterior leaflet thickening (3 points), MV excessive leaflet tip motion (3 points), MV regurgitation jet length ≥ 2 cm (6 points), aortic valve focal thickening (4 points) and any aortic regurgitation (5 points)), to panel results. Unfavorable outcome was defined as progression of diagnostic category (borderline to definite, mild definite to moderate/severe definite), worsening valve involvement or remaining with mild definite RHD.

RESULTS

799 patients (625 borderline and 174 definite RHD) were included, with median follow-up of 24 months. At total 116 patients (14.5%) had unfavorable outcome per study criteria, 57.8% not under prophylaxis. The score was strongly associated with unfavorable outcome (HR = 1.26, 95% CI 1.16-1.37, p < 0.001). Unfavorable outcome rates in low (≤6 points), intermediate (7-9 points) and high-risk (≥10 points) children at follow-up were 11.8%, 30.4%, and 42.2%, (p < 0.001) respectively (C-statistic = 0.64 (95% CI 0.59-0.69)).

CONCLUSIONS

The simple risk score provided an accurate prediction of RHD status at 2-years, showing a good performance in a population with milder RHD phenotypes.

Agreement between Handheld and Standard Echocardiography for Diagnosis of Latent Rheumatic Heart Disease in Brazilian Schoolchildren from High-Prevalence Settings (Agreement between Screening and Standard Echo for RHD)

Introduction: Handheld echocardiography (echo) is the tool of choice for rheumatic heart disease (RHD) screening. We aimed to assess the agreement between screening and standard echo for latent RHD diagnosis in schoolchildren from an endemic setting. Methods: Over 14 months, 3 nonphysicians used handheld machines and the 2012 WHF Criteria to determine RHD prevalence in consented schoolchildren from Brazilian low-income public schools. Studies were interpreted by telemedicine by 3 experts (Brazil, US). RHD-positive children (borderline/definite) and those with congenital heart disease (CHD) were referred for standard echo, acquired and interpreted by a cardiologist. Agreement between screening and standard echo, by WHF subgroups, was assessed. Results: 1390 students were screened in 6 schools, with 110 (7.9%, 95% CI 6.5-9.5) being screen positive (14 ± 2 years, 72% women). Among 16 cases initially diagnosed as definite RHD, 11 (69%) were confirmed, 4 (25%) reclassified to borderline, and 1 to normal. Among 79 cases flagged as borderline RHD, 19 (24%) were confirmed, 50 (63%) reclassified to normal, 8 (10%) reclassified as definite RHD, and 2 had mild CHD. Considering the 4 diagnostic categories, kappa was 0.18. In patients with borderline RHD reclassified to non-RHD, the most frequent WHF criterion was B (isolated mitral regurgitation, 64%), followed by A (2 mitral valve morphological features, 31%). In 1 patient with definite RHD reclassified to normal, the WHF criterion was D (borderline RHD in aortic and mitral valves). After standard echo, RHD prevalence was 3.2% (95% CI 2.3-4.2). Conclusions: Although practical, RHD screening with handheld devices tends to overestimate prevalence.

Detection and management of latent rheumatic heart disease: a narrative review

Rheumatic heart disease (RHD) is a public health concern in many developing nations around the world. Early detection of latent or subclinical RHD can help in reversing mild lesions, retarding disease progression, reducing morbidity and mortality, and improving the quality of life of patients. Echocardiography is the gold-standard method for screening and confirming latent RHD cases. The rates and determinants of progression of latent RHD cases as assessed by echocardiography have been found to be variable through studies. Even though latent RHD has a slow rate of progression, the rate of progression of its subtype, 'definite' RHD, is substantial. A brief training of nonexpert operators on the use of handheld echocardiography with a simplified protocol is an important strategy to scale up the screening program to detect latent cases. Newer advancements in screening, such as deep-learning digital stethoscopes and telehealth services, have provided an opportunity to expand screening programs even in resource-constrained settings. Newer studies have established the efficacy and safety profile of secondary antibiotic prophylaxis in latent RHD. The concerned authorities in endemic regions of the world should work on improving the availability and accessibility of antibiotic prophylaxis.

Rheumatic Heart Disease in the Developing World

Despite recent public policy initiatives, rheumatic heart disease (RHD) remains a major source of morbidity worldwide. Rheumatic heart disease occurs as a sequela of Streptococcus pyogenes (group A streptococcal [GAS]) infection in patients with genetic susceptibility. Strategies for prevention of RHD or progression of RHD include prevention of GAS infection with community initiatives, effective treatment of GAS infection, and secondary prophylaxis with intramuscular penicillin. The cardiac surgical community has attempted to improve the availability of surgery in RHD-endemic areas with some success, and operative techniques and outcomes of valve repair continue to improve, potentially offering patients a safer, more durable operation. Innovation offers hope for a more scalable solution with improved biomaterials and transcatheter delivery technology; however, cost remains a barrier.

Development and validation of a predictive model for the diagnosis of rheumatic heart disease in low-income countries based on two cross-sectional studies

Objectives

We developed a questionnaire-based risk-scoring system to identify children at risk for rheumatic heart disease (RHD) in rural India. The resulting predictive model was validated in Nepal, in a population with a similar demographic profile to rural India.

Methods

The study involved 8646 students (mean age 13.0 years, 46% boys) from 20 middle and high schools in the West Midnapore district of India. The survey asked questions about the presence of different signs and symptoms of RHD. Students with possible RHD who experienced sore throat and joint pain were offered an echocardiogram to screen for RHD. Their findings were compared with randomly selected students without these symptoms. The data were analyzed to develop a predictive model for identifying RHD.

Results

Based on our univariate analyses, seven variables were used for building a predictive model. A four-variable model (joint pain plus sore throat, female sex, shortness of breath, and palpitations) best predicted the risk of RHD with a C-statistic of 0.854. A six-point scoring system developed from the model was validated among similarly aged children in Nepal.

Conclusions

A simple questionnaire-based predictive instrument could identify children at higher risk for this disease in low-income countries where RHD remains prevalent. Echocardiography could then be used in these high-risk children to detect RHD in its early stages. This may support a strategy for more effective secondary prophylaxis of RHD.

Rheumatic heart disease in the heart of Himalayas

Rheumatic heart disease results from the damage to heart valves caused by one or more episodes of rheumatic fever leading to a variety of cardiac complications. Although less common in developed parts of the world, it is one of the most common acquired heart diseases in low- and middle-income countries including Nepal, affecting children and young people. Primary prevention with prompt treatment of streptococcal throat infections and long-term secondary antibiotic prophylaxis with benzathine penicillin G are the key intervention strategies. Echocardiography based screening in schoolchildren has become an effective measure for early identification of the cases. More coordinated policies and effective interventions are needed to successfully decrease the burden of the rheumatic heart disease in resource limited settings like Nepal.

Prevalence of latent structural heart disease in Nepali schoolchildren

BACKGROUND

The present study aimed to quantify the burden of structural heart disease in Nepali children.

METHODS

We performed a school-based cross-sectional echocardiographic screening study with cluster random sampling among children 5-16 years of age.

RESULTS

Between December 2012 and January 2019, 6573 children (mean age 10.6 ± 2.9 years) from 41 randomly selected schools underwent echocardiographic screening. Structural heart disease was detected in 14.0 per 1000 children (95% CI 11.3-17.1) and was congenital in 3.3 per 1000 (95% CI 2.1-5.1) and rheumatic in 10.6 per 1000 (95% CI 8.3-13.4). Rates of rheumatic heart disease were higher among children attending public as compared to private schools (OR 2.8, 95% CI 1.6-5.2, p = 0.0001).

CONCLUSION

Rheumatic heart disease accounted for three out of four cases of structural heart disease and was more common among children attending public as compared to private schools.

Secondary prevention of rheumatic heart disease in Ethiopia: a multicenter study

BACKGROUND

Ethiopia has a high acute rheumatic fever (ARF) and rheumatic heart disease (RHD) prevalence, and to our knowledge, there are no data on the status of secondary prevention in children with RHD. This study describes the status of secondary RHD prevention.

METHODS

A multicenter, prospective study was performed on children aged 5-17 years with RHD in Ethiopia. Good adherence was defined as at least 80% completion of benzathine penicillin (BPG) or oral Amoxicillin within the previous year. The primary outcome measure was adherence to prophylaxis, expressed as a proportion. Socio-demographics, severity of RHD, and ARF recurrence were evaluated.

RESULTS

A total of 337 children with a mean age of 12.9 ± 2.6 years were included. The majority (73%) had severe aortic/mitral disease. Participants were on BPG (80%) or Amoxicillin (20%) prophylaxis. Female sex (P = 0.04) use of BPG (0.03) and shorter mean duration of prophylaxis in months (48.5 ± 31.5 vs. 60.7 ± 33, respectively, P < 0.008) predicted good adherence. Running out of medications (35%), interrupted follow-up (27%), and the COVID-19 pandemic (26%) were the most common reasons for missing prophylaxis. Recurrence of ARF was higher in participants on Amoxicillin compared with BPG (40% vs. 16%, P < 0.001) and in those with poor adherence compared with good adherence (36.8% vs. 17.9%, respectively, P = 0.005). Type and duration of prophylaxis (OR 0.5, CI = 0.24, 0.9, P = 0.02; OR = 1.1, CI = 1.1, 1.2, P = 0.04, respectively), and sex (OR = 1.9, CI = 1.1, 3.4, P = 0.03) were independent predictors of poor adherence.

CONCLUSION

Poor adherence is prevalent in Ethiopian children living with RHD. Amoxicillin is a suboptimal option for prophylaxis as its use is associated with lower adherence and a higher rate of ARF recurrence.

Investigation of the Familial Risk of Rheumatic Heart Disease with Systematic Echocardiographic Screening: Data from the PROVAR+ Family Study

We aimed to use echocardiographic (echo) screening to evaluate the risk of Rheumatic Heart Disease (RHD) among the relatives of patients with advanced RHD, who were enrolled in the University Hospital’s outpatient clinics from February 2020 to September 2021. Consenting first-degree relatives were invited for echo screening using handheld devices (GE VSCAN) by non-physicians, with remote interpretation. Matched controls (spouses, neighbors) living in the same household were enrolled in a 1:5 fashion. A standard echo (GE Vivid-IQ) was scheduled if abnormalities were observed. In 16 months, 226 relatives and 47 controls of 121 patients were screened, including 129 children, 77 siblings and 20 parents. The mean age was 40 ± 17 years, 67% of the patients were women, and 239 (88%) lived with the index case for >10 years. Echo findings suggestive of RHD were confirmed in zero controls and 14 (7.5%) relatives (p = 0.05): 11 patients had mild/moderate mitral regurgitation, and four were associated with mitral stenosis and abnormal morphology. Two patients had mild aortic regurgitation and abnormal morphology, which were associated with mild aortic and mitral stenosis, and two patients with advanced RHD had bioprostheses in the mitral (2) and aortic (1) positions. In conclusion, first-degree relatives of individuals with clinical RHD are at greater risk of having RHD, on top of socioeconomic conditions.

Saving time saves lives! A time focused evaluation of a single-view echocardiographic screening protocol for subclinical rheumatic heart disease

BACKGROUND

Rheumatic heart disease affects 33 million people in low and middle income countries and is the leading cause of cardiovascular death among children and young adults. Evidence increasingly supports that simplified screening protocols can identify at risk children with good accuracy. One of the more proximal and pragmatic hurdles that has not been completely explored is the time required for executing the screening exam.

METHODS

We conducted an observational study comparing three different echocardiographic strategies in four separate school-based screening programs in Kenya and Cameroon.

RESULTS

In a sample of 911 children, we found that a single-view screening strategy can be obtained in an average time of 1.2 min/child, the two-view in an average of 2.1 min/child, and multi-view in an average of 5 min/child.

CONCLUSIONS

Our study demonstrates that there are significant differences in the time required to execute different screening protocols and is an essential consideration in the feasibility of large scale populations based rheumatic heart disease screening programs.

The Global Impact of Rheumatic Heart Disease

PURPOSE OF REVIEW

Rheumatic heart disease (RHD) is a neglected disease of poverty, which presents challenges for patients, communities, and health systems. These effects are magnified in low resource countries, which bear the highest disease burden. When considering the impact of RHD, it is imperative that we widen our lens in order to better understand how RHD impacts the over 40 million people currently living with this preventable condition and their communities. We aimed to perform an updated literature review on the global impact of RHD, examining a broad range of aspects from disease burden to impact on healthcare system to socioeconomic implications.

RECENT FINDINGS

RHD accounts for 1.6% of all cardiovascular deaths, resulting in 306,000 deaths yearly, with a much higher contribution in low- and middle-income countries, where 82% of the deaths occurred in 2015. RHD can result in severe health adverse outcomes, markedly heart failure, arrhythmias, stroke and embolisms, and ultimately premature death. Thus, preventive, diagnostic and therapeutic interventions are required, although insufficiently available in undersourced settings. As examples, anticoagulation management is poor in endemic regions - and novel oral anticoagulants cannot be recommended - and less than 15% of those in need have access to interventional procedures and valve replacement in Africa. RHD global impact remains high and unequally distributed, with a marked impact on lower resourced populations. This preventable disease negatively affects not only patients, but also the societies and health systems within which they live, presenting broad challenges and high costs along the pathway of prevention, diagnosis, and management.

Persisting burden and challenges of rheumatic heart disease

Rheumatic heart disease (RHD) is the result of episodes of acute rheumatic fever with valvular (and other cardiac) damage caused by an abnormal immune response to group A streptococcal infections, usually during childhood and adolescence. As a result of improved living conditions and the introduction of penicillin, RHD was almost eradicated in the developed world by the 1980s. However, being a disease of poverty, its burden remains disproportionately high in the developing world, despite being a fundamentally preventable disease. Rheumatic heart disease generates relatively little attention from the medical and science communities, in contrast to other common infectious problems (such as malaria, HIV, tuberculosis), despite the major cardiovascular morbidity/mortality burden imposed by RHD. This relative neglect and paucity of funding have probably contributed to limited fundamental medical advances in this field for over 50 years. Given the importance of prevention before the onset of major valvular damage, the main challenges for RHD prevention are improving social circumstances, early diagnosis, and effective delivery of antibiotic prophylaxis. Early identification through ultrasound of silent, subclinical rheumatic valve lesions could provide an opportunity for early intervention. Simple echocardiographic diagnostic criteria and appropriately trained personnel can be valuable aids in large-scale public health efforts. In addition, a better understanding of the immunogenic determinants of the disease may provide potential routes to vaccine development and other novel therapies.

Mid-term outcome of children with latent rheumatic heart disease in eastern Nepal

Introduction

Systematic echocardiographic screening of children in regions with an endemic pattern of rheumatic heart disease allows for the early detection of valvular lesions suggestive of subclinical rheumatic heart disease. The natural course of latent rheumatic heart disease is, however, incompletely understood at this time.

Methods

We performed a prospective cohort study of children detected to have echocardiographic evidence of definite or borderline rheumatic heart disease according to the World Heart Federation Criteria.

Results

Among 53 children found to have definite (36) or borderline (17) rheumatic heart disease, 44 (83%) children underwent follow-up at a median of 1.9 years (IQR 1.1–4.5). The median age of the children was 11 years (IQR 9–14) and 34 (64.2%) were girls. Among children with definite rheumatic heart disease, 21 (58.3%) were adherent to secondary antibiotic prophylaxis, 7 (19.4%) were not, information on adherence was missing in 2 (5.6%) children and 6 (16.7%) were lost to follow-up. Regression of disease was observed in 10 children (27.8%), whereas 20 children (55.6%) had stable disease. Among children adherent to secondary prophylaxis, seven (33.3%) showed regression of disease. Among children with borderline disease, seven (41.2%) showed regression of disease, three (17.6%) progression of disease, four (23.5%) remained stable and three (17.6%) were lost to follow-up. On univariate analysis, we identified no predictors of disease regression, and no predictors for lost to follow-up or non-adherence with secondary antibiotic prophylaxis.

Conclusion

Definite rheumatic heart disease showed regression in one in four children. Borderline disease was spontaneously reversible in less than half of the children and progressed to definite rheumatic heart disease in one in five children.

Trial registration number

NCT01550068.