Understanding valvular heart disease in the dental setting

BACKGROUND

Limited evidence is available regarding dentists' knowledge and interpretation of infective endocarditis (IE) prophylaxis guidelines. The aim of this study was to determine understanding and management of rheumatic and non-rheumatic valvular heart disease (VHD) in the dental setting in Western Australia (WA).

METHODS

A cross-sectional survey of dentists within Perth utilized an online Qualtrics questionnaire developed after consultation with stakeholders. A sampling frame was compiled from the Australian Health Practitioner Regulation Agency with contact details obtained from the White Pages (online), using five quintiles of Socio-Economic Indexes for Areas according to dentist's place of practice.

RESULTS

Of 41 (13.7% of 300 approached) dentists completing the survey (95.1% general dentists, mean years of practice = 15.6), 90.2% reported following the Australian Therapeutic Guidelines (ATG) regarding IE antibiotic prophylaxis in VHD. Most (92.7%) were unaware of the rheumatic heart disease (RHD) control program. Nearly all participants indicated prophylaxis for clearly invasive procedures such as tooth extraction (100.0%) and periodontal surgery (95.1%). Many dentists made the decision to prescribe antibiotics themselves (36.6%).

CONCLUSIONS

The majority of dentists followed the ATG's IE prophylaxis recommendations for cardiac lesions and dental procedures. There was limited knowledge of the national RHD guidelines and the WA RHD control program.

P5354Echocardiographic findings in pregnant indigenous Australians: under utilised?

Background

The Indigenous population of Australia has one of the highest prevalence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) globally. RHD is more common in females and the incidence peaks in the 3rd to 4th decade of life, corresponding with child-bearing age. It is the number one cause of cardiac complications in pregnancy globally. Signs and symptoms of normal pregnancy may overlap with those of cardiac pathology. Significant valvular disease can complicate pregnancy and delivery. Current practice sees pregnant women referred for echocardiography if there are signs or symptoms of possible cardiac pathology or a history of RHD.

Aim

To assess the current practice of echocardiography in pregnant women in a region with a high prevalence of rheumatic heart disease.

Method

A retrospective study of all echocardiograms requested for an indication relating to pregnancy over a three-year period were reviewed in the Northern Territory of Australia. Data collected included patient demographics, echocardiography indication, history of RHD, ARF or other cardiac disease, echocardiographic parameters, location of delivery, peri-partum morbidity and mortality.

Results

The total number of patients reviewed were 257. The 158 Indigenous Australian women had a mean age of 25 years and the 99 non-indigenous women had a mean age of 30 years. The Indigenous women had a higher rate of abnormal echocardiograms, 36.1% compared with 9.1% for non-indigenous women. Table 1 outlines echocardiography indications and outcomes. Indigenous women had extremely high rates of ARF or RHD representing 37% of echocardiography referrals, with 17.1% (27/158) having moderate or severe valve lesions. 5 cases (3.2%) had a history of prior valve surgery. 10 (6.3%) Indigenous patients required transfer to a tertiary centre with valve intervention services available for delivery. There was one maternal death, one post-partum stroke and one foetal death in utero.

Echocardiogram indications and outcomes Incidental murmur Cardiac symptoms Other cardiac disease History of RHD and/or ARF Normal study Rheumatic heart disease Congenital heart disease Other heart disease Indigenous (n=158) 60 (38%) 15 (9.4%) 24 (15%) 59 (37.3%) 101 (63.9%) 47 (29.7%) 7 (4.4%) 3 (1.9%) Non-indigenous (n=99) 44 (44.4%) 24 (24.2%) 31 (31.3%) 0 90 (91%) 2 (2%) 3 (3%) 4 (4%)

Conclusion

In the Top End of Australia, Indigenous patients have a very high rate of abnormal echocardiograms during pregnancy compared with their non-indigenous counterparts, mainly as a result of RHD. Data suggests that pregnant Indigenous women are being under serviced by the current medical model and referral practices. Guidelines are urgently needed in relation to echocardiography and pregnancy in populations that are burdened by RHD.

P3133Single parasternal long axis echocardiography by briefly trained health workers using handheld devices for detection of rheumatic heart disease: a prospective study of diagnostic accuracy

Introduction

Echocardiographic screening can detect rheumatic heart disease (RHD) in high-risk populations,but is limited by reliance on highly-trained experts and equipment. We sought to determine the diagnostic utility of an ultra-abbreviated single parasternal-long-axis-sweep of the heart (SPLASH) echocardiography protocol to detect RHD, performed by briefly-trained health workers.

Methods

In Timor-Leste and Northern Australia, individuals aged 5–20y were offered school-based echocardiographic screening. Health workers completed online modules followed by one-week of practical training, logging 50 echocardiograms prior to study. The index test was SPLASH, performed and reported by health workers using handheld GE V-scan devices. The index test was abnormal if any mitral or aortic regurgitation was detected. The reference test was a comprehensive echocardiogram, performed by an echocardiographers or cardiologist on a GE Vivid-Q, reported according to World Heart Federation criteria. The diagnostic accuracy of the index test was determined.

Results

2590 subjects underwent index and reference tests. Prevalence of definite RHD was 3.2% (83/2590). Sensitivity and specificity of index test were 0.75 (95% CI 0.64–0.83) and 0.77 (95% CI 0.75–0.78) respectively for detection of any definite RHD, and 0.91 (95% CI 0.74–0.98) and 0.76 (95% CI 0.74–0.78) respectively for detection of moderate or severe RHD.

Conclusion

Health workers using SPLASH detected the vast majority of moderate and severe RHD cases, but lacked sensitivity for detection of mild RHD. Further analysis is underway to evaluate the learning curve and other performance indicators of health workers performing and interpreting echocardiograms. This will allow refinement of SPLASH protocol and augmentation of health worker training to increase detection rates and accuracy for future population screening initiatives.

Acknowledgement/Funding

Heart Foundation Australia Vanguard Grant, Menzies HOT-NORTH pilot project grant, Snow Foundation, Rotary, Bawinanga Aboriginal Corporation, Mala'la