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Nascimento BR, Nunes MCP, da Silva JLP, Steer A, Engelman D, Okello E, Rwebembera J, Zuhlke L, Mirabel M, Nakitto M, Sarnacki R, Ribeiro ALP, Sable CA, Beaton AZ. Outcomes of latent rheumatic heart disease: External validation of a simplified score in patients with and without secondary prophylaxis. Int J Cardiol 2024; 399:131662. [PMID: 38141728 DOI: 10.1016/j.ijcard.2023.131662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Secondary antibiotic prophylaxis reduces progression of latent rheumatic heart disease (RHD) but not all children benefit. Improved risk stratification could refine recommendations following positive screening. We aimed to evaluate the performance of a previously developed echocardiographic risk score to predict mid-term outcomes among children with latent RHD. METHODS We included children who completed the GOAL, a randomized trial of secondary antibiotic prophylaxis among children with latent RHD in Uganda. Outcomes were determined by a 4-member adjudication panel. We applied the point-based score, consisting of 5 variables (mitral valve (MV) anterior leaflet thickening (3 points), MV excessive leaflet tip motion (3 points), MV regurgitation jet length ≥ 2 cm (6 points), aortic valve focal thickening (4 points) and any aortic regurgitation (5 points)), to panel results. Unfavorable outcome was defined as progression of diagnostic category (borderline to definite, mild definite to moderate/severe definite), worsening valve involvement or remaining with mild definite RHD. RESULTS 799 patients (625 borderline and 174 definite RHD) were included, with median follow-up of 24 months. At total 116 patients (14.5%) had unfavorable outcome per study criteria, 57.8% not under prophylaxis. The score was strongly associated with unfavorable outcome (HR = 1.26, 95% CI 1.16-1.37, p < 0.001). Unfavorable outcome rates in low (≤6 points), intermediate (7-9 points) and high-risk (≥10 points) children at follow-up were 11.8%, 30.4%, and 42.2%, (p < 0.001) respectively (C-statistic = 0.64 (95% CI 0.59-0.69)). CONCLUSIONS The simple risk score provided an accurate prediction of RHD status at 2-years, showing a good performance in a population with milder RHD phenotypes.
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Affiliation(s)
- Bruno R Nascimento
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil; Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil; Serviço de Hemodinâmica, Hospital Madre Teresa, Belo Horizonte, MG, Brazil.
| | - Maria Carmo P Nunes
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil; Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Jose Luiz P da Silva
- Departamento de Estatística, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Andrew Steer
- Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel Engelman
- Melbourne Children's Global Health, Royal Children's Hospital, Melbourne, Australia, and Telethon Kids Institute, Perth Children's Hospital, University of Western Australia, Perth, Australia
| | - Emmy Okello
- Uganda Heart Institute and the Department of Medicine, Makerere University, Kampala, Uganda
| | - Joselyn Rwebembera
- Uganda Heart Institute and the Department of Medicine, Makerere University, Kampala, Uganda
| | - Liesl Zuhlke
- South African Medical Research Council, Parow Cape Town, Division of Paediatric Cardiology, Department of Paediatrics, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | | | - Miriam Nakitto
- Uganda Heart Institute and the Department of Medicine, Makerere University, Kampala, Uganda
| | - Rachel Sarnacki
- Cardiology, Children's National Hospital, Washington, DC, USA
| | - Antonio Luiz P Ribeiro
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil; Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Craig A Sable
- Cardiology, Children's National Hospital, Washington, DC, USA
| | - Andrea Z Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center, and the University of Cincinnati School of Medicine, Cincinnati, OH, USA
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Urina-Jassir M, Jaimes-Reyes MA, Urina-Jassir D, Urina-Triana M, Urina-Triana M. The role of echocardiographic screening in reducing the burden of rheumatic heart disease in Latin America. Rev Panam Salud Publica 2023; 47:e158. [PMID: 38089109 PMCID: PMC10712574 DOI: 10.26633/rpsp.2023.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/07/2023] [Indexed: 03/08/2024] Open
Abstract
The objectives of this article are to reflect on the rationale behind the use of echocardiographic screening for rheumatic heart disease and to provide key recommendations about steps needed to implement and improve echocardiographic screening programs in Latin America. Rheumatic heart disease remains a public health problem affecting mainly low-income and lower-middle-income countries and populations. Latin America is an area with economic inequalities, and the epidemiology of rheumatic heart disease remains largely unknown. Echocardiographic screening is useful for updating the epidemiology and providing early diagnosis of the disease. We discuss different approaches used in successful echocardiographic screening programs worldwide and in Latin America. We then identify the key elements needed to establish successful echocardiographic screening programs in Latin America, including increased awareness and involvement from multiple sectors (e.g. the community, health care professionals, scientific organizations and public health entities), identification of areas in need, development of a plan and structure that include different screening approaches, and how to ensure appropriate follow up for those who screen positive.
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Affiliation(s)
- Manuel Urina-Jassir
- Department of MedicineBoston University Chobanian and Avedisian School of MedicineBostonUnited States of AmericaDepartment of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, United States of America
| | - Maria Alejandra Jaimes-Reyes
- Department of Internal MedicineMedStar Washington Hospital CenterWashington, D.C.United States of AmericaDepartment of Internal Medicine, MedStar Washington Hospital Center, Washington, D.C., United States of America
| | - Daniela Urina-Jassir
- Section of CardiologyJohn W. Deming Department of MedicineTulane University School of MedicineNew OrleansUnited States of AmericaSection of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, United States of America
| | - Manuel Urina-Triana
- Unidad de Epidemiología ClínicaCentro de Investigación en Ciencias de la VidaUniversidad Simón BolívarBarranquillaColombiaUnidad de Epidemiología Clínica, Centro de Investigación en Ciencias de la Vida, Universidad Simón Bolívar, Barranquilla, Colombia
| | - Miguel Urina-Triana
- Programa de CardiologíaFacultad de Ciencias de la SaludUniversidad Simón BolívarBarranquillaColombiaPrograma de Cardiología, Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla, Colombia
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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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Hunter LD, Doubell AF, Pecoraro AJK, Monaghan M, Lloyd G, Lombard C, Herbst PG. Morpho-mechanistic screening criteria for the echocardiographic detection of rheumatic heart disease. Heart 2023:heartjnl-2022-322192. [PMID: 37117004 DOI: 10.1136/heartjnl-2022-322192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/24/2023] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Screening echocardiography, guided by the current World Heart Federation (WHF) criteria, has important limitations that impede the establishment of large-scale rheumatic heart disease (RHD) control programmes in endemic regions. The criteria misclassify a significant number of normal cases as borderline RHD. Prior attempts to simplify them are limited by incorporation bias due to the lack of an externally validated, accurate diagnostic test for RHD. We set out to assess novel screening criteria designed to avoid incorporation bias and to compare this against the performance of the current WHF criteria. METHODS The performance of the WHF and the morpho-mechanistic (MM) RHD screening criteria (a novel set of screening criteria that evaluate leaflet morphology, motion and mechanism of regurgitation) as well as a simplified RHD MM 'rule-out' test (based on identifying a predefined sign of anterior mitral valve leaflet restriction for the mitral valve and any aortic regurgitation for the aortic valve) were assessed in two contrasting cohorts: first, a low-risk RHD cohort consisting of children with a very low-risk RHD profile. and second, a composite reference standard (CRS) RHD-positive cohort that was created using a composite of two criteria to ensure a cohort with the highest possible likelihood of RHD. Subjects included in this group required (1) proven, prior acute rheumatic fever and (2) current evidence of predefined valvular regurgitation on echocardiography. RESULTS In the low-risk RHD cohort (n=364), the screening specificities for detecting RHD of the MM and WHF criteria were 99.7% and 95.9%, respectively (p=0.0002). The MM rule-out test excluded 359/364 cases (98.6%). In the CRS RHD-positive cohort (n=65), the screening sensitivities for the detection of definite RHD by MM and WHF criteria were 92.4% and 89.2%, respectively (p=0.2231). The MM RHD rule-out test did not exclude any cases from the CRS RHD-positive cohort. CONCLUSION Our proposed MM approach showed an equal sensitivity to the WHF criteria but with significantly improved specificity. The MM RHD rule-out test excluded RHD-negative cases while identifying all cases within the CRS RHD-positive cohort. This holds promise for the development of a two-step RHD screening algorithm to enable task shifting in RHD endemic regions.
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Affiliation(s)
- Luke David Hunter
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Anton Frans Doubell
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Alfonso Jan Kemp Pecoraro
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Mark Monaghan
- Department of Cardiology, King's College Hospital, London, UK
| | - Guy Lloyd
- Echocardiography Laboratory, Barts Heart Centre, St Bartholomew's Hospital, London, UK
- Institute of Cardiovascular Sciences, University College London, London, UK
- William Harvey Research Institute Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Carl Lombard
- Division of Epidemiology and Biostatistics, Department of Global Health Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Philipus George Herbst
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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Seitler S, Zuhair M, Shamsi A, Bray JJH, Wojtaszewska A, Siddiqui A, Ahmad M, Fairley J, Providencia R, Akhtar A. Cardiac imaging in rheumatic heart disease and future developments. EUROPEAN HEART JOURNAL OPEN 2023; 3:oeac060. [PMID: 36876318 PMCID: PMC9981871 DOI: 10.1093/ehjopen/oeac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/26/2022] [Accepted: 09/20/2022] [Indexed: 02/22/2023]
Abstract
Rheumatic heart disease (RHD) is the most common cause of valvular heart disease worldwide, affecting millions, especially in low- and middle-income countries. Multiple imaging modalities such as cardiac CT, cardiac MRI, and three-dimensional echocardiography may be utilized in diagnosing, screening, and managing RHD. However, two-dimensional transthoracic echocardiography remains the cornerstone of imaging in RHD. Criteria developed by the World Heart Foundation in 2012 sought to unify the diagnostic imaging criteria for RHD, but concerns remain regarding their complexity and reproducibility. In the intervening years, further measures have been developed to find a balance between simplicity and accuracy. Nonetheless, there remain significant unresolved problems within imaging in RHD, including the development of a practical and sensitive screening tool to identify patients with RHD. The emergence of handheld echocardiography has the potential to revolutionize RHD management in resource-poor settings, but its role as a screening or diagnostic tool is yet to be fully established. The dramatic evolution of imaging modalities over the last few decades has not addressed RHD compared to other forms of structural heart disease. In this review, we examine the current and latest developments concerning cardiac imaging and RHD.
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Affiliation(s)
- Samuel Seitler
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Mohamed Zuhair
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Aamir Shamsi
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | | | - Alexandra Wojtaszewska
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Atif Siddiqui
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Mahmood Ahmad
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Jonathan Fairley
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Rui Providencia
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Abid Akhtar
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
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Pecoraro AJK, Herbst PG, Pienaar C, Taljaard J, Prozesky H, Janson J, Doubell AF. Modified Duke/European Society of Cardiology 2015 clinical criteria for infective endocarditis: time for an update? Open Heart 2022; 9:openhrt-2021-001856. [PMID: 35534094 PMCID: PMC9086646 DOI: 10.1136/openhrt-2021-001856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 04/21/2022] [Indexed: 11/21/2022] Open
Abstract
Background The diagnosis of infective endocarditis (IE) is based on the modified Duke/European Society of Cardiology (ESC) 2015 clinical criteria. The sensitivity of the criteria is unknown in South Africa, but high rates of blood culture negative endocarditis (BCNIE), coupled with a change in the clinical features of IE, may limit the sensitivity. Methods The Tygerberg Endocarditis Cohort study prospectively enrolled patients with IE between November 2019 and June 2021. A standardised protocol for organism detection, with management of patients by an Endocarditis Team, was employed. Patients with definite IE by pathological criteria were analysed to determine the sensitivity of the current clinical criteria. Results Eighty consecutive patients with IE were included of which 45 (56.3%) had definite IE by pathological criteria. In patients with definite IE by pathological criteria, 26/45 (57.8%) of patients were classified as definite IE by clinical criteria. BCNIE was present in 25/45 (55.6%) of patients and less than three minor clinical criteria were present in 32/45 (75.6%) of patients. The elevation of Bartonella serology to a major microbiological criterion of the modified Duke/ESC 2015 clinical criteria would increase the sensitivity (57.8% vs 77.8%; p=0.07). Conclusion The sensitivity of the modified Duke/ESC 2015 clinical criteria is lower than expected in patients with IE in South Africa, primarily due to the high rates of Bartonella-associated BCNIE. The elevation of Bartonella serology to a major microbiological criterion, similar to the status of Coxiella burnetii in the current criteria, would increase the sensitivity. The majority of patients with definite IE by pathological criteria had less than three minor criteria present.
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Affiliation(s)
- Alfonso Jan Kemp Pecoraro
- Division of Cardiology, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Philipus George Herbst
- Division of Cardiology, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Colette Pienaar
- Division of Medical Microbiology, Department of Pathology, Stellenbusch University Faculty of Medicine and Health Sceinces, Cape Town, Western Cape, South Africa.,National Health Laboratory Service, Johannesburg, Gauteng, South Africa
| | - Jantjie Taljaard
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Hans Prozesky
- Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Jacques Janson
- Division of Cardiothoracic Surgery, Department of Surgery, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Anton Frans Doubell
- Division of Cardiology, Department of Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
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