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Williamson J, Remenyi B, Francis J, Morris P, Whalley G. Echocardiographic Screening for Rheumatic Heart Disease: A Brief History and Implications for the Future. Heart Lung Circ 2024; 33:943-950. [PMID: 38670880 DOI: 10.1016/j.hlc.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 02/05/2024] [Accepted: 02/26/2024] [Indexed: 04/28/2024]
Abstract
Transthoracic echocardiography is the gold standard for early detection of rheumatic heart disease (RHD) in asymptomatic children living in high-risk regions. Advances in technology allowing miniaturisation and increased portability of echocardiography devices have improved the accessibility of this vital diagnostic tool in RHD-endemic locations. Automation of image optimisation techniques and simplified RHD screening protocols permit use by non-experts after a brief period of training. While these changes are welcome advances in the battle to manage RHD, it is important that the sensitivity and specificity of RHD detection be maintained by all echocardiography users on any device to ensure accurate and timely diagnosis of RHD to facilitate initiation of appropriate therapy. This review of the evolution of echocardiography and its use in the detection of rheumatic valve disease may serve as a reminder of the key strengths and potential pitfalls of this increasingly relied-upon diagnostic test.
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Affiliation(s)
- Jacqueline Williamson
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; NT Cardiac, Darwin, NT, Australia.
| | - Bo Remenyi
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; NT Cardiac, Darwin, NT, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Joshua Francis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Peter Morris
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Gillian Whalley
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Ali Sulafa KM, Karrar ZA, Elkurdufani N, Ibrahim N. Sudan's rheumatic fever and rheumatic heart disease guidelines: a simplified approach in an endemic country. Front Cardiovasc Med 2024; 11:1403131. [PMID: 38798925 PMCID: PMC11116708 DOI: 10.3389/fcvm.2024.1403131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/10/2024] [Indexed: 05/29/2024] Open
Abstract
Background Rheumatic heart disease (RHD) is a preventable sequelae of group A beta hemolytic streptococcal infection leading to an immune reaction: acute rheumatic fever (ARF) and progressive heart valve dysfunction. RHD is the leading cause of acquired heart disease in children and young adults in Sudan and many low/middle-income countries. In 2018, the World Health Organization (WHO) issued a resolution for RHD mandating that each country adopt updated guidelines for ARF and RHD management. These current guidelines are mainly directed to primary healthcare workers. Methods Sudan's Federal Ministry of Health (FMOH) in collaboration with the WHO East Mediterranean Regional Office (EMRO) assembled a committee for updating RHD guidelines. We conducted a systematic literature search from 2000 to 2022 in National Institute of Health Database (PubMed) under the following titles: streptococcal pharyngitis, acute rheumatic fever, rheumatic heart disease, benzathine penicillin. Best available, evidence-based practices for diagnosis and management of ARF/RHD were selected and adapted to Sudan's situation. The guidelines were critically appraised by the committee then endorsed to the FMOH and WHO EMRO Noncommunicable Disease Departments in January 2023. This paper describes the updated guidelines. Results Simplified algorithms are provided for diagnosis of bacterial pharyngitis including two clinical criteria: sore throat and the absence of viral symptoms in the target age group. A simplified algorithm for diagnosis and management of ARF is adopted using two levels of diagnosis: suspected case at primary level where penicillin prophylaxis is started and secondary/tertiary care where echocardiography is performed and diagnosis confirmed or excluded. Echocardiography screening is recognized as the standard method for early diagnosis of RHD; however, due to the anticipated limitations, its implementation was not adopted at this time. Streptococcal skin infection is included as a precursor of ARF and a detailed protocol for benzathine penicillin administration is described. Conclusion The Sudan guidelines for ARF/RHD management were updated. Endorsement of these guidelines to FMOH and WHO EMRO is expected to improve control of RHD in the region.
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Affiliation(s)
| | | | | | - Nazik Ibrahim
- Federal Ministry of Health and World Health Organization, Khartoum, Sudan
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Rwebembera J, Marangou J, Mwita JC, Mocumbi AO, Mota C, Okello E, Nascimento B, Thorup L, Beaton A, Kado J, Kaethner A, Kumar RK, Lawrenson J, Marijon E, Mirabel M, Nunes MCP, Piñeiro D, Pinto F, Ralston K, Sable C, Sanyahumbi A, Saxena A, Sliwa K, Steer A, Viali S, Wheaton G, Wilson N, Zühlke L, Reményi B. 2023 World Heart Federation guidelines for the echocardiographic diagnosis of rheumatic heart disease. Nat Rev Cardiol 2024; 21:250-263. [PMID: 37914787 DOI: 10.1038/s41569-023-00940-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 11/03/2023]
Abstract
Rheumatic heart disease (RHD) is an important and preventable cause of morbidity and mortality among children and young adults in low-income and middle-income countries, as well as among certain at-risk populations living in high-income countries. The 2012 World Heart Federation echocardiographic criteria provided a standardized approach for the identification of RHD and facilitated an improvement in early case detection. The 2012 criteria were used to define disease burden in numerous epidemiological studies, but researchers and clinicians have since highlighted limitations that have prompted a revision. In this updated version of the guidelines, we incorporate evidence from a scoping review, an expert panel and end-user feedback and present an approach for active case finding for RHD, including the use of screening and confirmatory criteria. These guidelines also introduce a new stage-based classification for RHD to identify the risk of disease progression. They describe the latest evidence and recommendations on population-based echocardiographic active case finding and risk stratification. Secondary antibiotic prophylaxis, echocardiography equipment and task sharing for RHD active case finding are also discussed. These World Heart Federation 2023 guidelines provide a concise and updated resource for clinical and research applications in RHD-endemic regions.
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Affiliation(s)
| | - James Marangou
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Julius Chacha Mwita
- Department of Internal Medicine, University of Botswana and Princess Marina Hospital, Gaborone, Botswana
| | | | - Cleonice Mota
- Departamento de Paediatria, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo, Horizonte, Brazil
- Divisão de Cardiologia Pediátrica e Fetal/Serviço de Cardiologia e Cirurgia Cardiovascular e Serviço de Paediatria, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo, Horizonte, Brazil
| | - Emmy Okello
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Bruno Nascimento
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo, Horizonte, Brazil
- Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo, Horizonte, Brazil
| | - Lene Thorup
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andrea Beaton
- Department of Paediatrics, School of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Joseph Kado
- Wesfarmers Centre of Vaccine and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Alexander Kaethner
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- NT Cardiac, Darwin, Northern Territory, Australia
| | | | - John Lawrenson
- Paediatric Cardiology Service of the Western Cape, Red Cross War Memorial Children's Hospital and Tygerberg Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, Paris, France
| | | | - Maria Carmo Pereira Nunes
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo, Horizonte, Brazil
- Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo, Horizonte, Brazil
| | - Daniel Piñeiro
- Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Fausto Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, The Cardiovascular Centre of the University of Lisbon, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Amy Sanyahumbi
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Anita Saxena
- Pt BD Sharma University of Health Sciences, Rohtak, India
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrew Steer
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | | | - Gavin Wheaton
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Starship Hospital, Te Whatu Ora, Auckland, New Zealand
| | - Liesl Zühlke
- South African Medical Research Council, Extramural Research & Internal Portfolio, Cape Town, South Africa
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Bo Reményi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- NT Cardiac, Darwin, Northern Territory, Australia
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
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Brown K, Roshanitabrizi P, Rwebembera J, Okello E, Beaton A, Linguraru MG, Sable CA. Using Artificial Intelligence for Rheumatic Heart Disease Detection by Echocardiography: Focus on Mitral Regurgitation. J Am Heart Assoc 2024; 13:e031257. [PMID: 38226515 PMCID: PMC10926790 DOI: 10.1161/jaha.123.031257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/18/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Identification of children with latent rheumatic heart disease (RHD) by echocardiography, before onset of symptoms, provides an opportunity to initiate secondary prophylaxis and prevent disease progression. There have been limited artificial intelligence studies published assessing the potential of machine learning to detect and analyze mitral regurgitation or to detect the presence of RHD on standard portable echocardiograms. METHODS AND RESULTS We used 511 echocardiograms in children, focusing on color Doppler images of the mitral valve. Echocardiograms were independently reviewed by an expert adjudication panel. Among 511 cases, 229 were normal, and 282 had RHD. Our automated method included harmonization of echocardiograms to localize the left atrium during systole using convolutional neural networks and RHD detection using mitral regurgitation jet analysis and deep learning models with an attention mechanism. We identified the correct view with an average accuracy of 0.99 and the correct systolic frame with an average accuracy of 0.94 (apical) and 0.93 (parasternal long axis). It localized the left atrium with an average Dice coefficient of 0.88 (apical) and 0.9 (parasternal long axis). Maximum mitral regurgitation jet measurements were similar to expert manual measurements (P value=0.83) and a 9-feature mitral regurgitation analysis showed an area under the receiver operating characteristics curve of 0.93, precision of 0.83, recall of 0.92, and F1 score of 0.87. Our deep learning model showed an area under the receiver operating characteristics curve of 0.84, precision of 0.78, recall of 0.98, and F1 score of 0.87. CONCLUSIONS Artificial intelligence has the potential to detect RHD as accurately as expert cardiologists and to improve with more data. These innovative approaches hold promise to scale echocardiography screening for RHD.
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Affiliation(s)
- Kelsey Brown
- Department of Pediatric CardiologyChildren’s National HospitalWashingtonDCUSA
| | - Pooneh Roshanitabrizi
- Sheikh Zayed Institute for Pediatric Surgical InnovationChildren’s National HospitalWashingtonDCUSA
| | | | | | - Andrea Beaton
- Department of Pediatric CardiologyCincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Marius George Linguraru
- Sheikh Zayed Institute for Pediatric Surgical InnovationChildren’s National HospitalWashingtonDCUSA
- Departments of Radiology and Pediatrics, School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDCUSA
| | - Craig A. Sable
- Department of Pediatric CardiologyChildren’s National HospitalWashingtonDCUSA
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Lamichhane P, Patel F, Al Mefleh R, Mohamed Gasimelseed SY, Ala A, Gawad G, Soni S. Detection and management of latent rheumatic heart disease: a narrative review. Ann Med Surg (Lond) 2023; 85:6048-6056. [PMID: 38098553 PMCID: PMC10718380 DOI: 10.1097/ms9.0000000000001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/08/2023] [Indexed: 12/17/2023] Open
Abstract
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.
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Affiliation(s)
| | - Fiuna Patel
- American University of Barbados School of Medicine, Wildey, Barbados
| | - Renad Al Mefleh
- Department of Pediatrics, Jordanian Royal Medical Services, Amman, Jordan
| | | | - Abdul Ala
- Faculty of Pharmacy, University of Tripoli, Tripoli, Libya
| | - Gamal Gawad
- Saba University School of Medicine, Saba, Dutch Caribbean
| | - Siddharath Soni
- Department of General Medicine, Shree Narayan Medical Institute and Hospital, Saharsa, Bihar Bihar, India
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Regmi PR, Adhikaree A, Bhattarai U, Chhetri S, Shakya U, Uranw S, Lamichhane P, Sharma SK. Rheumatic heart disease in school-attending Nepalese children: A descriptive analysis of the national heart screening database. Indian Heart J 2023; 75:363-369. [PMID: 37495016 PMCID: PMC10568058 DOI: 10.1016/j.ihj.2023.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/22/2023] [Accepted: 07/18/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVE Rheumatic Heart Disease (RHD) remains a significant public health problem with high morbidity and mortality in children and young adults from lower-middle income countries like Nepal. However, a nation-wide database of the disease is lacking for designing effective future prevention and control programmes and strategies. The aim of our study is to estimate the prevalence of RHD in school-attending Nepalese children. METHODS We performed a cross-sectional descriptive analysis of a nationally representative database of Nepal Heart Foundation (NHF) national RHD screening programme which included school-attending Nepalese children between five and sixteen years of age. The screening was conducted between May 2015 and March 2020 in 236 schools, representing all seven provinces, across all three ecological zones of Nepal. Transthoracic two-dimensional echocardiography was performed in all eligible children with more than grade one murmur on cardiac auscultation. We estimated the prevalence of RHD among school-attending children as the number of RHD cases per 1000 school-attending children with a 95% confidence interval. RESULTS The database included a total of 107,340 children who were screened clinically, of whom 10,600 (9·9%) underwent transthoracic two-dimensional echocardiography. The overall prevalence of RHD was 2.22 cases per 1000 school-attending children (95% CI:1·94 - 2·50). The highest prevalence was observed among children living in the southern Terai ecological zone (2·89 per 1000, 95% CI (2·32-3·46)) of Nepal. Among the provinces, Karnali had the highest prevalence of RHD (3·45 per 1000, 95% CI (2·42-4·48)). Among the districts screened, Kalikot had the highest RHD prevalence (5.47 per 1000, 95% CI (3.02-7.92)). CONCLUSION Primordial, primary and secondary prevention programmes should pay special attention to southern Terai zone, particularly the under-privileged children from remote districts.
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Affiliation(s)
- Prakash Raj Regmi
- National Academy of Medical Sciences, Kathmandu, Nepal; Nepal Heart Foundation, Kathmandu, Nepal.
| | | | - Urza Bhattarai
- B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Sunit Chhetri
- B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Urmila Shakya
- Shahid Gangalal National Heart Center, Kathmandu, Nepal.
| | - Surendra Uranw
- B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
| | - Pratik Lamichhane
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal.
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Peck D, Rwebembera J, Nakagaayi D, Minja NW, Ollberding NJ, Pulle J, Klein J, Adams D, Martin R, Koepsell K, Sanyahumbi A, Beaton A, Okello E, Sable C. The Use of Artificial Intelligence Guidance for Rheumatic Heart Disease Screening by Novices. J Am Soc Echocardiogr 2023; 36:724-732. [PMID: 36906047 DOI: 10.1016/j.echo.2023.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/11/2023]
Abstract
INTRODUCTION A novel technology utilizing artificial intelligence (AI) to provide real-time image-acquisition guidance, enabling novices to obtain diagnostic echocardiographic images, holds promise to expand the reach of echo screening for rheumatic heart disease (RHD). We evaluated the ability of nonexperts to obtain diagnostic-quality images in patients with RHD using AI guidance with color Doppler. METHODS Novice providers without prior ultrasound experience underwent a 1-day training curriculum to complete a 7-view screening protocol using AI guidance in Kampala, Uganda. All trainees then scanned 8 to 10 volunteer patients using AI guidance, half RHD and half normal. The same patients were scanned by 2 expert sonographers without the use of AI guidance. Images were evaluated by expert blinded cardiologists to assess (1) diagnostic quality to determine presence/absence of RHD and (2) valvular function and (3) to assign an American College of Emergency Physicians score of 1 to 5 for each view. RESULTS Thirty-six novice participants scanned a total of 50 patients, resulting in a total of 462 echocardiogram studies, 362 obtained by nonexperts using AI guidance and 100 obtained by expert sonographers without AI guidance. Novice images enabled diagnostic interpretation in >90% of studies for presence/absence of RHD, abnormal MV morphology, and mitral regurgitation (vs 99% by experts, P ≤ .001). Images were less diagnostic for aortic valve disease (79% for aortic regurgitation, 50% for aortic stenosis, vs 99% and 91% by experts, P < .001). The American College of Emergency Physicians scores of nonexpert images were highest in the parasternal long-axis images (mean, 3.45; 81% ≥ 3) compared with lower scores for apical 4-chamber (mean, 3.20; 74% ≥ 3) and apical 5-chamber images (mean, 2.43; 38% ≥ 3). CONCLUSIONS Artificial intelligence guidance with color Doppler is feasible to enable RHD screening by nonexperts, performing significantly better for assessment of the mitral than aortic valve. Further refinement is needed to optimize acquisition of color Doppler apical views.
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Affiliation(s)
- Daniel Peck
- University of Minnesota, Minneapolis, Minnesota.
| | | | - Doreen Nakagaayi
- Uganda Heart Institute, Kampala, Uganda; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Neema W Minja
- Uganda Heart Institute, Kampala, Uganda; Department of Global Health, University of Washington, Seattle, Washington; Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Jennifer Klein
- Children's National Hospital, Washington, District of Columbia
| | | | | | | | - Amy Sanyahumbi
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Andrea Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Craig Sable
- Children's National Hospital, Washington, District of Columbia
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Chillo P, Mutagaywa R, Nkya D, Njelekela M, Kwesigabo G, Kahabuka F, Kerry V, Kamuhabwa A. Sub-clinical rheumatic heart disease (RHD) detected by hand-held echocardiogram in children participating in a school-based RHD prevention program in Tanzania. BMC Cardiovasc Disord 2023; 23:155. [PMID: 36966309 PMCID: PMC10040127 DOI: 10.1186/s12872-023-03186-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 03/15/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Rheumatic Heart Disease (RHD) continues to cause suffering and premature deaths in many sub-Saharan Africa (SSA) countries, where the disease is still endemic. RHD is largely preventable and determining its community burden is an important critical step in any RHD prevention program. METHODS We conducted a cross-sectional study of 5-16 years old pupils from 11 primary schools participating in an RHD prevention program in 4 districts in Tanzania, between 2018 and 2019. At the school, all children were invited to participate after receiving consent from their parents/guardians. Participating children filled a questionnaire and were auscultated for cardiac murmurs. Echocardiographic screening was done by two experienced cardiologists, using a hand-held machine (V-Scan, GE®). All positive screening tests were stored for further examination by the same two cardiologists to reach to a consensus of definite, borderline or no RHD, using a modified World Heart Federation (WHF) criterion. RESULTS Of the 6895 children invited, 4738 (68.7%) were screened and 4436 (64.3%) had complete data. The mean (SD) age was 10.04 (2.43) years, and 2422 (54.6%) were girls. Fifty three (1.2%) children were found to have a murmur. The proportion of children with trace or mild valvular regurgitation, sub-valvular/chordal thickening and valvular thickening/deformity were 8.3%, 1.3%, and 1.0%, respectively. Sub-clinical RHD was found in 95 children (59 definite and 36 borderline), giving a prevalence of 2.1%, [95% CI 1.7% - 2.6%]. Sub-clinical RHD was independently associated with female sex (aOR 1.83, 95% CI 1.18-2.85, p = 0.007), older age groups (aOR 1.73, 95% CI 1.10-2.72, p = 0.018 for age group 11-14 years; and aOR 3.02 95% CI 1.01-9.05, p = 0.048 for age group 15-16 years), as well as presence of a cardiac murmur, aOR 5.63 95% CI 2.31-13.69, p < 0.0001. None of the studied socio- or economic factors was associated with the presence of sub-clinical RHD in this study. CONCLUSION The prevalence of sub-clinical RHD among primary school children in Tanzania is 2.1%, similar to previous reports in SSA. Efforts to prevent and control RHD in our communities are highly warranted.
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Affiliation(s)
- Pilly Chillo
- Department of Internal Medicine, Section of Cardiology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Reuben Mutagaywa
- Department of Internal Medicine, Section of Cardiology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Deogratias Nkya
- Department of Paediatric and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Marina Njelekela
- Department of Physiology, Muhimbili University of Health and Allied Sciences and Deloitte Consulting Limited, Dar es Salaam, Tanzania
| | - Gideon Kwesigabo
- Department of Epidemiology and Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Febronia Kahabuka
- Department of Orthodontics Paedodontics & Community Dentistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Vanessa Kerry
- Department of Global Health and Social Medicine, Seed Global Health Partnerships, Boston, USA
- Harvard Medical School, Center for Global Health, Mass General Hospital, Boston, MA, USA
| | - Appolinary Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Vaid A, Argulian E, Lerakis S, Beaulieu-Jones BK, Krittanawong C, Klang E, Lampert J, Reddy VY, Narula J, Nadkarni GN, Glicksberg BS. Multi-center retrospective cohort study applying deep learning to electrocardiograms to identify left heart valvular dysfunction. COMMUNICATIONS MEDICINE 2023; 3:24. [PMID: 36788316 PMCID: PMC9929085 DOI: 10.1038/s43856-023-00240-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/09/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Aortic Stenosis and Mitral Regurgitation are common valvular conditions representing a hidden burden of disease within the population. The aim of this study was to develop and validate deep learning-based screening and diagnostic tools that can help guide clinical decision making. METHODS In this multi-center retrospective cohort study, we acquired Transthoracic Echocardiogram reports from five Mount Sinai hospitals within New York City representing a demographically diverse cohort of patients. We developed a Natural Language Processing pipeline to extract ground-truth labels about valvular status and paired these to Electrocardiograms (ECGs). We developed and externally validated deep learning models capable of detecting valvular disease, in addition to considering scenarios of clinical deployment. RESULTS We use 617,338 ECGs paired to transthoracic echocardiograms from 123,096 patients to develop a deep learning model for detection of Mitral Regurgitation. Area Under Receiver Operating Characteristic curve (AUROC) is 0.88 (95% CI:0.88-0.89) in internal testing, and 0.81 (95% CI:0.80-0.82) in external validation. To develop a model for detection of Aortic Stenosis, we use 617,338 Echo-ECG pairs for 128,628 patients. AUROC is 0.89 (95% CI: 0.88-0.89) in internal testing, going to 0.86 (95% CI: 0.85-0.87) in external validation. The model's performance increases leading up to the time of the diagnostic echo, and it performs well in validation against requirement of Transcatheter Aortic Valve Replacement procedures. CONCLUSIONS Deep learning based tools can increase the amount of information extracted from ubiquitous investigations such as the ECG. Such tools are inexpensive, can help in earlier disease detection, and potentially improve prognosis.
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Affiliation(s)
- Akhil Vaid
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Edgar Argulian
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Cardiology, Mount Sinai Morningside Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stamatios Lerakis
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Cardiology, Mount Sinai Morningside Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brett K Beaulieu-Jones
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Section of Biomedical Data Science, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Eyal Klang
- Sheba Medical Center, Department of Diagnostic Imaging, Tel Hashomer, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, 52621, Israel
| | - Joshua Lampert
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Cardiology, Mount Sinai Morningside Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Girish N Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The Division of Data Driven and Digital Medicine (D3M), The Department of Medicine, Icahn School of Medicine at Mount Siniai, New York, NY, USA
| | - Benjamin S Glicksberg
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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10
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Edwards LA, Feng F, Iqbal M, Fu Y, Sanyahumbi A, Hao S, McElhinney DB, Ling XB, Sable C, Luo J. Machine Learning for Pediatric Echocardiographic Mitral Regurgitation Detection. J Am Soc Echocardiogr 2023; 36:96-104.e4. [PMID: 36191670 DOI: 10.1016/j.echo.2022.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Echocardiography-based screening for valvular disease in at-risk asymptomatic children can result in early diagnosis. These screening programs, however, are resource intensive and may not be feasible in many resource-limited settings. Automated echocardiographic diagnosis may enable more widespread echocardiographic screening, early diagnosis, and improved outcomes. In this feasibility study, the authors sought to build a machine learning model capable of identifying mitral regurgitation (MR) on echocardiography. METHODS Echocardiograms were labeled by clip for view and by frame for the presence of MR. The labeled data were used to build two convolutional neural networks to perform the stepwise tasks of classifying the clips (1) by view and (2) by the presence of any MR, including physiologic, in parasternal long-axis color Doppler views. The view classification model was developed using 66,330 frames, and model performance was evaluated using a hold-out testing data set with 45 echocardiograms (11,730 frames). The MR detection model was developed using 938 frames, and model performance was evaluated using a hold-out testing data set with 42 echocardiograms (182 frames). Metrics to evaluate model performance included accuracy, precision, recall, F1 score (average of precision and recall, ranging from 0 to 1, with 1 suggesting perfect precision and recall), and receiver operating characteristic analysis. RESULTS For the parasternal long-axis view with color Doppler, the view classification convolutional neural network achieved an F1 score of 0.97. The MR detection convolutional neural network achieved testing accuracy of 0.86 and an area under the receiver operating characteristic curve of 0.91. CONCLUSIONS A machine learning model is capable of discerning MR on transthoracic echocardiography. This is an encouraging step toward machine learning-based diagnosis of valvular heart disease on pediatric echocardiography.
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Affiliation(s)
- Lindsay A Edwards
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Fei Feng
- University of Michigan-Shanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Mehreen Iqbal
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Yong Fu
- University of Michigan-Shanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Amy Sanyahumbi
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Shiying Hao
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - X Bruce Ling
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Craig Sable
- Department of Pediatrics, Children's National Health System, Washington, District of Columbia
| | - Jiajia Luo
- Biomedical Engineering Department, Peking University, Beijing, China.
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11
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Chugh Y, Lohese O, Sorajja P, Garberich R, Stanberry L, Cavalcante J, Gossl M. Adoptability and accuracy of point-of-care ultrasound in screening for valvular heart disease in the primary care setting. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:265-270. [PMID: 34818437 DOI: 10.1002/jcu.23062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE Despite continued efforts, a majority of patients with valvular heart disease (VHD) remain undiagnosed and untreated. This study aimed to assess the adoptability and accuracy of point-of-care handheld echocardiographic assessments (POCE) in the primary care setting. METHODS Eleven previously untrained primary care providers were trained to use the Vscan Extend (GE, WI) POCE to assess VHD, left ventricular function (LVEF), and major extra-cardiac findings. Their assessments were compared to those of three blinded expert readers. A total of 175 patients underwent POCE assessments which were evaluated using Kappa statistics (κ) together with their estimated standard error, p value, and 95% CI bounds. RESULTS Each patient had a mean of 3.3 ± 1.1 (±SD) assessments performed. Identical or nearly identical agreement between previously untrained primary providers and expert readers was evident for the diagnosis of tricuspid regurgitation, mitral regurgitation, pericardial effusion, and volume status. These agreements were strongest in apical long axis (κ = 1, p < 0.001) and parasternal long and short axis views (κ > =0.82 p < 0.001), though agreement remained robust in apical 4-chamber views (κ ≥ 0.76). The agreements in LVEF assessment were identical in the apical long axis view (κ = 1, p < 0.001) and robust in the remaining 3 views (κ > =0.66, p < 0.001). The assessments of aortic stenosis (parasternal/long, κ = 0.42, and parasternal/short, κ = 0.47, both p < 0.001) were weak in their agreement. CONCLUSION Compared to expert echocardiography readers, the untrained providers' use of POCE for VHD shows high user adoptability and diagnostic accuracies in the primary care setting.
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Affiliation(s)
- Yashasvi Chugh
- Valve Science Center at the Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Opema Lohese
- Valve Science Center at the Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Paul Sorajja
- Valve Science Center at the Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ross Garberich
- Valve Science Center at the Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Larissa Stanberry
- Valve Science Center at the Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - João Cavalcante
- Valve Science Center at the Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Mario Gossl
- Valve Science Center at the Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
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12
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Rwebembera J, Nascimento BR, Minja NW, de Loizaga S, Aliku T, dos Santos LPA, Galdino BF, Corte LS, Silva VR, Chang AY, Dutra WO, Nunes MCP, Beaton AZ. Recent Advances in the Rheumatic Fever and Rheumatic Heart Disease Continuum. Pathogens 2022; 11:179. [PMID: 35215123 PMCID: PMC8878614 DOI: 10.3390/pathogens11020179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Nearly a century after rheumatic fever (RF) and rheumatic heart disease (RHD) was eradicated from the developed world, the disease remains endemic in many low- and middle-income countries (LMICs), with grim health and socioeconomic impacts. The neglect of RHD which persisted for a semi-centennial was further driven by competing infectious diseases, particularly the human immunodeficiency virus (HIV) pandemic. However, over the last two-decades, slowly at first but with building momentum, there has been a resurgence of interest in RF/RHD. In this narrative review, we present the advances that have been made in the RF/RHD continuum over the past two decades since the re-awakening of interest, with a more concise focus on the last decade's achievements. Such primary advances include understanding the genetic predisposition to RHD, group A Streptococcus (GAS) vaccine development, and improved diagnostic strategies for GAS pharyngitis. Echocardiographic screening for RHD has been a major advance which has unearthed the prevailing high burden of RHD and the recent demonstration of benefit of secondary antibiotic prophylaxis on halting progression of latent RHD is a major step forward. Multiple befitting advances in tertiary management of RHD have also been realized. Finally, we summarize the research gaps and provide illumination on profitable future directions towards global eradication of RHD.
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Affiliation(s)
- Joselyn Rwebembera
- Department of Adult Cardiology (JR), Uganda Heart Institute, Kampala 37392, Uganda
| | - Bruno Ramos Nascimento
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Neema W. Minja
- Rheumatic Heart Disease Research Collaborative in Uganda, Uganda Heart Institute, Kampala 37392, Uganda;
| | - Sarah de Loizaga
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
| | - Twalib Aliku
- Department of Paediatric Cardiology (TA), Uganda Heart Institute, Kampala 37392, Uganda;
| | - Luiza Pereira Afonso dos Santos
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Bruno Fernandes Galdino
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Luiza Silame Corte
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Vicente Rezende Silva
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
| | - Andrew Young Chang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Walderez Ornelas Dutra
- Laboratory of Cell-Cell Interactions, Institute of Biological Sciences, Department of Morphology, Federal University of Minas Gerais, Belo Horizonte 30130-100, MG, Brazil;
- National Institute of Science and Technology in Tropical Diseases (INCT-DT), Salvador 40170-970, BA, Brazil
| | - Maria Carmo Pereira Nunes
- Departamento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (B.R.N.); (L.P.A.d.S.); (B.F.G.); (L.S.C.); (V.R.S.); (M.C.P.N.)
- Servico de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaude, Hospital das Clinicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st Floor, Belo Horizonte 30130-100, MG, Brazil
| | - Andrea Zawacki Beaton
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA; (S.d.L.); (A.Z.B.)
- Cincinnati Children’s Hospital Medical Center, The Heart Institute, Cincinnati, OH 45229, USA
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13
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Kazahura PT, Mushi TL, Pallangyo P, Janabi M, Kisenge R, Albaghdadi M, Majani N, Kija E. Prevalence and risk factors for Subclinical Rheumatic Heart Disease among primary school children in Dar es Salaam, Tanzania: a community based cross-sectional study. BMC Cardiovasc Disord 2021; 21:610. [PMID: 34930122 PMCID: PMC8686380 DOI: 10.1186/s12872-021-02377-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) is the most common acquired heart disease occurring in children and adolescents. RHD is associated with significant morbidity and mortality particularly in low and middle- income countries (LMICs) where the burden is estimated to be higher compared to high income countries. Subclinical RHD is the presence of valvular lesion diagnosed by echocardiography in a person with no clinical manifestation of RHD. This study aimed at determining the prevalence, types and factors associated with subclinical RHD among primary school children in Dar Es Salaam, Tanzania. METHODS A descriptive community-based cross-sectional study was conducted in primary school children from February to May 2019. A standardized structured questionnaire was used to collect demographic characteristics, history of upper respiratory tract infections (URTIs), anthropometric measurements, and chest auscultation findings. Moreover echocardiographic screening was done to all children recruited into the study. World Heart Federation echocardiographic classification was used to define the types and prevalence of subclinical RHD. RESULTS A total of 949 primary school children were enrolled with females being predominant (57.1%). The prevalence of subclinical RHD was 34 per 1000. All the participants had mitral valve disease only whereby 17 had definite disease and 15 had a borderline disease. The associated factors for subclinical RHD were older age of more than 9 years (OR 10.8, 95% CI 1.4-82.2, P = 0.02) having three or more episodes of URTI in previous six months (OR 21, 95% CI 9.6-46, P = 0.00) and poor hygiene (OR 3, 95% CI 1.3-6.8, P = 0.009). CONCLUSION Subclinical RHD as detected by echocardiographic screening is prevalent in primary school children, uniformly affects the mitral valve, and is associated with potentially modifiable risk factors. Children with a history of more than three episodes of URTI in six months represents a high-risk population that should be targeted for RHD screening.
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Affiliation(s)
- Parvina Titus Kazahura
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania.
- Department of Paediatric Cardiology, Jakaya Kikwete Cardiac Institute, P.O Box 54141, Dar es Salaam, Tanzania.
| | - Theophylly L Mushi
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
- Department of Paediatric Cardiology, Jakaya Kikwete Cardiac Institute, P.O Box 54141, Dar es Salaam, Tanzania
| | - Pedro Pallangyo
- Department of Adult Cardiology, Jakaya Kikwete Cardiac Institute, P.O Box 54141, Dar es Salaam, Tanzania
| | - Mohamed Janabi
- Department of Adult Cardiology, Jakaya Kikwete Cardiac Institute, P.O Box 54141, Dar es Salaam, Tanzania
| | - Rodrick Kisenge
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
| | - Mazen Albaghdadi
- Division of Cardiology and Section of Vascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Naizihijwa Majani
- Department of Paediatric Cardiology, Jakaya Kikwete Cardiac Institute, P.O Box 54141, Dar es Salaam, Tanzania
| | - Edward Kija
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
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14
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Bennett J, Rentta NN, Leung W, Atkinson J, Wilson N, Webb R, Baker MG. Early diagnosis of acute rheumatic fever and rheumatic heart disease as part of a secondary prevention strategy: Narrative review. J Paediatr Child Health 2021; 57:1385-1390. [PMID: 34296804 DOI: 10.1111/jpc.15664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 07/05/2021] [Accepted: 07/14/2021] [Indexed: 01/07/2023]
Abstract
Acute rheumatic fever (ARF) and its sequela rheumatic heart disease (RHD) remain significant causes of morbidity and mortality. In New Zealand, ARF almost exclusively affects Indigenous Māori and Pacific children. This narrative review aims to present secondary interventions to improve early and accurate diagnosis of ARF and RHD, in order to minimise disease progression in New Zealand. Medline, EMBASE and Scopus databases were searched as well as other electronic publications. Included were 56 publications from 1980 onwards. Diagnosing ARF and RHD as early as possible is central to reducing disease progression. Recent identification of specific ARF biomarkers offer the opportunity to aid initial diagnosis and portable echocardiography has the potential to detect undiagnosed RHD in high-risk areas. However, further research into the benefits and risks to children with subclinical RHD is necessary, as well as an economic evaluation.
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Affiliation(s)
- Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Neilenuo N Rentta
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - William Leung
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - June Atkinson
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Rachel Webb
- Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand.,KidzFirst Children's Hospital, Counties Manukau District Health Board, Auckland, New Zealand.,Department of Paediatric Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
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15
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Vieira MLC, Branco CEDB, Gazola ASL, Vieira PPAC, Benvenuti LA, Demarchi LMMF, Gutierrez PS, Aiello VD, Tarasoutchi F, Sampaio RO. 3D Echocardiography for Rheumatic Heart Disease Analysis: Ready for Prime Time. Front Cardiovasc Med 2021; 8:676938. [PMID: 34355026 PMCID: PMC8329529 DOI: 10.3389/fcvm.2021.676938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/15/2021] [Indexed: 11/13/2022] Open
Abstract
Rheumatic heart disease (RHD) remains to be a very important health issue worldwide, mainly in underdeveloped countries. It continues to be a leading cause of morbidity and mortality throughout developing countries. RHD is a delayed non-suppurative immunologically mediated inflammatory response to the throat infection caused by a hemolytic streptococcus from the A group (Streptococcus pyogenes). RHD keeps position 1 as the most common cardiovascular disease in young people aged <25 years considering all the continents. The disease can lead to valvular cardiac lesions as well as to carditis. Rheumatic fever valvular injuries lead most commonly to the fusion and thickening of the edges of the cusps and to the fusion, thickening, and shortening of the chordae and ultimately to calcification of the valves. Valvular commissures can also be deeply compromised, leading to severe stenosis. Atrial and ventricular remodeling is also common following rheumatic infection. Mixed valvular lesions are more common than isolated valvular disorders. Echocardiography is the most relevant imaging technique not only to provide diagnostic information but also to enable prognostic data. Further, it presents a very important role for the correction of complications after surgical repair of rheumatic heart valvulopathies. Three-dimensional (3D) echocardiography provides additional anatomical and morphofunctional information of utmost importance for patients presenting rheumatic valvopathies. Accordingly, three-dimensional echocardiography is ready for routine use in patients with RHD presenting with valvular abnormalities.
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Affiliation(s)
- Marcelo Luiz Campos Vieira
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
| | | | | | | | | | | | | | | | - Flávio Tarasoutchi
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
| | - Roney Orismar Sampaio
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
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16
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Marijon E, Mocumbi A, Narayanan K, Jouven X, Celermajer DS. Persisting burden and challenges of rheumatic heart disease. Eur Heart J 2021; 42:3338-3348. [PMID: 34263296 DOI: 10.1093/eurheartj/ehab407] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/02/2021] [Accepted: 06/13/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Eloi Marijon
- University of Paris, PARCC, INSERM, Global Health Unit, Paris F-75015, France.,Cardiology Department, European Georges Pompidou Hospital, Paris, France
| | - Ana Mocumbi
- Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique.,Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Kumar Narayanan
- University of Paris, PARCC, INSERM, Global Health Unit, Paris F-75015, France.,Medicover Hospitals, Hyderabad, India
| | - Xavier Jouven
- University of Paris, PARCC, INSERM, Global Health Unit, Paris F-75015, France.,Cardiology Department, European Georges Pompidou Hospital, Paris, France
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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17
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Bimerew M, Beletew B, Getie A, Wondmieneh A, Gedefaw G, Demis A. Prevalence of rheumatic heart disease among school children in East Africa: a systematic review and meta-analysis. Pan Afr Med J 2021; 38:242. [PMID: 34104290 PMCID: PMC8164427 DOI: 10.11604/pamj.2021.38.242.26058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 02/08/2021] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Melaku Bimerew
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Biruk Beletew
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Addisu Getie
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Adam Wondmieneh
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Getnet Gedefaw
- Department of Midwifery, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Asmamaw Demis
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
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18
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Severe Pharyngodynia Followed by Migratory Polyarthritis and High Fever in Young Immigrants: Remember That Rheumatic Fever Is Still Relevant in 2020! Case Rep Infect Dis 2020; 2020:8854868. [PMID: 33204550 PMCID: PMC7657701 DOI: 10.1155/2020/8854868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 11/22/2022] Open
Abstract
Acute rheumatic fever (ARF) is the immune-mediated sequelae of untreated group-A streptococcal infection. In this regard, rheumatic heart disease is the most prominent manifestation with devastating long-term complications. In the postantibiotic era, ARF is extremely rare in high-income countries; thus, its diagnosis might escape the clinicians' notice. However, its incidence remains high not only in certain low- and middle-income regions with poor public health systems but also in socioeconomically vulnerable populations residing in high-income countries. Herein, we report two cases of ARF in young immigrant adults in order to highlight the need for increased clinical suspicion to establish a prompt and timely diagnosis of ARF and describe in detail its differential diagnosis and approach to treatment.
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Bhaya M, Panwar S, Sharma A, Chaudhary D, Singh S, Beniwal R, Panwar RB, Nanda NC. Comparison of the newer proposed diagnostic score with the World Heart Federation criteria for echocardiographic detection of rheumatic heart disease. Echocardiography 2019; 36:2259-2264. [DOI: 10.1111/echo.14547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 09/22/2019] [Accepted: 10/28/2019] [Indexed: 01/17/2023] Open
Affiliation(s)
- Maneesha Bhaya
- Cardiology Clinique Du Bon Pasteur Beau Bassin‐Rose Hill Mauritius
| | | | - Arvind Sharma
- Community Medicine Rajasthan University of Health Sciences Jaipur India
| | | | - Shatakashi Singh
- General Medicine Mahatma Gandhi National Institute of Medical Sciences Jaipur India
| | - Rajesh Beniwal
- Community Medicine Anna Medical University Solitude Mauritius
| | | | - Navin C. Nanda
- Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham Alabama
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Noubiap JJ, Agbor VN, Bigna JJ, Kaze AD, Nyaga UF, Mayosi BM. Prevalence and progression of rheumatic heart disease: a global systematic review and meta-analysis of population-based echocardiographic studies. Sci Rep 2019; 9:17022. [PMID: 31745178 PMCID: PMC6863880 DOI: 10.1038/s41598-019-53540-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 10/21/2019] [Indexed: 11/30/2022] Open
Abstract
This systematic review and meta-analysis aimed to provide a contemporaneous estimate of the global burden of rheumatic heart disease (RHD) from echocardiographic population-based studies. We searched multiple databases between January 01, 1996 and October 17, 2017. Random-effect meta-analysis was used to pool data. We included 82 studies (1,090,792 participant) reporting data on the prevalence of RHD and 9 studies on the evolution of RHD lesions. The pooled prevalence of RHD was 26.1‰ (95%CI 19.2-33.1) and 11.3‰ (95%CI 7.2-16.2) for studies which used the World Heart Federation (WHF) and World Health Organization (WHO) criteria, respectively. The prevalence of RHD varied inversely with the level of a country's income, was lower with the WHO criteria compared to the WHF criteria, and was lowest in South East Asia. Definite RHD progressed in 7.5% (95% CI 1.5-17.6) of the cases, while 60.7% (95% CI 42.4-77.5) of cases remained stable over the course of follow-up. The proportion of cases borderline RHD who progressed to definite RHD was 11.3% (95% CI 6.9-16.5). The prevalence of RHD across WHO regions remains high. The highest prevalence of RHD was noted among studies which used the WHF diagnostic criteria. Definite RHD tends to progress or remain stable over time.
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Affiliation(s)
- Jean Jacques Noubiap
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Valirie N Agbor
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jean Joel Bigna
- Department of Epidemiology and Public Health, Centre Pasteur of Cameroon, Yaoundé, Cameroon.
- School of Public Health, Faculty of Medicine, University of Paris Sud XI, Le Kremlin-Bicêtre, France.
| | - Arnaud D Kaze
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Ulrich Flore Nyaga
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Bongani M Mayosi
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
- The Dean's Office, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Abstract
BACKGROUND The aim of this study is to investigate the prevalence of subclinical rheumatic heart disease in schoolchildren aged 5-18 by using portable echocardiography in Ankara, Turkey. METHODS The portable echocardiography screening was performed by a paediatric cardiologist for all of the cases. The mean age of 2550 healthy students was 11.09 ± 2.91 years (1339 females, 1211 males) in three private and three public schools. Echocardiographic studies were assessed according to 2012 World Heart Federation criteria for rheumatic heart disease. RESULTS After reviewing the echocardiographic images, 73 students were reevaluated by an advanced echocardiography device in the university hospital. Evidence of definite subclinical rheumatic heart disease was found in 39 students (15/1000) and borderline rheumatic heart disease in 20 students (8/1000). No children had any clinical symptoms. The mean age of children diagnosed with rheumatic heart disease and borderline rheumatic heart disease is 12.4 and 11.4 years, respectively. The risk of rheumatic heart disease was found to be increased sevenfold in girls between 14 and 18 years. We surprisingly observed that the prevalence of definite rheumatic heart disease in private schools located in high-income areas of Ankara was higher than that in public schools. CONCLUSIONS This is the first and largest single-centred echocardiographic screening study for subclinical rheumatic heart disease in Turkish schoolchildren. The frequency of rheumatic heart disease has been found to be 15/1000. This finding is similar to those of recent echocardiographic screening studies performed in middle and high-risk populations. We conclude that to decrease the burden of rheumatic heart disease, echocardiographic screening studies are necessary, and long-term follow-up of children with echocardiographically diagnosed subclinical rheumatic heart disease is needed.
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Beaton A, Okello E, Engelman D, Grobler A, Scheel A, DeWyer A, Sarnacki R, Omara IO, Rwebembera J, Sable C, Steer A. Determining the impact of Benzathine penicillin G prophylaxis in children with latent rheumatic heart disease (GOAL trial): Study protocol for a randomized controlled trial. Am Heart J 2019; 215:95-105. [PMID: 31301533 DOI: 10.1016/j.ahj.2019.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 06/01/2019] [Indexed: 11/15/2022]
Abstract
Rheumatic heart disease (RHD) remains a high prevalence condition in low- and middle-income countries. Most individuals with RHD present late, missing the opportunity to benefit from secondary antibiotic prophylaxis. Echocardiographic screening can detect latent RHD, but the impact of secondary prophylaxis in screen-detected individuals is not known. METHODS/DESIGN This trial aims to determine if secondary prophylaxis with every-4-week injectable Benzathine penicillin G (BPG) improves outcomes for children diagnosed with latent RHD. This is a randomized controlled trial in consenting children, aged 5 to 17 years in Northern Uganda, confirmed to have borderline RHD or mild definite RHD on echocardiography, according to the 2012 World Heart Federation criteria. Qualifying children will be randomized to every-4-week injectable intramuscular BPG or no medical intervention and followed for a period of 2 years. Ongoing intervention adherence and retention in the trial will be supported through the establishment of peer support groups for participants in the intervention and control arms. A blinded echocardiography adjudication panel consisting of four independent experts will determine the echocardiographic classification at enrollment and trajectory through consensus review. The primary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic progression of latent RHD compared to those in the control arm. The secondary outcome is the proportion of children in the BPG-arm who demonstrate echocardiographic regression of latent RHD compared to those in the control arm. A sample size of 916 participants will provide 90% power to detect a 50% relative risk reduction assuming a 15% progression in the control group. The planned study duration is from 2018-2021. DISCUSSION Policy decisions on the role of echocardiographic screening for RHD have stalled because of the lack of evidence of the benefit of secondary prophylaxis. The results of our study will immediately inform the standard of care for children diagnosed with latent RHD and will shape, over 2-3 years, practical and scalable programs that could substantially decrease the burden of RHD in our lifetime. TRIAL REGISTRATION ClinicalTrials.gov: NCT03346525. Date Registered: November 17, 2017.
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Affiliation(s)
- Andrea Beaton
- Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | | | - Daniel Engelman
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Anneke Grobler
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Amy Scheel
- Emory School of Medicine, Atlanta, GA, USA
| | - Alyssa DeWyer
- Children's National Medical Center, Washington, DC, USA
| | | | | | | | - Craig Sable
- Children's National Medical Center, Washington, DC, USA
| | - Andrew Steer
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Royal Children's Hospital, Melbourne, Victoria, Australia
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Alqanatish J, Alfadhel A, Albelali A, Alqahtani D. Acute rheumatic fever diagnosis and management: Review of the global implications of the new revised diagnostic criteria with a focus on Saudi Arabia. J Saudi Heart Assoc 2019; 31:273-281. [PMID: 31516307 PMCID: PMC6734099 DOI: 10.1016/j.jsha.2019.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/28/2019] [Accepted: 07/30/2019] [Indexed: 12/03/2022] Open
Abstract
Rheumatic fever (RF) is a common cause of acquired heart disease in children worldwide. It is a delayed, nonsuppurative, autoimmune phenomenon following pharyngitis, impetigo, or scarlet fever caused by group A β-hemolytic streptococcal (GAS) infection. RF diagnosis is clinical and based on revised Jones criteria. The first version of the criteria was developed by T. Duckett Jones in 1944, then subsequently revised by the American Heart Association (AHA) in 1992 and 2015. However, RF remains a diagnostic challenge for clinicians because of the lack of specific clinical or laboratory findings. As a result, it has been difficult for some time to maintain a balance between over- and underdiagnosis of RF cases. The Jones criteria were revised in 2015 by the AHA, and the main modifications were as follows: the population was subdivided into moderate- to high-risk and low risk; the concept of subclinical carditis was introduced; and monoarthritis was included as a feature of musculoskeletal inflammation in the moderate- to high-risk population. This review will highlight the major changes in the AHA 2015 revised Jones criteria for pediatricians and general practitioners.
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Affiliation(s)
- Jubran Alqanatish
- Department of Pediatrics, King Abdulaziz Medical City, Riyadh, Saudi ArabiaSaudi Arabia.,King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi ArabiaSaudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSaudi Arabia
| | - Abdulmajeed Alfadhel
- Department of Pediatrics, King Abdulaziz Medical City, Riyadh, Saudi ArabiaSaudi Arabia.,King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi ArabiaSaudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSaudi Arabia
| | - Areej Albelali
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi ArabiaSaudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaSaudi Arabia
| | - Dhafer Alqahtani
- Department of Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi ArabiaSaudi Arabia
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Culliford-Semmens N, Nicholson R, Tilton E, Stirling J, Sidhu K, Webb R, Wilson N. The World Heart Federation criteria raise the threshold of diagnosis for mild rheumatic heart disease: Three reviewers are better than one. Int J Cardiol 2019; 291:112-118. [PMID: 30851993 DOI: 10.1016/j.ijcard.2019.02.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 02/18/2019] [Accepted: 02/25/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The World Heart Federation (WHF) criteria, published in 2012, provided an evidence-based guideline for the minimal diagnosis of echocardiographically-detected RHD. Primary aim of the study was to determine whether use of the WHF criteria altered the threshold for the diagnosis of echocardiographically-detected RHD compared with the previous WHO/NIH criteria. A secondary aim was to explore the utility of a three reviewer reporting system compared to a single or two reviewer reporting structure. METHODS 144 de-identified echocardiograms (RHD, congenital valvar abnormality, physiological valvar regurgitation) were independently reported using the WHF criteria by two reviewers blinded to the previous WHO/NIH diagnosis. If there was discordance between the two reviewers, a third cardiologist independently performed a tie-breaker review. RESULTS There was a 21% reduction of cases classified as RHD using the WHF criteria compared to the modified WHO/NIH criteria (68 cases compared to 86, p = 0.04). There was a 60% consensus across the different diagnostic categories with 2 reviewers, 89% majority agreement with 3 reviewers. 11% required an open label discussion. There was moderate agreement between 2 reviewers for any RHD, kappa 0.57 (CI 0.44-0.70), with no significant difference in agreement between the different categories. CONCLUSION The WHF criteria have raised the threshold for the diagnosis of RHD compared to the WHO/NIH criteria. However, inter-reporter variability of the WHF criteria is high. A three reviewer system is likely more accurate than a single or two reporter system for the diagnosis of mild RHD. This has resource implications for echocardiographic screening programmes.
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Affiliation(s)
- Nicola Culliford-Semmens
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
| | - Ross Nicholson
- Department of Paediatrics and Child Health, Kidz First Children's Hospital, Auckland, New Zealand
| | - Elizabeth Tilton
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
| | - John Stirling
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
| | - Karishma Sidhu
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
| | - Rachel Webb
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand
| | - Nigel Wilson
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand.
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Status of Pediatric Cardiac Care in Developing Countries. CHILDREN-BASEL 2019; 6:children6020034. [PMID: 30823591 PMCID: PMC6406635 DOI: 10.3390/children6020034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 11/16/2022]
Abstract
About 1.35 million babies are born with congenital heart disease each year globally. Most of these are expected to lead normal, productive lives if they are treated in time. However, 90% of babies born with congenital heart disease live in regions where medical care is inadequate or unavailable. The privilege of early diagnosis and timely intervention is restricted to only those born in developed countries. Added to the burden of congenital heart disease is rheumatic heart disease, which remains a global health problem in many low-income and middle-income countries. Providing optimal care for all these children is a daunting task, and requires funds and proper planning at various levels of the health care system. This article describes the burden of pediatric heart disease, including lacunae in the current state, as well as challenges and opportunities for providing optimal care to this large population of children.
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Favarato D, Aiello VD. Case 4 - A 59-Year-Old Woman with Rheumatic Mitral Valve Disease (Severe Stenosis and Regurgitation), Severe Dyspnea, Shock and Pulmonary Condensation. Arq Bras Cardiol 2018; 111:215-222. [PMID: 30183990 PMCID: PMC6122908 DOI: 10.5935/abc.20180157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/06/2018] [Indexed: 11/20/2022] Open
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Musuku J, Engel ME, Musonda P, Lungu JC, Machila E, Schwaninger S, Mtaja A, Mulendele E, Kavindele D, Spector J, Tadmor B, Gutierrez MM, Van Dam J, Colin L, Long A, Fishman MC, Mayosi BM, Zühlke LJ. Prevalence of rheumatic heart disease in Zambian school children. BMC Cardiovasc Disord 2018; 18:135. [PMID: 29969998 PMCID: PMC6029054 DOI: 10.1186/s12872-018-0871-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 06/24/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The large global burden of rheumatic heart disease (RHD) has come to light in recent years following robust epidemiologic studies. As an operational research component of a broad program aimed at primary and secondary prevention of RHD, we sought to determine the current prevalence of RHD in the country's capital, Lusaka, using a modern imaging-based screening methodology. In addition, we wished to evaluate the practicality of training local radiographers in echocardiography screening methods. METHODS Echocardiography was conducted on a random sample of students in 15 schools utilizing a previously validated, abbreviated screening protocol. Through a task-shifting scheme, and in the spirit of capacity-building to enhance local diagnostic and research skills, general radiographers based at Lusaka University Teaching Hospital (UTH) were newly trained to use portable echocardiography devices. Students deemed as screen-positive were referred for comprehensive echocardiography and clinical examination at UTH. Cardiac abnormalities were classified according to standard World Heart Federation criteria. RESULTS Of 1102 students that were consented and screened, 53 students were referred for confirmatory echocardiography. Three students had definite RHD, 10 had borderline RHD, 29 were normal, and 11 students were lost to follow-up. The rates of definite, borderline, and total RHD were 2.7 per 1000, 9.1 per 1000, and 11.8 per 1000, respectively. Anterior mitral valve leaflet thickening and chordal thickening were the most common morphological defects. The pairwise kappa test showed fair agreement between the local radiographers and an echocardiographer quality assurance specialist. CONCLUSION The prevalence of asymptomatic RHD in urban communities in Zambia is within the range of results reported in other sub-Saharan African countries using the WHF criteria. Task-shifting local radiographers to conduct echocardiography was feasible. The results of this study will be used to inform ongoing efforts in Zambia to control and eventually eliminate RHD. TRIAL REGISTRATION The study was registered on clinicaltrials.gov ( #NCT02661763 ).
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Affiliation(s)
- John Musuku
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Mark E Engel
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Patrick Musonda
- School of Public Health University of Zambia, Lusaka, Zambia
| | - Joyce Chipili Lungu
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Elizabeth Machila
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Sherri Schwaninger
- Global Health, Novartis Institutes for BioMedical Research, Cambridge, MA, USA.
| | - Agnes Mtaja
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Evans Mulendele
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Dorothy Kavindele
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Jonathan Spector
- Global Health, Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Brigitta Tadmor
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Marcelo M Gutierrez
- Global Health, Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Joris Van Dam
- Global Drug Development, Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Laurence Colin
- Global Drug Development, Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Aidan Long
- Department of Allergy and Clinical Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Mark C Fishman
- Harvard Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA, USA
| | - Bongani M Mayosi
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Liesl J Zühlke
- Department of Paediatrics, Red Cross War Memorials Children's Hospital, Cape Town, South Africa
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Abstract
The Jones criteria of 2 major criteria or 1 major plus 2 minor criteria that have been classically used to establish the diagnosis have been significantly modified in 2015 by the American Heart Association. The criteria now include the utilization of echocardiography and Doppler color flow mapping as diagnostic tools for carditis, along with defining criteria in relation to overall population risk, delineating low- versus moderate-high risk populations. Monoarthritis and polyarthralgia are now major criteria for moderate- to high-risk groups.
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Abul-Fadl AMAM, Mourad MM, Ghamrawy A, Sarhan AE. Trends in Deaths from Rheumatic Heart Disease in the Eastern Mediterranean Region: Burden and Challenges. J Cardiovasc Dev Dis 2018; 5:E32. [PMID: 29848951 PMCID: PMC6023336 DOI: 10.3390/jcdd5020032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/25/2018] [Accepted: 05/25/2018] [Indexed: 01/19/2023] Open
Abstract
Rheumatic heart disease (RHD) is a preventable disease that is prevalent in developing regions of the world. Its eradication from most of the developed world indicates that this disease can be controlled and eliminated. Aim: To conduct an in-depth analysis of the trends and challenges of controlling RHD in the Eastern Mediterranean region (EMR). Methodology: Global data from the World Health Organization (WHO) data banks were retrieved for total deaths and age standardized death rate per 100,000 (ASDR) by age group, sex, and year (from 2000 to 2015). The data was compared with the five other WHO regions of the world. We also performed in-depth analysis by socio-economic groups in relation to other attributes in the region related to population growth, illiteracy, and nutritional status. Indicators of service delivery were correlated with ASDR from RHD. Findings: Prevalence of RHD in 2015 in the EMR region was one-third of that of the total deaths reported in the Asian and West Pacific regions. The total deaths for the region peaked twice: in early adulthood and again later in old age, and was higher in females than in males. There was a rising trend in deaths from RHD from 2000 to 2015. The highest total deaths were reported from Egypt, Pakistan, Iran, Afghanistan, and Yemen, representing 80% of the total death rates for the region (35,248). The highest ASDR was Afghanistan (27.5), followed by Yemen (18.78) and Egypt (15.59). The ASDR for RHD was highest in low income countries. It correlated highly, in all income groups, with anemia during pregnancy. Conclusions: Trends and patterns of deaths from RHD in the EMR have shifted to a later age group and are linked with poverty related to inequalities in development and service delivery for certain age groups and gender.
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Affiliation(s)
| | - Maha M Mourad
- Pediatric Department, Pediatric Cardiology Unit, Cairo University, Cairo 11562, Egypt.
| | - Alaa Ghamrawy
- Non communicable Disease Department, Ministry of Health and Population, Cairo 11562 Egypt.
| | - Ayah Ebada Sarhan
- Department of Psychology, American University in Cairo, Fifth settlement, Cairo 11835, Egypt.
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Gardezi SKM, Myerson SG, Chambers J, Coffey S, d’Arcy J, Hobbs FDR, Holt J, Kennedy A, Loudon M, Prendergast A, Prothero A, Wilson J, Prendergast BD. Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients. Heart 2018; 104:1832-1835. [DOI: 10.1136/heartjnl-2018-313082] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/13/2022] Open
Abstract
ObjectiveCardiac auscultation is a key clinical skill, particularly for the diagnosis of valvular heart disease (VHD). However, its utility has declined due to the widespread availability of echocardiography and diminishing emphasis on the importance of clinical examination. We aim to determine the contemporary accuracy of auscultation for diagnosing VHD in primary care.MethodsCardiac auscultation was undertaken by one of two experienced general practitioners (primary care/family doctors) in a subset of 251 asymptomatic participants aged >65 years undergoing echocardiography within a large community-based screening study of subjects with no known VHD. Investigators were blinded to the echocardiographic findings. Newly detected VHD was classified as mild (mild regurgitation of any valve or aortic sclerosis) or significant (at least moderate regurgitation or mild stenosis of any valve).ResultsNewly identified VHD was common, with mild disease in 170/251 participants (68%) and significant disease in 36/251 (14%). The sensitivity of auscultation was low for the diagnosis of mild VHD (32%) but slightly higher for significant VHD (44%), with specificities of 67% and 69%, respectively. Likelihood ratios were not statistically significant for the diagnosis of either mild or significant VHD in the overall cohort, but showed possible value for auscultation in non-overweight subjects (body mass index <25 kg/m2).ConclusionCardiac auscultation has limited accuracy for the detection of VHD in asymptomatic patients and is a poor diagnostic screening tool in primary care, particularly for overweight subjects. Ensuring easy access to echocardiography in patients with symptoms suggesting VHD is likely to represent a better diagnostic strategy.
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Munteanu V, Petaccia A, Contecaru N, Amodio E, Agostoni CV. Paediatric acute rheumatic fever in developed countries: Neglected or negligible disease? Results from an observational study in Lombardy (Italy). AIMS Public Health 2018; 5:135-143. [PMID: 30094276 PMCID: PMC6079050 DOI: 10.3934/publichealth.2018.2.135] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/21/2018] [Indexed: 11/29/2022] Open
Abstract
Introduction Acute Rheumatic Fever (ARF) is a multisystemic disease that results from an autoimmune reaction due to group A streptococcal infection. The disease affects predominantly children aged 5 to 15 years and although its incidence in developed Countries declined since the early 1900s, to date there is a paucity of data that confirm this epidemiological trend. Objective The study aimed to assess the burden of ARF in term of hospitalization and to describe the characteristics of acute rheumatic fever (ARF) in the paediatric population of Lombardy. Study design The study was carried out by analyzing hospital discharge records of patients resident of Lombardy and aged 0–17 years old who, from 2014 to 2016, were hospitalized with the diagnosis of ARF. The following variables have been studied: age, sex, municipality of residence, date of diagnosis of each patient, hospital of admission, and presentation of the disease. Results From 2014 to 2016, 215 patients were found to meet the inclusion criteria and diagnosed as affected from Acute Rheumatic Fever. The rate of hospitalization showed a slightly increasing trend from 3.42 in 2014 to about 5.0 in 2016. Moreover, ARF presented a typical seasonal trend with lower cases in the autumn and a peak of hospitalization in the spring. Conclusion To date, ARF seems to be a rare but not negligible disease in southern central European countries, and in Lombardy we estimated an annual hospitalization rate of 4.24 cases per 100,000 children. The increasing trend found in our study suggests that the burden of the disease could be reduced by involving multidisciplinary health professionals who, in addition to the paediatrician of free choice, would promote evidence based medicine management of the disease during all its clinical phases.
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Affiliation(s)
- Viorica Munteanu
- Department of Paediatrics, IRCCS Ospedale Maggiore Policlinico, DISCCO, University of Milan, Milan, Italy
| | - Antonella Petaccia
- Department of Paediatrics, IRCCS Ospedale Maggiore Policlinico, DISCCO, University of Milan, Milan, Italy
| | - Nicolae Contecaru
- Health Protection Agency of Brianza (Italy), Viale Elvezia n.2 Monza (MB) 20900
| | - Emanuele Amodio
- Health Protection Agency of Brianza (Italy), Viale Elvezia n.2 Monza (MB) 20900
| | - Carlo Virginio Agostoni
- Department of Paediatrics, IRCCS Ospedale Maggiore Policlinico, DISCCO, University of Milan, Milan, Italy
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Kotit S, Said K, ElFaramawy A, Mahmoud H, Phillips DIW, Yacoub MH. Prevalence and prognostic value of echocardiographic screening for rheumatic heart disease. Open Heart 2017; 4:e000702. [PMID: 29344370 PMCID: PMC5761310 DOI: 10.1136/openhrt-2017-000702] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 08/24/2017] [Accepted: 11/07/2017] [Indexed: 12/20/2022] Open
Abstract
Objective Rheumatic heart disease (RHD) remains a major health problem in many low-income and middle-income countries. The use of echocardiographic imaging suggests that subclinical disease is far more widespread than previously appreciated, but little is known as to how these mild forms of RHD progress. We have determined the prevalence of subclinical RHD in a large group of schoolchildren in Aswan, Egypt and have evaluated its subsequent progression. Methods Echocardiographic screening was performed on 3062 randomly selected schoolchildren, aged 5–15 years, in Aswan, Egypt. Follow-up of children with a definite or borderline diagnosis of RHD was carried out 48–60 months later to determine how the valvular abnormalities altered and to evaluate the factors influencing progression. Results Sixty children were initially diagnosed with definite RHD (19.6 per 1000 children) and 35 with borderline disease (11.4 per 1000); most had mitral valve disease. Of the 72 children followed up progression was documented in 14 children (19.4%) and regression in 30 (41.7%) children. Boys had lower rates of progression while older children had lower rates of regression. Functional defects of the valve even in the presence of structural features were associated with lower rates of progression and higher rates of regression than structural changes. Conclusions RHD has a high prevalence in Egypt. Although a high proportion of the abnormalities originally detected persisted at follow-up, both progression and regression of valve lesions were demonstrated.
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Affiliation(s)
- Susy Kotit
- National Heart and Lung Institute, Imperial College, London, UK.,Aswan Heart Centre, Aswan, Egypt.,Harefield Heart Science Centre, Imperial College London, London, UK
| | - Karim Said
- Aswan Heart Centre, Aswan, Egypt.,Cardiology Department, Kasr El Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr ElFaramawy
- Aswan Heart Centre, Aswan, Egypt.,Cardiology Department, Kasr El Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - David I W Phillips
- Developmental Origins of Health and Disease Division, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Magdi H Yacoub
- National Heart and Lung Institute, Imperial College, London, UK.,Aswan Heart Centre, Aswan, Egypt.,Harefield Heart Science Centre, Imperial College London, London, UK
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Beaton A, Aliku T, Dewyer A, Jacobs M, Jiang J, Longenecker CT, Lubega S, McCarter R, Mirabel M, Mirembe G, Namuyonga J, Okello E, Scheel A, Tenywa E, Sable C, Lwabi P. Latent Rheumatic Heart Disease: Identifying the Children at Highest Risk of Unfavorable Outcome. Circulation 2017; 136:2233-2244. [PMID: 28972003 PMCID: PMC5716883 DOI: 10.1161/circulationaha.117.029936] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Screening echocardiography has emerged as a potentially powerful tool for early diagnosis of rheumatic heart disease (RHD). The utility of screening echocardiography hinges on the rate of RHD progression and the ability of penicillin prophylaxis to improve outcome. We report the longitudinal outcomes of a cohort of children with latent RHD and identify risk factors for unfavorable outcomes. METHODS This was a prospective natural history study conducted under the Ugandan RHD registry. Children with latent RHD and ≥1 year of follow-up were included. All echocardiograms were re-reviewed by experts (2012 World Heart Federation criteria) for inclusion and evidence of change. Bi- and multivariable logistic regression, Kaplan-Meier analysis, and Cox proportional hazards models, as well, were developed to search for risk factors for unfavorable outcome and compare progression-free survival between those treated and not treated with penicillin. Propensity and other matching methods with sensitivity analysis were implemented for the evaluation of the penicillin effect. RESULTS Blinded review confirmed 227 cases of latent RHD: 164 borderline and 63 definite (42 mild, 21 moderate/severe). Median age at diagnosis was 12 years and median follow-up was 2.3 years (interquartile range, 2.0-2.9). Penicillin prophylaxis was prescribed in 49.3% with overall adherence of 84.7%. Of children with moderate-to-severe definite RHD, 47.6% had echocardiographic progression (including 2 deaths), and 9.5% had echocardiographic regression. Children with mild definite and borderline RHD showed 26% and 9.8% echocardiographic progression and 45.2% and 46.3% echocardiographic improvement, respectively. Of those with mild definite RHD or borderline RHD, more advanced disease category, younger age, and morphological mitral valve features were risk factors for an unfavorable outcome. CONCLUSIONS Latent RHD is a heterogeneous diagnosis with variable disease outcomes. Children with moderate to severe latent RHD have poor outcomes. Children with both borderline and mild definite RHD are at substantial risk of progression. Although long-term outcome remains unclear, the initial change in latent RHD may be evident during the first 1 to 2 years following diagnosis. Natural history data are inherently limited, and a randomized clinical trial is needed to definitively determine the impact of penicillin prophylaxis on the trajectory of latent RHD.
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Affiliation(s)
- Andrea Beaton
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.).
| | - Twalib Aliku
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Alyssa Dewyer
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Marni Jacobs
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Jiji Jiang
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Chris T Longenecker
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Sulaiman Lubega
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Robert McCarter
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Mariana Mirabel
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Grace Mirembe
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Judith Namuyonga
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Emmy Okello
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Amy Scheel
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Emmanuel Tenywa
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Craig Sable
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
| | - Peter Lwabi
- Children's National Health System, Washington DC (A.B., A.D., M.J., J.J., R.M., A.S., C.S.). Gulu University, Uganda (T.A.). Case Western Reserve University, Cleveland, OH (C.T.L.). Uganda Heart Institute, Kampala (S.L., J.N., E.O., E.T., P.L.). INSERM U970 (French National Institute of Health and Medical Research), Paris-Cardiovascular Research Center PARCC, France (M.M.). Joint Clinical Research Centers, Kampala, Uganda (G.M.)
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Abstract
Rheumatic heart disease (RHD) is a chronic valvular disease resulting after severe or repetitive episodes of acute rheumatic fever (ARF), an autoimmune response to group A Streptococcus infection. RHD has been almost eliminated with improved social and health infrastructure in affluent countries while it remains a neglected disease with major cause of morbidity and mortality in many low- and middle-income countries, and resource-limited regions of high-income countries. Despite our evolving understanding of the pathogenesis of RHD, there have not been any significant advances to prevent or halt progression of disease in recent history. Long-term penicillin-based treatment and surgery remain the backbone of a RHD control program in the absence of an effective vaccine. The advent of echocardiographic screening algorithms has improved the accuracy of diagnosing RHD and has shed light on the enormous burden of disease. Encouragingly, this has led to a rekindled commitment from researchers in the most affected countries to advocate and take bold actions to end this disease of social inequality.
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Affiliation(s)
- Bethel Woldu
- Vanderbilt Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Suite 750, Nashville, TN, 37203, USA
| | - Gerald S Bloomfield
- Duke Clinical Research Institute, Duke University, 2400 Pratt Street, Durham, NC, 27705, USA.
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Robinson A, Hulme-Moir S, Puloka V, Smith M, Stanley J, Signal L. Housing as a Determinant of Tongan Children's Health: Innovative Methodology Using Wearable Cameras. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:E1170. [PMID: 28976919 PMCID: PMC5664671 DOI: 10.3390/ijerph14101170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 11/17/2022]
Abstract
Housing is a significant determinant of health, particularly in developing countries such as Tonga. Currently, very little is known about the quality of the housing in Tonga, as is the case with many developing countries, nor about the interaction between children and the home environment. This study aimed to identify the nature and extent of health risk factors and behaviours in Tongan houses from a child's perspective. An innovative methodology was used, Kids'Cam Tonga. Seventy-two Class 6 children (10 to 13-year-olds) were randomly selected from 12 randomly selected schools in Tongatapu, the main island. Each participating child wore a wearable camera on lanyards around their neck. The device automatically took wide-angled, 136° images of the child's perspective every seven seconds. The children were instructed to wear the camera all day from Friday morning to Sunday evening, inclusive. The analysis showed that the majority of Tongan children in the study live in houses that have structural deficiencies and hazards, including water damage (42%), mould (36%), and electrical (89%) and burn risk factors (28%). The findings suggest that improvements to the housing stock may reduce the associated health burden and increase buildings' resilience to natural hazards. A collaborative approach between communities, community leaders, government and non-governmental organisations (NGOs) is urgently needed. This research methodology may be of value to other developing countries.
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Affiliation(s)
- Andrew Robinson
- Health Promotion & Policy Research Unit, University of Otago, 6242 Wellington, New Zealand.
| | - Sarah Hulme-Moir
- Health Promotion & Policy Research Unit, University of Otago, 6242 Wellington, New Zealand.
| | - Viliami Puloka
- Health Promotion & Policy Research Unit, University of Otago, 6242 Wellington, New Zealand.
| | - Moira Smith
- Health Promotion & Policy Research Unit, University of Otago, 6242 Wellington, New Zealand.
| | - James Stanley
- Health Promotion & Policy Research Unit, University of Otago, 6242 Wellington, New Zealand.
| | - Louise Signal
- Health Promotion & Policy Research Unit, University of Otago, 6242 Wellington, New Zealand.
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A rapid echocardiographic screening protocol for rheumatic heart disease in Samoa: a high prevalence of advanced disease. Cardiol Young 2017; 27:1599-1605. [PMID: 28857729 DOI: 10.1017/s1047951117000907] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Saxena A, Desai A, Narvencar K, Ramakrishnan S, Thangjam RS, Kulkarni S, Jacques' E Costa AK, Mani K, Dias A, Sukharamwala R. Echocardiographic prevalence of rheumatic heart disease in Indian school children using World Heart Federation criteria - A multi site extension of RHEUMATIC study (the e-RHEUMATIC study). Int J Cardiol 2017; 249:438-442. [PMID: 28966041 DOI: 10.1016/j.ijcard.2017.09.184] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/18/2017] [Accepted: 09/20/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Rheumatic heart disease (RHD) continues to be major public health burden in developing world. Echocardiographic screening in school children has shown that subclinical RHD cases are several times more than clinical cases. Recent reports have used World Heart Federation (WHF) criteria. Objective of present study was to determine RHD prevalence using WHF criteria in Indian children. METHODS Children (5-15years) from randomly selected schools across four sites were included. After focused clinical evaluation, echocardiography was performed using WHF criteria in all children. Images/loops of abnormal cases were analyzed independently by an additional experienced cardiologist. Children with murmur and confirmatory echocardiography were categorized 'clinical RHD'; those with abnormal echocardiography alone were labeled 'subclinical RHD'. RESULTS Among 16,294 children included, mean age was 10.8 ± 2.9years; 55.1% were males; 11,405 (70%) were from rural areas and 3978 (24.4%) were from government schools. We detected RHD by echocardiography in 125 children [prevalence: 7.7/1000 (95% CI 6.3, 9.0)]. Borderline RHD was present in 93 children (5.7/1000, 95% CI 4.6, 6.9), definite RHD in 32 (2/1000, 95% CI 1.2, 2.6), and clinical RHD in six [0.36/1000, 95% CI: 0.1-0.7]. On univariate analysis, older age, female gender, and higher waist circumference were associated while on multivariate analysis, older age (OR 1.18, 95% CI: 1.09, 1.26) and female gender (OR 1.61, 95% CI: 1.13, 2.3) were associated with RHD. CONCLUSION RHD prevalence varies in different parts of India. Echocardiographic prevalence is several times higher than clinical and underscores importance of echocardiographic screening in community.
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Affiliation(s)
- Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
| | - Ankush Desai
- Department of Medicine, Goa Medical College, Bambolim, Goa, India
| | | | | | - Rajendra Singh Thangjam
- Department of Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
| | | | | | - Kalaivani Mani
- Department of Biostatistics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Amit Dias
- Department of Preventive & Social Medicine, Goa Medical College, Bambolim, Goa, India
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Branco CEDB, Sampaio RO, Bracco MM, Morhy SS, Vieira MLC, Guilherme L, Rizzo LV, Tarasoutch F. Rheumatic Fever: a neglected and underdiagnosed disease. New perspective on diagnosis and prevention. Arq Bras Cardiol 2017; 107:482-484. [PMID: 27982273 PMCID: PMC5137393 DOI: 10.5935/abc.20160150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 08/08/2016] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Mario Maia Bracco
- Hospital Israelita Albert Einstein, São Paulo, SP - Brazil.,Centro de Estudos e Pesquisas Dr. João Amorim (CEJAM) - São Paulo, SP - Brazil
| | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração - InCor, São Paulo, SP - Brazil.,Hospital Israelita Albert Einstein, São Paulo, SP - Brazil
| | | | | | - Flavio Tarasoutch
- Instituto do Coração - InCor, São Paulo, SP - Brazil.,Hospital Israelita Albert Einstein, São Paulo, SP - Brazil
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Webb RH, Culliford-Semmens N, Sidhu K, Wilson NJ. Normal echocardiographic mitral and aortic valve thickness in children. HEART ASIA 2017; 9:70-75. [PMID: 28405228 DOI: 10.1136/heartasia-2016-010872] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE We aimed to define the normal range of aortic and mitral valve thickness in healthy schoolchildren from a high prevalence rheumatic heart disease (RHD) region, using a standardised protocol for imaging and measurement. METHODS Measurements were performed in 288 children without RHD. Anterior mitral valve leaflet (AMVL) thickness measurements were performed at the midpoint and tip of the leaflet in the parasternal long axis (PSLA) in diastole, when the AMVL was approximately parallel to the ventricular septum. Thickness of the aortic valve was measured from PSLA imaging in systole when the leaflets were at maximum excursion. The right coronary and non-coronary closure lines of the aortic valve were measured in diastole in parasternal short axis (PSSA) imaging. Results were compared with 51 children with RHD classified by World Heart Federation diagnostic criteria. RESULTS In normal children, median AMVL tip thickness was 2.0 mm (IQR 1.7-2.4) and median AMVL midpoint thickness 2.0 mm (IQR 1.7-2.4). The median aortic valve thickness was 1.5 mm (IQR 1.3-1.6) in the PSLA view and 1.4 mm (IQR 1.2-1.6) in the PSSA view. The interclass correlation coefficient for the AMVL tip was 0.85 (0.71 to 0.92) and for the AMVL midpoint was 0.77 (0.54 to 0.87). CONCLUSIONS We have described a standardised method for mitral and aortic valve measurement in children which is objective and reproducible. Normal ranges of left heart valve thickness in a high prevalence RHD population are established. These results provide a reference range for school-age children in high prevalence RHD regions undergoing echocardiographic screening.
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Affiliation(s)
- Rachel H Webb
- Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand; Paediatric Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
| | - Nicola Culliford-Semmens
- Green Lane Paediatric and Congenital Cardiac Services , Starship Children's Hospital , Auckland , New Zealand
| | - Karishma Sidhu
- Green Lane Cardiovascular Services , Auckland City Hospital , Auckland , New Zealand
| | - Nigel J Wilson
- Green Lane Paediatric and Congenital Cardiac Services , Starship Children's Hospital , Auckland , New Zealand
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Group A Streptococcus, Acute Rheumatic Fever and Rheumatic Heart Disease: Epidemiology and Clinical Considerations. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:15. [PMID: 28285457 PMCID: PMC5346434 DOI: 10.1007/s11936-017-0513-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OPINION STATEMENT Early recognition of group A streptococcal pharyngitis and appropriate management with benzathine penicillin using local clinical prediction rules together with validated rapi-strep testing when available should be incorporated in primary health care. A directed approach to the differential diagnosis of acute rheumatic fever now includes the concept of low-risk versus medium-to-high risk populations. Initiation of secondary prophylaxis and the establishment of early medium to long-term care plans is a key aspect of the management of ARF. It is a requirement to identify high-risk individuals with RHD such as those with heart failure, pregnant women, and those with severe disease and multiple valve involvement. As penicillin is the mainstay of primary and secondary prevention, further research into penicillin supply chains, alternate preparations and modes of delivery is required.
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41
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Abstract
Primarily affecting the young, rheumatic heart disease (RHD) is a neglected chronic disease commonly causing premature morbidity and mortality among the global poor. Standard clinical prevention and treatment is based on studies from the early antimicrobial era, as research investment halted soon after the virtual eradication of the disease from developed countries. The emergence of new global data on disease burden, new technologies, and a global health equity platform have revitalized interest and investment in RHD. This review surveys past and current evidence for standard RHD diagnosis and treatment, highlighting gaps in knowledge.
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Affiliation(s)
- Shanti Nulu
- Section of Cardiovascular Medicine, Yale School of Medicine, 789 Howard Avenue, New Haven, CT 06519, USA
| | - Gene Bukhman
- Division of Global Health Equity, Brigham and Women's Hospital, 641 Huntington Avenue, Boston, MA 02115, USA; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Gene F Kwan
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA; Section of Cardiovascular Medicine, Boston University Medical Center, Boston University School of Medicine, 88 East Newton Street, D8, Boston, MA 02118, USA.
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43
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Abstract
Rheumatic heart disease (RHD) is a disease of poverty, is almost entirely preventable, and is the most common cardiovascular disease worldwide in those under 25 years. RHD is caused by acute rheumatic fever (ARF) which typically results in cumulative valvular lesions that may present clinically after a number of years of subclinical disease. Therapeutic interventions, therefore, typically focus on preventing subsequent ARF episodes (with penicillin prophylaxis). However, not all patients with ARF develop symptoms and not all symptomatic cases present to a physician or are correctly diagnosed. Therefore, if we hope to control ARF and RHD at the population level, we need a more reliable discriminator of subclinical disease. Recent studies have examined the utility of echocardiographic screening, which is far superior to auscultation at detecting RHD. However, there are many concerns surrounding this approach. Despite the introduction of the World Heart Federation diagnostic criteria in 2012, we still do not really know what constitutes the most subtle changes of RHD by echocardiography. This poses serious problems regarding whom to treat and what to do with the rest, both important decisions with widespread implications for already stretched health-care systems. In addition, issues ranging from improving the uptake of penicillin prophylaxis in ARF/RHD-positive patients, improving portable echocardiographic equipment, understanding the natural history of subclinical RHD and how it might respond to penicillin, and developing simplified diagnostic criteria that can be applied by nonexperts, all need to be effectively tackled before routine widespread screening for RHD can be endorsed.
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Affiliation(s)
- Scott Dougherty
- Department of Internal Medicine, Ministry of Health, Belau National Hospital, Koror, Republic of Palau
| | - Maziar Khorsandi
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Philip Herbst
- Division of Cardiology, Tygerberg Academic Hospital, University of Stellenbosch, Cape Town, South Africa
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Rheumatic heart disease in a developing country: Incidence and trend (Monastir; Tunisia: 2000-2013). Int J Cardiol 2016; 228:628-632. [PMID: 27883972 DOI: 10.1016/j.ijcard.2016.11.249] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/07/2016] [Accepted: 11/10/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND The penicillin therapy of β hemolytic streptococcal pharyngitis has aided in the decrease of rheumatic heart disease (RHD) in developing countries. Tunisia is an endemic area, however, and incidence of RHD is weakly documented. We aimed at establishing the standardized incidence rate (SIR) of RHD in Monastir governorate and at determining RHD prevalence among hospitalized patients in two cardiology departments. METHODS From the regional register of Monastir Hospital morbidity, we have selected newly diagnosed patients with RHD, residents of Monastir, and hospitalized to the 2 cardiology departments between 2000 and 2013 (2001 not included). FINDINGS We studied 676 newly admitted patients. We estimate 1060 to be the number of new annual RHD cases in Tunisia. The SIR per 105 person-years was 10.97, being 9.3 in men and 19.1 in women, respectively. We have notified a negative trend of crude incidence rate/105 Inhabitants (Inh) (CIR) (r=-0.23, p<10-3), and a strong positive correlation between age and CIR/105 Inh (r=0.989, p<10-4). RHD lethality was 1%. We have registered 728 hospitalizations for RHD, representing 2.5% of all cardiology hospitalizations [95% CI: 2.3-2.7%], with a prevalence for 13.3% for women aged 15-29years. The median hospital stay was 9days (IQR: 5-15). CONCLUSION Our results confirm the RHD incidence decrease, consistent with epidemiological transition in Tunisia. We have also emphasized on the close trend of RHD with age and the predominance of RHD among women especially at the procreation age.
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Abstract
PURPOSE OF REVIEW The purpose is to provide a broad overview of the current state of knowledge of pathogenesis, diagnosis, and management of rheumatic heart disease (RHD). RECENT FINDINGS Studies on pathogenesis of RHD have focused on autoimmunity because of molecular mimicry between the streptococcal M antigen α-helical coiled-coil structure and sarcomeric proteins such as myosin and tropomyosin. More recently, nonsarcomeric autoantigens, endothelial injury and the innate immune system have been proposed to play key roles in the pathogenesis of RHD. In the 2015 revised Jones Criteria, the importance of echocardiography and subclinical carditis in the diagnosis of acute rheumatic fever is highlighted. Experimental studies with targeted anti-inflammatory therapeutics have been largely unsuccessful and the only established treatment is still lifelong antibiotics. Efforts to improve patient selection and outcomes with percutaneous mitral balloon valvuloplasty are ongoing. With regard to surgical management, several groups have demonstrated excellent operative and midterm outcomes from valve repair as opposed to valve replacement. SUMMARY There are still many unanswered questions regarding RHD pathogenesis. The only accepted medical treatment is still long-term antibiotic therapy, whereas advances in mitral repair techniques have led to successful durable repairs being performed in high-volume, expert centers.
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Evaluation of a focussed protocol for hand-held echocardiography and computer-assisted auscultation in detecting latent rheumatic heart disease in scholars. Cardiol Young 2016; 26:1097-106. [PMID: 26423122 DOI: 10.1017/s1047951115001857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED Introduction Echocardiography is the diagnostic test of choice for latent rheumatic heart disease. The utility of echocardiography for large-scale screening is limited by high cost, complex diagnostic protocols, and time to acquire multiple images. We evaluated the performance of a brief hand-held echocardiography protocol and computer-assisted auscultation in detecting latent rheumatic heart disease with or without pathological murmur. METHODS A total of 27 asymptomatic patients with latent rheumatic heart disease based on the World Heart Federation criteria and 66 healthy controls were examined by standard cardiac auscultation to detect pathological murmur. Hand-held echocardiography using a focussed protocol that utilises one view - that is, the parasternal long-axis view - and one measurement - that is, mitral regurgitant jet - and a computer-assisted auscultation utilising an automated decision tool were performed on all patients. RESULTS The sensitivity and specificity of computer-assisted auscultation in latent rheumatic heart disease were 4% (95% CI 1.0-20.4%) and 93.7% (95% CI 84.5-98.3%), respectively. The sensitivity and specificity of the focussed hand-held echocardiography protocol for definite rheumatic heart disease were 92.3% (95% CI 63.9-99.8%) and 100%, respectively. The test reliability of hand-held echocardiography was 98.7% for definite and 94.7% for borderline disease, and the adjusted diagnostic odds ratios were 1041 and 263.9 for definite and borderline disease, respectively. CONCLUSION Computer-assisted auscultation has extremely low sensitivity but high specificity for pathological murmur in latent rheumatic heart disease. Focussed hand-held echocardiography has fair sensitivity but high specificity and diagnostic utility for definite or borderline rheumatic heart disease in asymptomatic patients.
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Affiliation(s)
- Rachel Hajar
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Corsenac P, Heenan RC, Roth A, Rouchon B, Guillot N, Hoy D. An epidemiological study to assess the true incidence and prevalence of rheumatic heart disease and acute rheumatic fever in New Caledonian school children. J Paediatr Child Health 2016; 52:739-44. [PMID: 27203400 DOI: 10.1111/jpc.13185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/30/2015] [Accepted: 02/19/2016] [Indexed: 11/29/2022]
Abstract
AIM To provide in New Caledonian school children (i) the prevalence of rheumatic heart disease (RHD) detected by annual screening program using new World Heart Federation diagnostic criteria; (ii) the point prevalence of acute rheumatic fever (ARF); and (iii) to investigate socio-demographic risk factors associated with RHD. METHODS This study linked data from national ARF/RHD programs by combining ARF incidence data from the register with RHD prevalence data from echocardiographic screening data for a single age year of the population for overall point prevalence ARF/RHD rates. For the analysis, cases of echocardiographic detection of RHD are presumed to be synonymous with undiagnosed ARF. All results were weighted to minimise the bias introduced from absent pupils of each annual screening program. Incidence and prevalence were age-standardised to the WHO World Standard Population. Each 2013 cumulative prevalence of definite and borderline RHD was studied using a multivariate logistic regression adjusted for socio-demographic factors. RESULTS The overall age-standardised incidence of clinical and undiagnosed ARF (i.e. echocardiographic-detected RHD) was combined as point prevalence and estimated to be 99/10 000 cases in 2012 and 114/10 000 cases in 2013. This included 40/10 000 prevalent cases of asymptomatic RHD detected by screening each year. Being Melanesian, OR 23.2 (95% CI: 3.4-157.3), or Polynesian, OR 21.5 (95% CI: 2.9-157.7), was associated with a higher prevalence of having definite RHD compared with being Caucasian. Being a girl was associated with a higher risk of having borderline RHD, OR 1.9 (95% CI: 1.03-3.3). CONCLUSION Without echocardiographic screening, ARF/RHD burden is substantially underestimated.
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Affiliation(s)
- Philippe Corsenac
- Department of Epidemiology, ASSNC, Noumea, New Caledonia.,Health and Social Agency of New Caledonia (ASSNC), Noumea, New Caledonia
| | - Rachel C Heenan
- The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Adam Roth
- Public Health Agency of Sweden, 171 82, Stockholm, Sweden.,Research Evidence and Information Programme, Secretariat of the Pacific Community, Noumea, New Caledonia
| | - Bernard Rouchon
- Health and Social Agency of New Caledonia (ASSNC), Noumea, New Caledonia
| | - Nina Guillot
- Health and Social Agency of New Caledonia (ASSNC), Noumea, New Caledonia.,Department of ARF and RHD, ASSNC, Noumea, New Caledonia
| | - Damian Hoy
- Public Health Agency of Sweden, 171 82, Stockholm, Sweden
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Roberts KV, Maguire GP, Brown A, Atkinson DN, Remenyi B, Wheaton G, Ilton M, Carapetis J. Rheumatic heart disease in Indigenous children in northern Australia: differences in prevalence and the challenges of screening. Med J Aust 2016; 203:221.e1-7. [PMID: 26852054 DOI: 10.5694/mja15.00139] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/19/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To compare regional differences in the prevalence of rheumatic heart disease (RHD) detected by echocardiographic screening in high-risk Indigenous Australian children, and to describe the logistical and other practical challenges of RHD screening. DESIGN Cross-sectional screening survey performed between September 2008 and November 2010. SETTING Thirty-two remote communities in four regions of northern and central Australia. PARTICIPANTS 3946 Aboriginal or Torres Strait Islander children aged 5-15 years. INTERVENTION Portable echocardiography was performed by cardiac sonographers. Echocardiograms were recorded and reported offsite by a pool of cardiologists. MAIN OUTCOME MEASURES RHD was diagnosed according to 2012 World Heart Federation criteria. RESULTS The prevalence of definite RHD differed between regions, from 4.7/1000 in Far North Queensland to 15.0/1000 in the Top End of the Northern Territory. The prevalence of definite RHD was greater in the Top End than in other regions (odds ratio, 2.3; 95% CI, 1.2-4.6, P = 0.01). Fifty-three per cent of detected cases of definite RHD were new cases; the prevalence of new cases of definite RHD was 4.6/1000 for the entire sample and 7.0/1000 in the Top End. Evaluation of socioeconomic data suggests that the Top End group was the most disadvantaged in our study population. CONCLUSIONS The prevalence of definite RHD in remote Indigenous Australian children is significant, with a substantial level of undetected disease. Important differences were noted between regions, with the Top End having the highest prevalence of definite RHD, perhaps explained by socioeconomic factors. Regional differences must be considered when evaluating the potential benefit of widespread echocardiographic screening in Australia.
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Affiliation(s)
| | | | - Alex Brown
- South Australian Health and Medical Research Institute, Adelaide, SA
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Lee ES, Vedanthan R, Jeemon P, Kamano JH, Kudesia P, Rajan V, Engelgau M, Moran AE. Quality Improvement for Cardiovascular Disease Care in Low- and Middle-Income Countries: A Systematic Review. PLoS One 2016; 11:e0157036. [PMID: 27299563 PMCID: PMC4907518 DOI: 10.1371/journal.pone.0157036] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/24/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care. OBJECTIVES As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs. METHODS We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD. RESULTS From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months. CONCLUSIONS The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.
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Affiliation(s)
- Edward S. Lee
- Department of Medicine, Division of Geriatric, Hospital, Palliative and General Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California, United States of America
| | - Rajesh Vedanthan
- Department of Medicine, Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Panniyammakal Jeemon
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Kerala, India
| | - Jemima H. Kamano
- Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Preeti Kudesia
- Health, Nutrition and Population Global Practice, The World Bank, Kathmandu, Nepal
| | | | - Michael Engelgau
- Center for Translation Research and Implementation Science, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Andrew E. Moran
- Department of Medicine, Division of General Medicine, Columbia University Medical Center, New York, New York, United States of America
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