Rheumatic heart disease screening by "point-of-care" echocardiography: an acceptable alternative in resource limited settings?

At the Heart of the Community: Implementation of Echocardiographic Screening for Rheumatic Heart Disease in Primary Care Facilities of Northern Borneo Island

BACKGROUND

Rheumatic heart disease (RHD) is a potentially life-threatening condition that causes long-standing public health concerns. Echocardiography is a reliable diagnostic and screening technique for many cardiovascular conditions, including RHD. It is commonly used in tertiary care facilities worldwide but less so in the community setting. The primary aim of this study was to introduce and elaborate on the echocardiographic screening for RHD that was implemented by a Malaysian primary care clinic in Penampang district, Sabah. We also set out to present the uptake of the service in its initial years of establishment, as well as the challenges faced.

METHODS

In the first part of this study, document reviews were conducted to compile relevant information about the conceptualization and implementation of this service. Following that, we also obtained secondary data on the echocardiographic screening service from its first implementation in April 2020 until May 2021 to examine the uptake and the patient profile.

RESULTS

From April 2020 to May 2021, a total of 189 echocardiographic screening was conducted by primary care doctors using handheld ultrasound. Of the 189 children screened, 19 (10.1%) were found to have cardiac anomalies and were referred for a formal echocardiogram. Upon follow-up, 8 were detected with mild mitral regurgitation and referred to the nearest tertiary hospital for further management.

CONCLUSION

Based on our review, the echocardiographic screening for RHD among children conducted by the Penampang Health Clinic was deemed successful. Echocardiogram service provided by primary care centers located in suburban and rural areas is highly beneficial for patients with poor access to specialized health care services because they stay far away from tertiary care facilities. Tapping into family medicine physicians located closer to communities to conduct echocardiographic screening and review the results can improve the detection of cardiac anomalies requiring further investigation. With the success of this project, echocardiographic services in the primary healthcare setting can be expanded by garnering the necessary collaborative efforts and consistent support from various stakeholders.

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

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

Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: a systematic review and meta-analysis of diagnostic accuracy

OBJECTIVE

To summarise the accuracy of handheld echocardiography (HAND) which, if shown to be sufficiently similar to that of standard echocardiography (STAND), could usher in a new age of rheumatic heart disease (RHD) screening in endemic areas.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Scopus, EBSCOHost and ISI Web of Science were initially searched on 27 September 2017 and again on 3 March 2020 for studies published from 2012 onwards.

ELIGIBILITY CRITERIA

Studies assessing the accuracy of HAND compared with STAND when performed by an experienced cardiologist in conjunction with the 2012 World Heart Federation criteria among populations of children and adolescents living in endemic areas were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and assessed the methodological quality of included studies against review-specific Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 criteria. A meta-analysis using the hierarchical summary receiver operating characteristic model was conducted to produce summary results of sensitivity and specificity. Forest plots and scatter plots in receiver operating characteristic space in combination with subgroup analyses were used to investigate heterogeneity. Publication bias was not investigated.

RESULTS

Six studies (N=4208) were included in the analysis. For any RHD detection, the pooled results from six studies were as follows: sensitivity: 81.56% (95% CI 76.52% to 86.61%) and specificity: 89.75% (84.48% to 95.01%). Meta-analytical results from five of the six included studies were as follows: sensitivity: 91.06% (80.46% to 100%) and specificity: 91.96% (85.57% to 98.36%) for the detection of definite RHD only and sensitivity: 62.01% (31.80% to 92.22%) and specificity: 82.33% (65.15% to 99.52%) for the detection of borderline RHD only.

CONCLUSIONS

HAND displayed good accuracy for detecting definite RHD only and modest accuracy for detecting any RHD but demonstrated poor accuracy for the detection of borderline RHD alone. Findings from this review provide some evidence for the potential of HAND to increase access to echocardiographic screening for RHD in resource-limited and remote settings; however, further research into feasibility and cost-effectiveness of wide-scale screening is still needed.

PROSPERO REGISTRATION NUMBER

CRD42016051261.

Stakeholder Perceptions of Point-of-Care Ultrasound Implementation in Resource-Limited Settings

Background: Nearly half of the world lacks access to diagnostic imaging. Point of care ultrasound (POCUS) is a versatile and relatively affordable imaging modality that offers promise as a means of bridging the radiology gap and improving care in low resource settings. Methods: We performed semi-structured interviews of key stakeholders at two diverse hospitals where POCUS implementation programs had recently been conducted: one in a rural private hospital in Haiti and the other in a public referral hospital in Malawi. Questions regarding the clinical utility of POCUS, as well as barriers and facilitators of its implementation, were asked of study participants. Using the Framework Method, analysis of interview transcripts was guided by the WHO ASSURED criteria for point of care diagnostics. Results: Fifteen stakeholders with diverse roles in POCUS implementation were interviewed. Interviewees from both sites considered POCUS a valuable diagnostic tool that improved clinical decisions. They perceived barriers to adequate training as one of the most important remaining barriers to POCUS implementation. Conclusions: In spite of the increasing affordability and portability of ultrasounds devices, there are still important barriers to the implementation of POCUS in resource-limited settings.

Current status of rheumatic heart disease in India

The rheumatic heart disease continues to be an important cause of disease burden in India, affecting the population in their prime and productive phase of the life. The prevalence of rheumatic heart disease is varied in different Indian studies, because of the inclusion of different populations at different point of times and using different screening methods for the diagnosis. The data on incidence and prevalence on a nationally represented sample are lacking. There is a need for establishing a population-based surveillance system in the country for monitoring trends, management practices, and outcomes to formulate informed guidelines for initiating contextual interventions for prevention and control of rheumatic heart disease.

Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: protocol for a systematic review

INTRODUCTION

Rheumatic heart disease (RHD) is a preventable and treatable chronic condition which persists in many developing countries largely affecting impoverished populations. Handheld echocardiography presents an opportunity to address the need for more cost-effective methods of diagnosing RHD in developing countries, where the disease continues to carry high rates of morbidity and mortality. Preliminary studies have demonstrated moderate sensitivity as well as high specificity and diagnostic odds for detecting RHD in asymptomatic patients. We describe a protocol for a systematic review on the diagnostic performance of handheld echocardiography compared to standard echocardiography using the 2012 World Heart Federation criteria for diagnosing subclinical RHD.

METHODS AND ANALYSIS

Electronic databases including PubMed, Scopus, Web of Science and EBSCOhost as well as reference lists and citations of relevant articles will be searched from 2012 to date using a predefined strategy incorporating a combination of Medical Subject Heading terms and keywords. The methodological validity and quality of studies deemed eligible for inclusion will be assessed against review specific Quality Assessment of Diagnostic Accuracy Studies 2 criteria and information on metrics of diagnostic accuracy and demographics extracted. Forest plots of sensitivity and specificity as well as scatter plots in receiver operating characteristic (ROC) space will be used to investigate heterogeneity. If possible, a meta-analysis will be conducted to produce summary results of sensitivity and specificity using the Hierarchical Summary ROC method. In addition, a sensitivity analysis will be conducted to investigate the effect of studies with a high risk of bias.

ETHICS AND DISSEMINATION

Ethics approval is not required for this systematic review of previously published literature. The planned review will provide a summary of the diagnostic accuracy of handheld echocardiography. Results may feed into evidence-based guidelines and should the findings of this review warrant a change in clinical practice, a summary report will be disseminated among leading clinicians and healthcare professionals in the field.

PROSPERO REGISTRATION NUMBER

CRD42016051261.

Group A Streptococcus, Acute Rheumatic Fever and Rheumatic Heart Disease: Epidemiology and Clinical Considerations

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.