Reversibility of mitral regurgitation following rheumatic fever: clinical profile and echocardiographic evaluation

Standardization of Epidemiological Surveillance of Acute Rheumatic Fever

Acute rheumatic fever (ARF) is a multiorgan inflammatory disorder that results from the body’s autoimmune response to pharyngitis or a skin infection caused by Streptococcus pyogenes (Strep A). Acute rheumatic fever mainly affects those in low- and middle-income nations, as well as in indigenous populations in wealthy nations, where initial Strep A infections may go undetected. A single episode of ARF puts a person at increased risk of developing long-term cardiac damage known as rheumatic heart disease. We present case definitions for both definite and possible ARF, including initial and recurrent episodes, according to the 2015 Jones Criteria, and we discuss current tests available to aid in the diagnosis.

We outline the considerations specific to ARF surveillance methodology, including discussion on where and how to conduct active or passive surveillance (eg, early childhood centers/schools, households, primary healthcare, administrative database review), participant eligibility, and the surveillance population. Additional considerations for ARF surveillance, including implications for secondary prophylaxis and follow-up, ARF registers, community engagement, and the impact of surveillance, are addressed. Finally, the core elements of case report forms for ARF, monitoring and audit requirements, quality control and assurance, and the ethics of conducting surveillance are discussed.

Rheumatic Myocarditis: A Poorly Recognized Etiology of Left Ventricular Dysfunction in Valvular Heart Disease Patients

Background: Heart failure occurs in ~10% of patients with acute rheumatic fever (RF), and several studies have shown that cardiac decompensation in RF results primarily from valvular disease and is not due to primary myocarditis. However, the literature on this topic is scarce, and a recent case series has shown that recurrent RF can cause ventricular dysfunction even in the absence of valvular heart disease. Methods: The present study evaluated the clinical, laboratory and imaging characteristics of 25 consecutive patients with a clinical diagnosis of myocarditis confirmed by 18F-FDG PET/CT or gallium-67 cardiac scintigraphy and RF reactivation according to the revised Jones Criteria. Patients underwent three sequential echocardiograms at (1) baseline, (2) during myocarditis and (3) post corticosteroid treatment. Patients were divided according to the presence (Group 1) or absence (Group 2) of reduced left ventricular ejection fraction (LVEF) during myocarditis episodes. Results: The median age was 42 (17-51) years, 64% of patients were older than 40 years, and 64% were women. Between Group 1 (n = 16) and in Group 2 (n = 9), there were no demographic, echocardiographic or laboratory differences except for NYHA III/IV heart failure (Group 1: 100.0% vs. Group 2: 50.0%; p = 0.012) and LVEF (30 [25-37] vs. 56 [49-62]%, respectively; p < 0.001), as expected. Group 1 patients showed a significant reduction in LVEF during carditis with further improvement after treatment. There was no correlation between LVEF and valvular dysfunction during myocarditis. Among all patients, 19 (76%) underwent 18F-FDG PET/CT, with a positive scan in 68.4%, and 21 (84%) underwent gallium-67 cardiac scintigraphy, with positive uptake in 95.2%, there was no difference between these groups. Conclusion: Myocarditis due to rheumatic fever reactivation can cause left ventricular dysfunction despite valvular disease, and it is reversible after corticosteroid treatment.

Inter-rater and intra-rater reliability and agreement of echocardiographic diagnosis of rheumatic heart disease using the World Heart Federation evidence-based criteria

OBJECTIVE

Different definitions have been used for screening for rheumatic heart disease (RHD). This led to the development of the 2012 evidence-based World Heart Federation (WHF) echocardiographic criteria. The objective of this study is to determine the intra-rater and inter-rater reliability and agreement in differentiating no RHD from mild RHD using the WHF echocardiographic criteria.

METHODS

A standard set of 200 echocardiograms was collated from prior population-based surveys and uploaded for blinded web-based reporting. Fifteen international cardiologists reported on and categorised each echocardiogram as no RHD, borderline or definite RHD. Intra-rater and inter-rater reliability was calculated using Cohen's and Fleiss' free-marginal multirater kappa (κ) statistics, respectively. Agreement assessment was expressed as percentages. Subanalyses assessed reproducibility and agreement parameters in detecting individual components of WHF criteria.

RESULTS

Sample size from a statistical standpoint was 3000, based on repeated reporting of the 200 studies. The inter-rater and intra-rater reliability of diagnosing definite RHD was substantial with a kappa of 0.65 and 0.69, respectively. The diagnosis of pathological mitral and aortic regurgitation was reliable and almost perfect, kappa of 0.79 and 0.86, respectively. Agreement for morphological changes of RHD was variable ranging from 0.54 to 0.93 κ.

CONCLUSIONS

The WHF echocardiographic criteria enable reproducible categorisation of echocardiograms as definite RHD versus no or borderline RHD and hence it would be a suitable tool for screening and monitoring disease progression. The study highlights the strengths and limitations of the WHF echo criteria and provides a platform for future revisions.

A rapid echocardiographic screening protocol for rheumatic heart disease in Samoa: a high prevalence of advanced disease

BACKGROUND

Echocardiography has been proposed as a method to screen children for rheumatic heart disease. The World Heart Federation has established guidelines for echocardiographic screening. In this study, we describe a rapid echocardiogram screening protocol according to the World Heart Federation guidelines in Samoa, endemic for rheumatic heart disease.

METHODS

We performed echocardiogram screening in schoolchildren in Samoa between 2013 and 2015. A brief screening echocardiogram was performed on all students. Children with predefined criteria suspicious for rheumatic hear diseases were referred for a more comprehensive echocardiogram. Complete echocardiograms were classified according to the World Heart Federation guidelines and severity of valve disease.

RESULTS

Echocardiographic screening was performed on 11,434 children, with a mean age of 10.2 years; 51% of them were females. A total of 558 (4.8%) children underwent comprehensive echocardiography, including 49 students who were randomly selected as controls. Definite rheumatic heart disease was observed in 115 students (10.0 per 1000): 92 students were classified as borderline (8.0 per 1000) and 23 with CHD. Advanced disease was identified in 50 students (4.4 per 1000): 15 with severe mitral regurgitation, five with severe aortic regurgitation, 11 with mitral stenoses, and 19 with mitral and aortic valve disease.

CONCLUSIONS

We successfully applied a rapid echocardiographic screening protocol to a large number of students over a short time period - 28 days of screening over a 3-year time period - to identify a high prevalence of rheumatic heart disease. We also reported a significantly higher rate of advanced disease compared with previously published echocardiographic screening programmes.

A Short History of Cardiac Inspection: A Quest "To See with a Better Eye"

Cardiac examination has evolved over centuries. The goal of cardiac evaluation, regardless the era, is to "see" inside the heart to diagnose congenital and acquired intra-cardiac structural and functional abnormalities. This article briefly reviews the history of cardiac examination and discusses contemporary best, evidence-based methods of cardiac inspection.

Rheumatic Fever prevention program: long-term evolution and outcomes

This investigation aims to analyze the profile of long-term evolution of rheumatic fever in children and adolescents and outcomes after the control of recurrences. The cohort involved 702 patients followed from 1.3 to 16.9 years covering the two periods, before and after the implementation of a prevention program. Besides the establishment of the Reference Center in the State of Minas Gerais and the implementation of strategies to promote the compliance to prophylaxis, a project for education of health professionals was carried out in 23 cities. In addition to the clinical and epidemiological profile, the severity of the disease was analyzed. Mixed lesions were found in 27.1%, valvar regurgitation in 72.9%, and complete regression of the valvar lesions was seen in 34.4% of the patients, mostly presenting mild dysfunctions. The recurrence rate per patient-year was 0.058 and out of a total of 85 recurrences, 21.4% occurred in the first and 7.5% in the second period. More severe degrees of carditis and significant valvar sequels presented a higher prevalence in patients with recurrences. The comparative analysis between the two periods showed no changes regarding the age at the primary attack, gender, type, and site of valvar lesions and affected joints; however, important modifications in the indices of severity were observed after the control of recurrences. A significant decrease in the prevalence of severe carditis, obstructive valvar sequels, hospital admissions, surgical approach, and deaths was seen. This investigation showed that although the clinical profile of presentation remains unchanged, the control of repeated attacks can improve the morbimortality rates. In this context, the secondary prophylaxis should be the first priority in the control of the disease in developing countries, taking into account the difficulties found for effective primordial and primary prevention.

Increasing detection of rheumatic heart disease with echocardiography

Rheumatic heart disease (RHD) is estimated to affect over 20 million people worldwide, the vast majority being in developing countries. Screening for RHD has been recommended by the WHO since 2004. Conventionally, auscultation has been used for diagnosing RHD. Auscultation has its limitation and may not detect mild cases. A large number of studies have reported echocardiographic screening for RHD over the last several years. Most of these studies report an almost 10-fold higher prevalence of RHD by echocardiography as compared to conventional method of auscultation. Early diagnosis of such mild cases may be important as instituting secondary prophylaxis in such cases may reduce the burden of the disease. However, several concerns remain about the significance and natural history of these minor valvular changes detected by echocardiography. Whether secondary prophylaxis will reverse these abnormalities is also unclear. Long term follow up studies are required to answer some of these concerns.

World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease--an evidence-based guideline

Over the past 5 years, the advent of echocardiographic screening for rheumatic heart disease (RHD) has revealed a higher RHD burden than previously thought. In light of this global experience, the development of new international echocardiographic guidelines that address the full spectrum of the rheumatic disease process is opportune. Systematic differences in the reporting of and diagnostic approach to RHD exist, reflecting differences in local experience and disease patterns. The World Heart Federation echocardiographic criteria for RHD have, therefore, been developed and are formulated on the basis of the best available evidence. Three categories are defined on the basis of assessment by 2D, continuous-wave, and color-Doppler echocardiography: 'definite RHD', 'borderline RHD', and 'normal'. Four subcategories of 'definite RHD' and three subcategories of 'borderline RHD' exist, to reflect the various disease patterns. The morphological features of RHD and the criteria for pathological mitral and aortic regurgitation are also defined. The criteria are modified for those aged over 20 years on the basis of the available evidence. The standardized criteria aim to permit rapid and consistent identification of individuals with RHD without a clear history of acute rheumatic fever and hence allow enrollment into secondary prophylaxis programs. However, important unanswered questions remain about the importance of subclinical disease (borderline or definite RHD on echocardiography without a clinical pathological murmur), and about the practicalities of implementing screening programs. These standardized criteria will help enable new studies to be designed to evaluate the role of echocardiographic screening in RHD control.

What is the true frequency of carditis in acute rheumatic fever? A prospective clinical and Doppler blind study of 56 children with up to 60 months of follow-up evaluation

BACKGROUND

This study aimed to evaluate prospectively clinical and echocardiographic findings of patients who had rheumatic fever with and without clinical features of cardiac involvement.

METHODS

For this study, 56 consecutive patients (mean age, 11.4 years) with acute rheumatic fever diagnosed according to the 1992 modified Jones criteria were evaluated at diagnosis, after 3 and 6 months, then at 2 and 5 years. All assessments were performed blindly and included physical and cardiac examination, electrocardiogram, chest X-ray, and two-dimensional color-flow Doppler echocardiography.

RESULTS

Initial clinical carditis was observed for 27 patients (48.2%), all of whom had positive echocardiographic abnormalities. Echocardiographic abnormalities were observed in 11 patients who had arthritis or chorea presentation without initial clinical carditis. Persistence of the abnormalities was observed at a late follow-up evaluation in 72.7% of the cases. Sydenham's chorea was present in 8 patients with clinical carditis and in 10 without this disorder, 8 of whom had echocardiographic abnormalities.

CONCLUSION

Patients who had acute rheumatic fever without clinical signs of carditis showed acute and late follow-up echocardiographic abnormalities suggestive of cardiac involvement. Clinicians should be attentive for the presence of cardiac involvement among patients with chorea.

Rheumatic fever and rheumatic heart disease: clinical profile of 550 cases in India

BACKGROUND

The aims and objectives of this paper were to analyze the clinical presentation of children with rheumatic fever (RF) and rheumatic heart disease (RHD), to determine the cardiac sequel of RF and valvular affection due to RF, and to study clinical manifestations in recurrences of RF.

METHODS

Our study, a retrospective analysis, was conducted at a tertiary-care teaching hospital with specialty follow-up clinic for patients with RF/RHD. This retrospective study was conducted to include a period of 31 years (from January 1971 through December 2001). Pre-completed case protocols of patients with RF/RHD were analyzed to record the following information: demographic data; clinical features on admission/presentation; relevant investigations; recurrences; cardiac valvular affection, and outcome. Modified Jones' criteria were used for diagnosis of RF.

RESULTS

The study included 550 patients. Mean age of presentation was 9.62 years and sex ratio was 1.15:1 favoring males. A total of 250 patients presented with initial/first attack of RF. Arthritis and carditis were seen in 169 (67.6%) and 105 cases (42%), respectively. Chorea was seen in 47 cases (18.8%) and erythema marginatum, in four. A total of 224 patients presented with recurrence of RF (with pre-existing RHD). Arthritis and carditis were seen in 109 (48.66%) and 178 cases (79.46%), respectively, in these patients; 76 cases presented with chronic RHD. Mitral regurgitation was the most common cardiac valvular lesion observed (150 cases) followed by a combination of mitral stenosis and mitral regurgitation (98 cases). Congestive cardiac failure was seen in 201 cases (36.54%) and infective endocarditis in 30 (5.45%). 2-D echocardiography and/or color Doppler was performed in 201 patients (36.54%). Average duration of follow-up was 3.19 years; 74.72% of cases were lost to follow-up. Benzathine penicillin prophylaxis was regular in 42.18% cases. Positive family history of RF/RHD was present in 2% of cases. Twenty three patients (4.18%) died.

CONCLUSIONS

Arthritis was the most common manifestation in the initial attack of RF, while carditis was the most common manifestation in patients presenting with rheumatic recurrences (with pre-existing RHD) and mitral regurgitation was the most common valvular lesion. Rate of patient dropout from penicillin prophylaxis was high. Clinical manifestations in initial/first attack of RF have not significantly changed in the last 31 years.