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Providência R, Aali G, Zhu F, Katairo T, Ahmad M, Bray JJH, Pelone F, Khanji MY, Marijon E, Cassandra M, Celermajer DS, Shokraneh F. Handheld echocardiography for the screening and diagnosis of rheumatic heart disease: a systematic review to inform WHO guidelines. Lancet Glob Health 2024; 12:e983-e994. [PMID: 38762298 DOI: 10.1016/s2214-109x(24)00127-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/29/2024] [Accepted: 03/08/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Early detection and diagnosis of acute rheumatic fever and rheumatic heart disease are key to preventing progression, and echocardiography has an important diagnostic role. Standard echocardiography might not be feasible in high-prevalence regions due to its high cost, complexity, and time requirement. Handheld echocardiography might be an easy-to-use, low-cost alternative, but its performance in screening for and diagnosing acute rheumatic fever and rheumatic heart disease needs further investigation. METHODS In this systematic review and meta-analysis, we searched Embase, MEDLINE, LILACS, and Conference Proceedings Citation Index-Science up to Feb 9, 2024, for studies on the screening and diagnosis of acute rheumatic fever and rheumatic heart disease using handheld echocardiography (index test) or standard echocardiography or auscultation (reference tests) in high-prevalence areas. We included all studies with useable data in which the diagnostic performance of the index test was assessed against a reference test. Data on test accuracy in diagnosing rheumatic heart disease, acute rheumatic fever, or carditis with acute rheumatic fever (primary outcomes) were extracted from published articles or calculated, with authors contacted as necessary. Quality of evidence was appraised using GRADE and QUADAS-2 criteria. We summarised diagnostic accuracy statistics (including sensitivity and specificity) and estimated 95% CIs using a bivariate random-effects model (or univariate random-effects models for analyses including three or fewer studies). Area under the curve (AUC) was calculated from summary receiver operating characteristic curves. Heterogeneity was assessed by visual inspection of plots. This study was registered with PROSPERO (CRD42022344081). FINDINGS Out of 4868 records we identified 11 studies, and two additional reports, comprising 15 578 unique participants. Pooled data showed that handheld echocardiography had high sensitivity (0·87 [95% CI 0·76-0·93]), specificity (0·98 [0·71-1·00]), and overall high accuracy (AUC 0·94 [0·84-1·00]) for diagnosing rheumatic heart disease when compared with standard echocardiography (two studies; moderate certainty of evidence), with better performance for diagnosing definite compared with borderline rheumatic heart disease. High sensitivity (0·79 [0·73-0·84]), specificity (0·85 [0·80-0·89]), and overall accuracy (AUC 0·90 [0·85-0·94]) for screening rheumatic heart disease was observed when pooling data of handheld echocardiography versus standard echocardiography (seven studies; high certainty of evidence). Most studies had a low risk of bias overall. Some heterogeneity was observed for sensitivity and specificity across studies, possibly driven by differences in the prevalence and severity of rheumatic heart disease, and level of training or expertise of non-expert operators. INTERPRETATION Handheld echocardiography has a high accuracy and diagnostic performance when compared with standard echocardiography for diagnosing and screening of rheumatic heart disease in high-prevalence areas. FUNDING World Health Organization. TRANSLATIONS For the Chinese, French, Italian, Persian, Portuguese, Spanish and Urdu translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Rui Providência
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.
| | - Ghazaleh Aali
- Cochrane Heart, Institute of Health Informatics, University College London, London, UK
| | - Fang Zhu
- Systematic Review Consultants, Nottingham, UK
| | | | - Mahmood Ahmad
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Cardiology Department, Royal Free London NHS Foundation Trust, London, UK
| | - Jonathan J H Bray
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ferruccio Pelone
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK
| | - Mohammed Y Khanji
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, London, UK
| | - Eloi Marijon
- Paris Cardiovascular Research Centre, INSERM U970, European Georges Pompidou Hospital, Paris, France
| | - Miryan Cassandra
- Cardiology Department, Hospital Dr Ayres de Menezes, São Tomé, São Tomé and Príncipe
| | - David S Celermajer
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Farhad Shokraneh
- Genes Health and Social Care Evidence Synthesis Unit, Institute of Health Informatics, University College London, London, UK; Systematic Review Consultants, Nottingham, UK
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Diniz MG, Fraga LL, Nunes MCP, Oliveira KKB, Amaral IB, Chavez LMT, de Paula LH, Haiashi BC, Ferreira AM, Silva MHA, Veloso JEM, Silva CA, Gelape FA, Santos LPA, Amaral AM, Coelho CT, Diamante LC, Correia JS, Meira ZMA, Ribeiro ALP, Spaziani AM, Sable C, Nascimento BR. Agreement between Handheld and Standard Echocardiography for Diagnosis of Latent Rheumatic Heart Disease in Brazilian Schoolchildren from High-Prevalence Settings (Agreement between Screening and Standard Echo for RHD). Diagnostics (Basel) 2024; 14:392. [PMID: 38396431 PMCID: PMC10888211 DOI: 10.3390/diagnostics14040392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
Introduction: Handheld echocardiography (echo) is the tool of choice for rheumatic heart disease (RHD) screening. We aimed to assess the agreement between screening and standard echo for latent RHD diagnosis in schoolchildren from an endemic setting. Methods: Over 14 months, 3 nonphysicians used handheld machines and the 2012 WHF Criteria to determine RHD prevalence in consented schoolchildren from Brazilian low-income public schools. Studies were interpreted by telemedicine by 3 experts (Brazil, US). RHD-positive children (borderline/definite) and those with congenital heart disease (CHD) were referred for standard echo, acquired and interpreted by a cardiologist. Agreement between screening and standard echo, by WHF subgroups, was assessed. Results: 1390 students were screened in 6 schools, with 110 (7.9%, 95% CI 6.5-9.5) being screen positive (14 ± 2 years, 72% women). Among 16 cases initially diagnosed as definite RHD, 11 (69%) were confirmed, 4 (25%) reclassified to borderline, and 1 to normal. Among 79 cases flagged as borderline RHD, 19 (24%) were confirmed, 50 (63%) reclassified to normal, 8 (10%) reclassified as definite RHD, and 2 had mild CHD. Considering the 4 diagnostic categories, kappa was 0.18. In patients with borderline RHD reclassified to non-RHD, the most frequent WHF criterion was B (isolated mitral regurgitation, 64%), followed by A (2 mitral valve morphological features, 31%). In 1 patient with definite RHD reclassified to normal, the WHF criterion was D (borderline RHD in aortic and mitral valves). After standard echo, RHD prevalence was 3.2% (95% CI 2.3-4.2). Conclusions: Although practical, RHD screening with handheld devices tends to overestimate prevalence.
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Affiliation(s)
- Marina G. Diniz
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Lucas L. Fraga
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Maria Carmo P. Nunes
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Kaciane K. B. Oliveira
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Ingred Beatriz Amaral
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Luz Marina T. Chavez
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Luiza Haikal de Paula
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Beatriz C. Haiashi
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Alexandre M. Ferreira
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Mauro Henrique A. Silva
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Jéssica Elvira M. Veloso
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Cássia Aparecida Silva
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Fernanda A. Gelape
- Curso de Medicina, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte 30130-110, MG, Brazil; (F.A.G.); (L.P.A.S.)
| | - Luiza P. A. Santos
- Curso de Medicina, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte 30130-110, MG, Brazil; (F.A.G.); (L.P.A.S.)
| | - Arthur M. Amaral
- Departamento de Medicina, Universidade Federal de Ouro Preto, Ouro Preto 35400-000, MG, Brazil;
| | - Cecília T. Coelho
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Lucas C. Diamante
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Juliane S. Correia
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Zilda Maria A. Meira
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
| | - Antonio Luiz P. Ribeiro
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
| | - Alison M. Spaziani
- Cardiology, Children’s National Health System, Washington, DC 20010, USA; (A.M.S.); (C.S.)
| | - Craig Sable
- Cardiology, Children’s National Health System, Washington, DC 20010, USA; (A.M.S.); (C.S.)
| | - Bruno R. Nascimento
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil; (M.G.D.); (M.C.P.N.); (K.K.B.O.); (I.B.A.); (L.M.T.C.); (L.H.d.P.); (B.C.H.); (A.M.F.); (M.H.A.S.); (J.E.M.V.); (C.A.S.); (C.T.C.); (L.C.D.); (J.S.C.); (Z.M.A.M.); (A.L.P.R.)
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte 30130-100, MG, Brazil
- Serviço de Hemodinâmica, Hospital Madre Teresa, Belo Horizonte 30441-070, MG, Brazil
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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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Safiri S, Mousavi SE, Noori M, Nejadghaderi SA, Sullman MJM, Singh K, Kolahi AA. The burden of rheumatic heart disease in the Middle East and North Africa region, 1990-2019. Arch Cardiovasc Dis 2023; 116:542-554. [PMID: 37863752 DOI: 10.1016/j.acvd.2023.09.005] [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: 05/17/2023] [Revised: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Rheumatic heart disease (RHD) is a treatable and preventable condition resulting from acute rheumatic fever. AIM To report the prevalence, mortality and disability-adjusted life-years (DALY) due to RHD in the Middle East and North Africa (MENA) region from 1990 to 2019, by sex, age group, country and sociodemographic index (SDI). METHODS Information on the prevalence, mortality and DALY associated with RHD were obtained from the Global Burden of Disease Study 2019. Data were gathered for all countries in the MENA region over the period 1990-2019. These data included counts and age-standardized rates per 100,000, accompanied by 95% uncertainty intervals (UIs). RESULTS The MENA region had an age-standardized point prevalence of 388.9 per 100,000 in 2019, which was 5.4% higher than in 1990. The annual incidence rate was 1.6, which was 63.4% lower than in 1990. There were 379.4 thousand DALY attributable to RHD in 2019, with an age-standardized rate of 67.1, which was 61.3% lower than in 1990. In 2019, an estimated 7.4 thousand deaths were due to RHD, and the age-standardized death rate was 63.4% lower in 2019 than in 1990. DALY rates rose steadily with increasing age in both males and females. The SDI correlated negatively with the rate of DALY for RHD throughout the study period. CONCLUSION The burden of RHD in MENA declined from 1990 to 2019, demonstrating the importance of regularly updating health data and identifying risk factors, and developing effective guidelines on prevention.
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Affiliation(s)
- Saeid Safiri
- Clinical Research Development Unit of Tabriz-Valiasr Hospital, Tabriz University of Medical Sciences, Tabriz, Iran; Clinical Research Development Unit of Tabriz-Valiasr Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Seyed Ehsan Mousavi
- Neurosciences Research Center, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran; Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Noori
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Aria Nejadghaderi
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran; Systematic Review and Meta-analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mark J M Sullman
- Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus; Department of Social Sciences, University of Nicosia, Nicosia, Cyprus
| | - Kuljit Singh
- Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia; Department of Medicine, Griffith University, Southport, Queensland, Australia
| | - Ali-Asghar Kolahi
- Social Determinants of Health Research Center, Shahid-Beheshti University of Medical Sciences, Tehran, Iran.
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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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6
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Francis JR, Fairhurst H, Yan J, Fernandes Monteiro A, Lee AM, Maurays J, Kaethner A, Whalley GA, Hardefeldt H, Williamson J, Marangou J, Reeves B, Wheaton G, Robertson T, Horton A, Cush J, Wade V, Monteiro A, Draper ADK, Morris PS, Ralph AP, Remenyi B. Abbreviated Echocardiographic Screening for Rheumatic Heart Disease by Nonexperts with and without Offsite Expert Review: A Diagnostic Accuracy Study. J Am Soc Echocardiogr 2023; 36:733-745. [PMID: 36806665 DOI: 10.1016/j.echo.2023.02.007] [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: 10/19/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early detection of rheumatic heart disease (RHD) through echocardiographic screening can facilitate early access to effective treatment, which reduces the risk for progression. Accurate, feasible approaches to echocardiographic screening that can be incorporated into routine health services are needed. The authors hypothesized that offsite expert review could improve the diagnostic accuracy of nonexpert-obtained echocardiographic images. METHODS This prospective cross-sectional study was performed to evaluate the diagnostic accuracy of health worker-conducted single parasternal long-axis view with a sweep of the heart using hand-carried ultrasound for the detection of RHD in high-risk populations in Timor-Leste and Australia. In the primary analysis, the presence of any mitral or aortic regurgitation met the criteria for a positive screening result. Sensitivity and specificity were calculated for a screen-and-refer approach based on nonexpert practitioner assessment (approach 1) and for an approach using offsite expert review of nonexpert practitioner-obtained images to decide onward referral (approach 2). Each participant had a reference test performed by an expert echocardiographer on the same day as the index test. Diagnosis of RHD was determined by a panel of three experts, using 2012 World Heart Federation criteria. RESULTS The prevalence of borderline or definite RHD among 3,329 participants was 4.0% (95% CI, 3.4%-4.7%). The sensitivity of approach 1 for borderline or definite RHD was 86.5% (95% CI, 79.5%-91.8%), and the specificity was 61.4% (95% CI, 59.7%-63.1%). Approach 2 achieved similar sensitivity (88.4%; 95% CI, 81.5%-93.3%) and improved specificity (77.1%; 95% CI, 75.6%-78.6%). CONCLUSION Nonexpert practitioner-obtained single parasternal long-axis view with a sweep of the heart images, reviewed by an offsite expert, can detect borderline and definite RHD on screening with reasonable sensitivity and specificity. Brief training of nonexpert practitioners with ongoing support could be used as an effective strategy for scaling up echocardiographic screening for RHD in high-risk settings.
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Affiliation(s)
- Joshua R Francis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia.
| | - Helen Fairhurst
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Jennifer Yan
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
| | - Anferida Fernandes Monteiro
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | | | - Alex Kaethner
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; NT Cardiac, Darwin, Australia
| | - Gillian A Whalley
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | | | - Jacqui Williamson
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - James Marangou
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; NT Cardiac, Darwin, Australia; Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Benjamin Reeves
- Department of Paediatric Cardiology, Cairns Hospital, Cairns, Australia
| | - Gavin Wheaton
- Department of Cardiology, Women's and Children's Hospital, Adelaide, Australia
| | - Terry Robertson
- Department of Cardiology, Women's and Children's Hospital, Adelaide, Australia
| | - Ari Horton
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia; NT Cardiac, Darwin, Australia; Paediatric Cardiology, Monash Heart and Monash Children's Hospital, Melbourne, Australia
| | - James Cush
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
| | - Vicki Wade
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Andre Monteiro
- Department of Cardiology, Hospital Nacional Guido Valadares, Dili, Timor-Leste
| | - Anthony D K Draper
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Centre for Disease Control, Northern Territory Department of Health, Darwin, Australia; National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia
| | - Peter S Morris
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
| | - Anna P Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Division of Medicine, Royal Darwin Hospital, Darwin, Australia
| | - Bo Remenyi
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia; NT Cardiac, Darwin, Australia
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7
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Elazrag A, Altahir A, Abbas A, Hasabo EA, Ahmed H, Ali H, Abdelrazig I, Ahmed M, Almahal M, Siddig M, Asmally R, Alrawa S, Mohamedelrasheed S, Elnaiem W, Ali S. Handheld echocardiographic screening for rheumatic heart disease by non-experts in rural South Kordofan, Sudan: Supporting task shifting for control of a serious disease. Int J Cardiol 2023; 377:99-103. [PMID: 36681245 DOI: 10.1016/j.ijcard.2023.01.024] [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: 08/05/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Rheumatic heart disease (RHD) is a major and preventable cause of cardiac morbidity in Sudan. It can be detected early with a handheld echocardiography (HHE) machine. Our study aimed to screen for RHD in rural South Kordofan and to investigate the ability of non-experts to obtain good quality HHE records. METHODS A cross-sectional study was conducted in South Kordofan, Sudan. A team of non-experts was trained for two weeks on handheld echocardiographic screening for RHD using a simplified protocol. Cases were recorded and reviewed by a pediatric cardiologist. Demographic and clinical features of screened subjects were studied. Descriptive statistics were presented as "number (%)" or "mean ± SD". RHD frequency was expressed as cases per 1000, and the Chi-Square test/Fisher's Exact test was used to compare RHD findings between different groups. RESULTS A total of 467 subjects were screened. Echocardiographic quality was acceptable in 93% of recorded studies, hence 452 cases were included in the analysis. The disease frequency was found to be 50 per 1000. Out of 452 screened subjects (age 10-25 years), 23 were found to have RHD. The disease was mild in 70% and moderate or involving two valves in 30% of patients. Risk factors for the disease included the father's occupation and the village of residence. CONCLUSION Shortly trained non-expert medicals can assist in RHD surveillance in remote areas using HHE for early detection and management. South Kordofan state is highly endemic to RHD and a control program needs to be implemented.
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Affiliation(s)
- Amna Elazrag
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Anfal Altahir
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Azza Abbas
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Elfatih A Hasabo
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Hayat Ahmed
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Hiba Ali
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Ibrahim Abdelrazig
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Mohamed Ahmed
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Mohamed Almahal
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Musab Siddig
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Rofida Asmally
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan.
| | - Salma Alrawa
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | | | - Walaa Elnaiem
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Sulafa Ali
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
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8
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Galdino BF, Amaral AM, Santos LPA, de Nogueira MAA, Rocha RTL, Nunes MCP, Beaton AZ, Oliveira KKB, Franco J, Barbosa MM, Silva VRH, Reese AT, Ribeiro ALP, Sable CA, Nascimento BR. Reasons for disagreement between screening and standard echocardiography in primary care: data from the PROVAR + study : Disagreement between screening and standard echo. Int J Cardiovasc Imaging 2023; 39:929-937. [PMID: 36680683 DOI: 10.1007/s10554-023-02800-6] [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: 08/26/2022] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
We aimed to evaluate the reasons for disagreement between screening echocardiography (echo), acquired by nonexperts, and standard echo in the Brazilian primary care (PC). Over 20 months, 22 PC workers were trained on simplified handheld (GE VSCAN) echo protocols. Screening groups, consisting of patients aged 17-20, 35-40 and 60-65 years, and patients referred for clinical indications underwent focused echo. Studies were remotelyinterpreted in US and Brazil, and those diagnosed with major or severe HD were referred for standard echoperformed by an expert. Major HD was defined as moderate to severe valve disease, ventriculardysfunction/hypertrophy, pericardial effusion or wall-motion abnormalities. A random sample of exams wasselected for evaluation of variables accounting for disagreement. A sample of 768 patients was analyzed, 651(85%) in the referred group. Quality issues were reported in 5.8%, and the random Kappa for major HD between screening and standard echo was 0.51. The most frequent reasons for disagreement were: overestimation of mitral regurgitation (MR) (17.9%, N=138), left ventricular (LV) dysfunction (15.7%, N=121), aortic regurgitation (AR) (15.2%, N=117), LV hypertrophy (13.5%, N=104) and tricuspid regurgitation (12.7%, N=98). Misdiagnosis of mitral and aortic morphological abnormalities was observed in 12.4% and 3.0%, and underestimation of AR and MR occurred in 4.6% and 11.1%. Among 257 patients with suspected mild/moderate MR, 129 were reclassified to normal. In conclusion, although screening echo with task-shifting in PC is a promising tool in low-income areas, estimation of valve regurgitation and LV function and size account for considerable disagreement with standard exams.
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Affiliation(s)
- Bruno F Galdino
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Arthur M Amaral
- Faculdade de Medicina da Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil
| | - Luiza P A Santos
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Marcelo Augusto A de Nogueira
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Rodrigo T L Rocha
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Maria Carmo P Nunes
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.,Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil
| | - Andrea Z Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Kaciane K B Oliveira
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil
| | - Juliane Franco
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil
| | - Márcia M Barbosa
- Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil
| | - Victor R H Silva
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Alison T Reese
- Cardiology, Children's National Health System, Washington, DC, USA
| | - Antonio Luiz P Ribeiro
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.,Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil
| | - Craig A Sable
- Cardiology, Children's National Health System, Washington, DC, USA
| | - Bruno R Nascimento
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil. .,Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil. .,Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas, Universidade Federal de Minas Gerais, Minas Gerais, Rua Muzambinho, 710, apt. 802, CEP 30.210-530, Serra, Belo Horizonte, Brasil.
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9
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Pandian NG, Kim JK, Arias-Godinez JA, Marx GR, Michelena HI, Chander Mohan J, Ogunyankin KO, Ronderos RE, Sade LE, Sadeghpour A, Sengupta SP, Siegel RJ, Shu X, Soesanto AM, Sugeng L, Venkateshvaran A, Campos Vieira ML, Little SH. Recommendations for the Use of Echocardiography in the Evaluation of Rheumatic Heart Disease: A Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2023; 36:3-28. [PMID: 36428195 DOI: 10.1016/j.echo.2022.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Acute rheumatic fever and its chronic sequela, rheumatic heart disease (RHD), pose major health problems globally, and remain the most common cardiovascular disease in children and young people worldwide. Echocardiography is the most important diagnostic tool in recognizing this preventable and treatable disease and plays an invaluable role in detecting the presence of subclinical disease needing prompt therapy or follow-up assessment. This document provides recommendations for the comprehensive use of echocardiography in the diagnosis and therapeutic intervention of RHD. Echocardiographic diagnosis of RHD is made when typical findings of valvular and subvalvular abnormalities are seen, including commissural fusion, leaflet thickening, and restricted leaflet mobility, with varying degrees of calcification. The mitral valve is predominantly affected, most often leading to mitral stenosis. Mixed valve disease and associated cardiopulmonary pathology are common. The severity of valvular lesions and hemodynamic effects on the cardiac chambers and pulmonary artery pressures should be rigorously examined. It is essential to take advantage of all available modalities of echocardiography to obtain accurate anatomic and hemodynamic details of the affected valve lesion(s) for diagnostic and strategic pre-treatment planning. Intraprocedural echocardiographic guidance is critical during catheter-based or surgical treatment of RHD, as is echocardiographic surveillance for post-intervention complications or disease progression. The role of echocardiography is indispensable in the entire spectrum of RHD management.
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Affiliation(s)
| | - Jin Kyung Kim
- University of California, Irvine, Irvine, California
| | | | | | | | | | | | | | | | - Anita Sadeghpour
- MedStar Health Research Institute, Washington, District of Columbia
| | | | | | | | - Amiliana M Soesanto
- Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Lissa Sugeng
- North Shore University Hospital, Manhasset, New York
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10
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Shaddock L, Smith T. Potential for Use of Portable Ultrasound Devices in Rural and Remote Settings in Australia and Other Developed Countries: A Systematic Review. J Multidiscip Healthc 2022; 15:605-625. [PMID: 35378744 PMCID: PMC8976575 DOI: 10.2147/jmdh.s359084] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/17/2022] [Indexed: 02/02/2023] Open
Abstract
Introduction Objective Methods Results Conclusion
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Affiliation(s)
- Liam Shaddock
- Medical Radiation Science, School of Health Sciences, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Tony Smith
- The University of Newcastle Department of Rural Health & School of Health Sciences, The University of Newcastle, Newcastle, New South Wales, Australia
- Correspondence: Tony Smith, The University of Newcastle Department of Rural Health, C/- 69A High Street, Taree, Newcastle, NSW, Australia, Tel +61 466 440 037, Email
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11
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Focused Cardiac Ultrasound for the Evaluation of Heart Valve Disease in Resource-Limited Settings. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00945-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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