"Hurts less, lasts longer"; a qualitative study on experiences of young people receiving high-dose subcutaneous injections of benzathine penicillin G to prevent rheumatic heart disease in New Zealand

BACKGROUND

Four-weekly intramuscular (IM) benzathine penicillin G (BPG) injections to prevent acute rheumatic fever (ARF) progression have remained unchanged since 1955. A Phase-I trial in healthy volunteers demonstrated the safety and tolerability of high-dose subcutaneous infusions of BPG which resulted in a much longer effective penicillin exposure, and fewer injections. Here we describe the experiences of young people living with ARF participating in a Phase-II trial of SubCutaneous Injections of BPG (SCIP).

METHODOLOGY

Participants (n = 20) attended a clinic in Wellington, New Zealand (NZ). After a physical examination, participants received 2% lignocaine followed by 13.8mL to 20.7mL of BPG (Bicillin-LA®; determined by weight), into the abdominal subcutaneous tissue. A Kaupapa Māori consistent methodology was used to explore experiences of SCIP, through semi-structured interviews and observations taken during/after the injection, and on days 28 and 70. All interviews were recorded, transcribed verbatim, and thematically analysed.

PRINCIPAL FINDINGS

Low levels of pain were reported on needle insertion, during and following the injection. Some participants experienced discomfort and bruising on days one and two post dose; however, the pain was reported to be less severe than their usual IM BPG. Participants were 'relieved' to only need injections quarterly and the majority (95%) reported a preference for SCIP over IM BPG.

CONCLUSIONS

Participants preferred SCIP over their usual regimen, reporting less pain and a preference for the longer time gap between treatments. Recommending SCIP as standard of care for most patients needing long-term prophylaxis has the potential to transform secondary prophylaxis of ARF/RHD in NZ and globally.

Subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for rheumatic heart disease secondary prophylaxis: a phase 1 open-label population pharmacokinetic study

Since 1955, the recommended strategy for rheumatic heart disease (RHD) secondary prophylaxis has been benzathine penicillin G [BPG; 1.2 MU (900 mg)] injections administered intramuscularly every 4 weeks. Due to dosing frequency, pain, and programmatic challenges, adherence is suboptimal. It has previously been demonstrated that BPG delivered subcutaneously at a standard dose is safe and tolerable and has favorable pharmacokinetics, setting the scene for improved regimens with less frequent administration. The safety, tolerability, and pharmacokinetics of subcutaneous infusions of high-dose BPG were assessed in 24 healthy adult volunteers assigned to receive either 3.6, 7.2, or 10.8 MU (three, six, and nine times the standard dose, respectively) as a single subcutaneous infusion. The delivery of the BPG to the subcutaneous tissue was confirmed with ultrasonography. Safety assessments, pain scores, and penicillin concentrations were measured for 16 weeks post-dose. Subcutaneous infusion of penicillin (SCIP) was generally well tolerated with all participants experiencing transient, mild infusion-site reactions. Prolonged elevated penicillin concentrations were described using a combined zero-order (44 days) and first-order (t1/2 = 12 days) absorption pharmacokinetic model. In simulations, time above the conventionally accepted target concentration of 20 ng/mL (0.02 µg/mL) was 57 days for 10.8 MU delivered by subcutaneous infusion every 13 weeks compared with 9 days of every 4-weekly dosing interval for the standard 1.2 MU intramuscular dose (i.e., 63% and 32% of the dosing interval, respectively). High-dose SCIP (BPG) is safe, has acceptable tolerability, and may be suitable for up to 3 monthly dosing intervals for secondary prophylaxis of RHD.

Research opportunities for the primordial prevention of rheumatic fever and rheumatic heart disease-streptococcal vaccine development: a national heart, lung and blood institute workshop report

Streptococcus pyogenes, also known as group A streptococcus (StrepA), is a bacterium that causes a range of human diseases, including pharyngitis, impetigo, invasive infections, and post-infection immune sequelae such as rheumatic fever and rheumatic heart disease. StrepA infections cause some of the highest burden of disease and death in mostly young populations in low-resource settings. Despite decades of effort, there is still no licensed StrepA vaccine, which if developed, could be a cost-effective way to reduce the incidence of disease. Several challenges, including technical and regulatory hurdles, safety concerns and a lack of investment have hindered StrepA vaccine development. Barriers to developing a StrepA vaccine must be overcome in the future by prioritising key areas of research including greater understanding of StrepA immunobiology and autoimmunity risk, better animal models that mimic human disease, expanding the StrepA vaccine pipeline and supporting vaccine clinical trials. The development of a StrepA vaccine is a complex and challenging process that requires significant resources and investment. Given the global burden of StrepA infections and the potential for a vaccine to save lives and livelihoods, StrepA vaccine development is an area of research that deserves considerable support. This report summarises the findings of the Primordial Prevention Working Group-VAX, which was convened in November 2021 by the National Heart, Lung, and Blood Institute. The focus of this report is to identify research gaps within the current StrepA vaccine landscape and find opportunities and develop priorities to promote the rapid and successful advancement of StrepA vaccines.

Warfarin faring better: vitamin K antagonists beat rivaroxaban and apixaban in the INVICTUS and PROACT Xa trials

Although guidelines give preference to direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF), DOACs are not recommended in those with rheumatic heart disease or mechanical heart valves. The results of the INVICTUS trial (Investigation of Rheumatic AF Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies), which compared rivaroxaban with a VKA in patients with rheumatic heart disease-associated AF, and the PROACT Xa trial (A Trial to Determine if Participants with an On-X Aortic Valve Can be Maintained Safely on Apixaban), which compared apixaban with warfarin in patients with an On-X valve in the aortic position, support the use of VKAs for these indications. In this paper, we review the results of these trials, provide perspective on why VKAs were superior to DOACs, and discuss future directions for anticoagulation in these disorders.

The aetiology and incidence of infective endocarditis in people living with rheumatic heart disease in tropical Australia

PURPOSE

To define the incidence and microbiological aetiology of infective endocarditis (IE) in patients with rheumatic heart disease (RHD) in tropical Australia.

METHODS

A retrospective study that examined all episodes of IE between January 1998 and June 2021 among individuals on the RHD register in Far North Queensland, Australia.

RESULTS

There were 1135 individuals with a diagnosis of RHD on the register during the study period, representing 10962 patient-years at risk. Overall, there were 18 episodes of definite IE occurring in 16 individuals, although only 7 episodes occurred in native valves (11 occurred in prosthetic valves) equating to 0.7 episodes of native valve IE/1000 patient-years. No patient with mild RHD - and only one child with RHD - developed IE during the study period. Despite the study's tropical location, the causative organism was usually typical skin or oral flora. Among individuals with an indication for benzathine penicillin G (BPG) prophylaxis, only 1/6 episodes of IE due to a penicillin-susceptible organism received BPG in the month before presentation.

CONCLUSION

Although RHD predisposes individuals to IE, the absolute risk of IE in native valve disease in tropical Australia is low and might be reduced further by improved adherence to secondary BPG prophylaxis.

Penicillin Reactions in Patients With Severe Rheumatic Heart Disease: A Presidential Advisory From the American Heart Association

Secondary antibiotic prophylaxis with regular intramuscular benzathine penicillin G (BPG) is the cornerstone of rheumatic heart disease management. However, there is a growing body of evidence that patients with rheumatic heart disease who have severe valvular heart disease with or without reduced ventricular function may be dying from cardiovascular compromise following BPG injections. This advisory responds to these concerns and is intended to: (1) raise awareness, (2) provide risk stratification, and (3) provide strategies for risk reduction. Based on available evidence and expert opinion, we have divided patients into low- and elevated-risk groups, based on symptoms and the severity of underlying heart disease. Patients with elevated risk include those with severe mitral stenosis, aortic stenosis, and aortic insuffiency; those with decreased left ventricular systolic dysfunction; and those with no symptoms. For these patients, we believe the risk of adverse reaction to BPG, specifically cardiovascular compromise, may outweigh its theoretical benefit. For patients with elevated risk, we newly advise that oral prophylaxis should be strongly considered. In addition, we advocate for a multifaceted strategy for vasovagal risk reduction in all patients with rheumatic heart disease receiving BPG. As current guidelines recommend, all low-risk patients without a history of penicillin allergy or anaphylaxis should continue to be prescribed BPG for secondary antibiotic prophylaxis. We publish this advisory in the hopes of saving lives and avoiding events that can have devastating effects on patient and clinician confidence in BPG.

Secondary Antibiotic Prophylaxis for Latent Rheumatic Heart Disease

BACKGROUND

Rheumatic heart disease affects more than 40.5 million people worldwide and results in 306,000 deaths annually. Echocardiographic screening detects rheumatic heart disease at an early, latent stage. Whether secondary antibiotic prophylaxis is effective in preventing progression of latent rheumatic heart disease is unknown.

METHODS

We conducted a randomized, controlled trial of secondary antibiotic prophylaxis in Ugandan children and adolescents 5 to 17 years of age with latent rheumatic heart disease. Participants were randomly assigned to receive either injections of penicillin G benzathine (also known as benzathine benzylpenicillin) every 4 weeks for 2 years or no prophylaxis. All the participants underwent echocardiography at baseline and at 2 years after randomization. Changes from baseline were adjudicated by a panel whose members were unaware of the trial-group assignments. The primary outcome was echocardiographic progression of latent rheumatic heart disease at 2 years.

RESULTS

Among 102,200 children and adolescents who had screening echocardiograms, 3327 were initially assessed as having latent rheumatic heart disease, and 926 of the 3327 subsequently received a definitive diagnosis on the basis of confirmatory echocardiography and were determined to be eligible for the trial. Consent or assent for participation was provided for 916 persons, and all underwent randomization; 818 participants were included in the modified intention-to-treat analysis, and 799 (97.7%) completed the trial. A total of 3 participants (0.8%) in the prophylaxis group had echocardiographic progression at 2 years, as compared with 33 (8.2%) in the control group (risk difference, -7.5 percentage points; 95% confidence interval, -10.2 to -4.7; P<0.001). Two participants in the prophylaxis group had serious adverse events that were attributable to receipt of prophylaxis, including one episode of a mild anaphylactic reaction (representing <0.1% of all administered doses of prophylaxis).

CONCLUSIONS

Among children and adolescents 5 to 17 years of age with latent rheumatic heart disease, secondary antibiotic prophylaxis reduced the risk of disease progression at 2 years. Further research is needed before the implementation of population-level screening can be recommended. (Funded by the Thrasher Research Fund and others; GOAL ClinicalTrials.gov number, NCT03346525.).

[Analysis of outcome indexes in randomized controlled trials of traditional Chinese medicine for rheumatic heart disease]

The present study analyzed the efficacy evaluation indexes of the randomized controlled trials(RCTs) of Chinese medi-cine in the treatment of rheumatic heart disease to lay the foundation for the construction of the corresponding core outcome index set. Clinical RCTs with a definite diagnosis of rheumatic heart disease were retrieved from CNKI, Wanfang, VIP, Sino Med, Pub Med, EMbase, and Cochrane Library from January 1, 2010, to December 31, 2020. Thirty-five RCTs were included, involving 3 314 patients and 41 efficacy evaluation indexes, which covered seven domains [traditional Chinese medicine(TCM) symptoms/syndromes, symp-toms/signs, physical and chemical examination, quality of life, long-term prognosis, economic evaluation, and safety events]. Physi-cal and chemical examination(56. 91%) and symptoms/signs(29. 27%) were the more frequently applied. The number of indexes used in a single trial ranged from 1 to 15, with an average of 4. The measurement time points of the top five indexes in the frequency of use were as follows: total response rate was reported at five measurement time points, ranging from 14 days to 6 months; left ventri-cular ejection fraction was measured at eight time points ranging from 5 days to 6 months; left ventricular end systolic diameter was measured at six time points, ranging from 5 days to 6 months; interleukin-2(IL-2) and tumor necrosis factor-α(TNF-α) were repor-ted 28 days after treatment. At present, there are many problems in the efficacy outcome indexes of RCTs in the treatment of rheumatic heart disease with TCM, such as large difference in quantity, unclear primary and secondary indexes, unreasonable selection of &quot; surro-gate indexes&quot;, insufficient attention to long-term prognostic indexes and safety event indexes, non-standard application of composite in-dexes, long measurement period, and lack of TCM characteristics. It is urgent to establish the core outcome set for TCM treatment of rheumatic heart disease.

Examining the Ugandan health system's readiness to deliver rheumatic heart disease-related services

BACKGROUND

In 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda.

METHODOLOGY/PRINCIPAL FINDINGS

This was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare.

CONCLUSIONS/SIGNIFICANCE

Uganda's readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.

Quality of benzathine penicillin G: A multinational cross-sectional study

Benzathine penicillin G (BPG) is used as first-line treatment for most forms of syphilis and as secondary prophylaxis against rheumatic heart disease (RHD). Perceptions that poor quality of BPG is linked to reported adverse effects and therapeutic failure may impact syphilis and RHD control programs. Clinical networks and web-based advertising were used to obtain vials of BPG from a wide range of countries. The quality of BPG was assessed using a high performance liquid chromatography assay capable of detecting relevant impurities and degradation products. Tests for water content, presence of heavy metals and physical characteristics of BPG, including particle size analysis and optical microscopy, also were conducted. Thirty-five batches of BPG were sourced from 16 countries across 4 WHO regions. All batches passed the US Pharmacopeia requirements for BPG injection (content), with no evidence of breakdown products or other detected contaminants. Water content and heavy metal analysis (n = 11) indicated adherence to regulatory standards and Good Manufacturing Practice. Particle size analysis (n = 20) found two batches with aggregated particles (>400 µm) that were dispersed following sonication. Current batches of BPG were of satisfactory pharmaceutical quality but aggregated particles were found in a modest proportion of samples. Future studies should focus on the physical characteristics of BPG which may contribute to variations in plasma penicillin concentrations an observed needle blockages in clinical practice. Pharmacopeial monographs could be revised to include standards on particle size and crystal morphology of BPG.

The INVICTUS rheumatic heart disease research program: Rationale, design and baseline characteristics of a randomized trial of rivaroxaban compared to vitamin K antagonists in rheumatic valvular disease and atrial fibrillation

BACKGROUND

Rheumatic heart disease (RHD) is a neglected disease affecting 33 million people, mainly in low and middle income countries. Yet very few large trials or registries have been conducted in this population. The INVICTUS program of research in RHD consists of a randomized-controlled trial (RCT) of 4500 patients comparing rivaroxaban with vitamin K antagonists (VKA) in patients with RHD and atrial fibrillation (AF), a registry of 17,000 patients to document the contemporary clinical course of patients with RHD, including a focused sub-study on pregnant women with RHD within the registry. This paper describes the rationale, design, organization and baseline characteristics of the RCT and a summary of the design of the registry and its sub-study. Patients with RHD and AF are considered to be at high risk of embolic strokes, and oral anticoagulation with VKAs is recommended for stroke prevention. But the quality of anticoagulation with VKA is poor in developing countries. A drug which does not require monitoring, and which is safe and effective for preventing stroke in patients with valvular AF, would fulfill a major unmet need.

METHODS

The INVestIgation of rheumatiC AF Treatment Using VKAs, rivaroxaban or aspirin Studies (INVICTUS-VKA) trial is an international, multicentre, randomized, open-label, parallel group trial, testing whether rivaroxaban 20 mg given once daily is non-inferior (or superior) to VKA in patients with RHD, AF, and an elevated risk of stroke (mitral stenosis with valve area ≤2 cm2, left atrial spontaneous echo-contrast or thrombus, or a CHA2DS2VASc score ≥2). The primary efficacy outcome is a composite of stroke or systemic embolism and the primary safety outcome is the occurrence of major bleeding. The trial has enrolled 4565 patients from 138 sites in 23 countries from Africa, Asia and South America. The Registry plans to enroll an additional 17,000 patients with RHD and document their treatments, and their clinical course for at least 2 years. The pregnancy sub-study will document the clinical course of pregnant women with RHD.

CONCLUSION

INVICTUS is the largest program of clinical research focused on a neglected cardiovascular disease and will provide new information on the clinical course of patients with RHD, and approaches to anticoagulation in those with concomitant AF.

Outcomes and Care Quality Metrics for Women of Reproductive Age Living With Rheumatic Heart Disease in Uganda

Background Rheumatic heart disease disproportionately affects women of reproductive age, as it increases the risk of cardiovascular complications and death during pregnancy and childbirth. In sub-Saharan Africa, clinical outcomes and adherence to guideline-based therapies are not well characterized for this population. Methods and Results In a retrospective cohort study of the Uganda rheumatic heart disease registry between June 2009 and May 2018, we used multivariable regression and Cox proportional hazards models to compare comorbidities, mortality, anticoagulation use, and treatment cascade metrics among women versus men aged 15 to 44 with clinical rheumatic heart disease. We included 575 women and 252 men with a median age of 27 years. Twenty percent had New York Heart Association Class III-IV heart failure. Among patients who had an indication for anticoagulation, women were less likely than men to receive a prescription of warfarin (66% versus 81%; adjusted odds ratio, 0.37; 95% CI, 0.14-0.96). Retention in care (defined as a clinic visit within the preceding year) was poor among both sexes in this age group (27% for men, 24% for women), but penicillin adherence rates were high among those retained (89% for men, 92% for women). Mortality was higher in men than women (26% versus 19% over a median follow-up of 2.7 years; adjusted hazard ratio, 1.66; 95% CI, 1.18-2.33). Conclusions Compared with men, women of reproductive age with rheumatic heart disease in Uganda have lower rates of appropriate anticoagulant prescription but also lower mortality rates. Retention in care is poor among both men and women in this age range, representing a key target for improvement.

Determining the impact of Benzathine penicillin G prophylaxis in children with latent rheumatic heart disease (GOAL trial): Study protocol for a randomized controlled trial

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.

Poststreptococcal Illness: Recognition and Management

Group A beta-hemolytic streptococcus can cause several postinfectious, nonsuppurative immune- mediated diseases including acute rheumatic fever, poststreptococcal reactive arthritis, pediatric autoimmune neuropsychiatric disorders, and poststreptococcal glomerulonephritis. Except for sporadic outbreaks, poststreptococcal autoimmune syndromes occur most commonly in sub-Saharan Africa, India, Australia, and New Zealand. Children younger than three years are rarely affected by group A streptococcus pharyngitis or rheumatic fever, and usually do not require testing. Rheumatic fever is a rare condition that presents as a febrile illness characterized by arthritis, carditis or valvulitis, and neurologic and cutaneous disease, followed many years later by acquired valvular disease. Recurrence rates are high. In addition to evidence of recent streptococcal infection, two major or one major and two minor Jones criteria are required for diagnosis. Electrocardiography, chest radiography, erythrocyte sedimentation rate, and an antistreptolysin O titer are the most useful initial tests. Echocardiography is recommended to identify patients with subclinical carditis. The arthritis usually responds within three days to nonsteroidal anti-inflammatory drugs. Poststreptococcal reactive arthritis is nonmigratory, can affect any joint, and typically does not respond to aspirin. Pediatric autoimmune neuropsychiatric disorders affect the basal ganglia and are manifested by obsessive-compulsive and tic disorders. The presentation of poststreptococcal glomerulonephritis ranges from asymptomatic microscopic hematuria to gross hematuria, edema, hypertension, proteinuria, and elevated serum creatinine levels.

The impact of a peer support group for children with rheumatic heart disease in Uganda

OBJECTIVE

To assess the impact of a peer-support group on knowledge, quality of life, and social support for children with rheumatic heart disease (RHD).

METHODS

Children diagnosed with RHD and receiving 4-weekly injectable penicillin were invited to participate in a monthly support group for 6 months. Pre- and post-intervention assessments included a baseline RHD knowledge assessment, a measure of health related quality of life (HRQOL) (PedsQL_TM4.0), and a measure of social support (Hawthorne Friendship Scale). Groups incorporated elements of cooperative play and team building, RHD education, and emotional support.

RESULTS

42 participants attended ≥3 groups and were included in the analyses. Attending support groups resulted in increased total HRQOL scores (60.3v 70.2, p<0.001), as well as the following HRQOL sub-scores (physical functioning 55.3v 68.6 (p<0.001), social functioning 64.2v 75.8 (p<0.001) and school functioning 59.2v 69.1 (p=0.001)). Significant increases in Friendship Scale scores (15.4v 19.7, p<0.001) and RHD Knowledge scores were observed (3.6v 6.4, p<0.001).

CONCLUSIONS

Peer-support groups may be effective at normalizing decreased HRQOL scores and increasing RHD disease knowledge and social support.

PRACTICAL IMPLICATIONS

Peer-support groups implemented in conjunction with RHD screening can minimize the negative psychosocial effects associated with early RHD detection.

Latent Rheumatic Heart Disease: Identifying the Children at Highest Risk of Unfavorable Outcome

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.

An Ineffective Differential Diagnosis of Infective Endocarditis and Rheumatic Heart Disease after Streptococcal Skin and Soft Tissue Infection

We herein report the case of a 68-year-old woman with a skin and soft tissue infection at her extremities. The blood culture results were positive for Streptococcus pyogenes, and we started treatment using ampicillin and clindamycin, although subsequent auscultation revealed a new-onset heart murmur. We therefore suspected rheumatic heart disease and infective endocarditis. The case met both the Jones criteria and the modified Duke criteria. Transesophageal echocardiography revealed vegetation on the aortic valve, although the pathological findings were also compatible with both rheumatic heart disease and infective endocarditis. The present findings suggest that these two diseases can coexist in some cases.

Adequate adherence to benzathine penicillin secondary prophylaxis following the diagnosis of rheumatic heart disease by echocardiographic screening

AIMS

The primary aim of this study was to determine adherence to benzathine penicillin (BPG) for individuals diagnosed with rheumatic heart disease (RHD) by echocardiographic screening between 2007-2012.

METHODS

BPG records were obtained for 57 patients, median age 12 at time of diagnosis. A 'days at risk' analysis was undertaken. Annual adherence was calculated for each individual. A comparison with the Wellington region's Rheumatic Fever 2013 adherence data was undertaken.

RESULTS

Adherence to BPG was good with a median follow-up time of 5.8 years. Days at risk analysis: median 0% at year one and 2.7% at year five. The median adherence for the entire cohort over the entire follow-up period was 92%, range 0-100%. There was no difference of proportions of late doses compared to the Wellington region. Median adherence was higher for register based (94%, n=48) compared to primary health care penicillin delivery (37%, n=7), p<0.005. During follow-up, 30% of the cohort moved between regions or overseas.

CONCLUSIONS

Good adherence rates are achievable for secondary prophylaxis when RHD is diagnosed by echocardiographic screening. This likely reflects the benefit of rheumatic fever registers and community nursing services rather than the pathway of the diagnosis for RHD.

Safety and Efficacy of Enalapril in Multivalvular Heart Disease with Significant Mitral Stenosis—SCOPE-MS

Angiotensin-converting enzyme inhibitors (ACEI) are often used in preventing and treating heart failure due to regurgitant valve disease. The majority of patients with symptomatic rheumatic heart disease (RHD) have significant mitral stenosis (MS) and are denied ACEI therapy, because of the fear of hypotension in the presence of fixed obstruction. The authors assessed the safety and efficacy of ACEI in 109 consecutive patients with RHD and with significant mitral stenosis (mitral valve orifice, MVO <1.5 cm2) and with NYHA class III or IV heart failure symptoms. Mean age was 33.1 ±12 years, systolic blood pressure (BP) was 111 ±10, and diastolic BP was 73 ±8 mm Hg. MS was significant in 100 patients with mitral regurgitation in 46, aortic regurgitation in 19, and pulmonary hypertension in 60 patients. After initial stabilization, enalapril 2.5 mg bid was started in hospital and titrated up to 10 mg bid over 2 weeks. NYHA status, Borg score, and 6-minute walk test were assessed at baseline, and at 1, 2, and 4 weeks. Seventy-nine of the 100 patients who completed the study had severe MS (MVO <1.0 cm2). Enalapril was well tolerated by all study patients without hypotension or worsening of symptoms. NYHA class (3.2 ±0.5 baseline vs 2.3 ±0.5 at 4 weeks, p<0.01) Borg Dyspnea Index (7.6 ±1.3 vs 5.6 ±1.3, p<0.01), and 6-minute walk distance (226 ±106 vs 299 ±127 m, p<0.01) improved significantly with enalapril. Patients with associated regurgitant lesions showed more improvement in exercise capacity (120 ±93 vs 39 ±56 m, p<0.001). Enalapril was well tolerated in patients with RHD with moderate and severe MS. Irrespective of the valve pathology, enalapril improved functional status and exercise capacity with maximum benefit in patients with concomitant regurgitant valvular heart disease.

Control of Heart Rate Versus Rhythm in Rheumatic Atrial Fibrillation: A Randomized Study

Background: Patients with rheumatic heart disease with atrial fibrillation incur significant morbidity and mortality. Which approach, ventricular rate control or maintenance of sinus rhythm, in this setting might be superior is not known. The role of amiodarone in this patient population for maintaining sinus rhythm has not been evaluated.

Methods and Results: We prospectively studied 144 patients with chronic rheumatic atrial fibrillation in a double-blind protocol in which rhythm control (group I), comprising 48 patients each with amiodarone (group Ia) and placebo (group Ib), were compared with each other and with patients in a ventricular rate control group (group II) in which the effects by diltiazem were determined (n = 48, open-label). Direct current cardioversion was attempted in group I. The mean age of the study population was 38.6 ± 10.3 years, left atrial size, 4.7 ±0.6 cm; atrial fibrillation duration, 6.1 ± 5.4 years; and 72.9% had valvular interventions performed. At 1 year, 45 patients with sinus rhythm in group I compared with 48 in group II demonstrated an increase in exercise time (2.6 ± 1.9 vs. 0.6 ± 2.5 min, P = .001), improvement in New York Heart Association class of 1 or more ( P = .002), and improvement in the quality-of-life score of one or greater ( P = 0.01) with no difference in hospitalizations, systemic bleeds, or thromboembolism. Five patients died in group II; none died in group I ( P =.02). In group I, 73 of 87 (83.9%) patients converted to sinus rhythm and 45 of 86 (52.3%) patients maintained the rhythm at 1 year. Conversion rates were 38 of 43 (88.4%) with amiodarone versus 34 of 44 (77.3%) with placebo ( P = .49); the corresponding rate for maintaining sinus rhythm was 29 of 42 (69.1%) versus 16 of 44 (36.4%) ( P = .008). A larger number of electrical cardioversions were required in the placebo group (2.1 vs. 1.4, P = .011).

Conclusions: Maintenance of sinus rhythm is superior to ventricular rate control in patients with rheumatic atrial fibrillation with respect to effects on exercise capacity, quality of life, morbidity, and possibly mortality. Sinus rhythm could be restored in most patients, and amiodarone was superior to placebo in the restoration and maintenance of sinus rhythm.

Proportion of patients in the Uganda rheumatic heart disease registry with advanced disease requiring urgent surgical interventions

INTRODUCTION

Since the establishment of the Uganda Rheumatic Heart Registry, over 900 patients have been enrolled. We sought to stratify the patients in the registry according to disease severity and optimal management strategy.

METHODS

We reviewed data of 618 patients who had enrolled in the Registry between March 2010 and February 2013. The 67 patients who had died were excluded leaving 551 patients who were recruited. The optimum management strategy was determined according to the 2012 European Society of Cardiology guidelines on the management of valvular heart disease.

RESULTS

Out of the 551 patient's records evaluated, 398 (72.3%) required invasive intervention, with 332(60.3%) patients requiring surgery and 66 (12.0%) requiring percutaneous mitral commissurotomy (PMC). This leaves only 27.7% of patients who required only medical management. Currently, majority of the patients (498, 90.4%) in the registry are on medical treatment. Of the 60.3% requiring surgical intervention, only 8.0% (44 patients) underwent valvular surgery and 5(1.0%) patients of the 66 (12.0%) underwent PMC successfully.

CONCLUSION

There is a high proportion of patients with severe disease that require surgical treatment yet they cannot access this therapy due to absence of local expertise.

Anti-inflammatory treatment for carditis in acute rheumatic fever

BACKGROUND

Rheumatic heart disease remains an important cause of acquired heart disease in developing countries. Although prevention of rheumatic fever and management of recurrences have been well established, optimal management of active rheumatic carditis remains unclear. This is an update of a review published in 2003, and previously updated in 2009 and 2012.

OBJECTIVES

To assess the effects, both harmful and beneficial, of anti-inflammatory agents such as aspirin, corticosteroids and other drugs in preventing or reducing further valvular damage in patients with acute rheumatic fever.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (2013, Issue 9 of 12), MEDLINE (Ovid, 1948 to 2013 October Week 1), EMBASE (Ovid, 1980 to 2013 Week 41) and Latin American Caribbean Health Sciences Literature (LILACS) (1982 to 17 October 2013). We last searched Index Medicus (1950 to April 2001) in 2001. We checked reference lists of identified studies and applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins, pentoxifylline) versus placebo or controls, or comparing any of the anti-inflammatory agents versus one another, in adults and children with acute rheumatic fever diagnosed according to Jones, or modified Jones, criteria. The presence of cardiac disease one year after treatment was the major outcome criterion selected.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed risk of bias using the methodology outlined in the Cochrane Handbook of Systematic Reviews of Interventions. Standard methodological procedures as expected by The Cochrane Collaboration were used.

MAIN RESULTS

No new studies were included in this update. Eight randomised controlled trials involving 996 people were selected for inclusion in the review. Researchers compared several steroidal agents such as corticotrophin, cortisone, hydrocortisone, dexamethasone, prednisone and intravenous immunoglobulin versus aspirin, placebo or no treatment. Six trials were conducted between 1950 and 1965; one was done in 1990 and the final study was published in 2001. Overall there were no observed significant differences in risk of cardiac disease at one year between corticosteroid-treated and aspirin-treated groups (six studies, 907 participants, risk ratio 0.87, 95% confidence interval 0.66 to 1.15). Similarly, use of prednisone (two studies, 212 participants, risk ratio 1.13, 95% confidence interval 0.52 to 2.45) compared with aspirin did not reduce the risk of heart disease after one year. Investigators in five studies did not report adverse events. The three studies reporting on adverse events reported substantial adverse events. However, all results should be interpreted with caution because of the age of the studies and the substantial risk of bias.

AUTHORS' CONCLUSIONS

Little evidence of benefit was found when corticosteroids or intravenous immunoglobulins were used to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. In addition, risk of bias was substantial, so results should be viewed with caution. New randomised controlled trials in patients with acute rheumatic fever are warranted to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisolone and the effects of other new anti-inflammatory agents. Advances in echocardiography will allow more objective and precise assessments of cardiac outcomes.

[Effect of ligustrazine hydrochloride on coagulation reaction and inflammation reaction in single valve replacement patients with rheumatic heart disease undergoing cardiopulmonary bypass]

OBJECTIVE

To observe the protection effect of Ligustrazine Hydrochloride (LH) on coagulation reaction and inflammation reaction in single valve replacement patients with rheumatic heart disease undergoing cardiopulmonary bypass (CPB).

METHODS

Totally 40 patients undergoing single valve replacement were recruited in the study and randomly assigned to the two groups, the treatment group and the control group, 20 in each group. In treatment group LH (3 mg/kg) was intravenously infused from the jugular vein. LH (3 mg/kg) was also added in the CPB priming. In the control group LH was replaced by equal amount of normal saline. Endothelial micro-particles (EMP) count was detected before CPB, 30 min after CPB, 1 h and 24 h after CPB finished. The coagulation reaction time (R), coagulation time (K), clotting formation velocity (alpha angle), maximum amplitude (MA), coagulation index (CI), platelet (PLT), hypersensitive C reactive protein (hs-CRP), IL-6, and IL-10 were detected before CPB, 1 h and 24 h after CPB finished.

RESULTS

There was no statistical difference in aorta arresting time, period of CPB, post-operative drainage volume, plasma transfusion volume, post-operative respirator assistant time, and hospitalization time between the two groups (P >0.05). Compared with pre-CPB in the same group, the count of EMP was much higher at 30 min after CPB and 1 h after CPB finished (P < 0.01). R and K, hs-CRP, IL-6, and IL-10 increased at 1 h and 24 h after CPB finished (P <0.01,P < 0.05). The alpha angle,.MA, CI, and PLT decreased 1 h after CPB finished (P <0.01). The a angle increased, while CI and PLT decreased 24 h after CPB finished (P <0.05). Compared with the control group in the same period, the count of EMP was lower in the treatment group 30 min after CPB and 1 h after CPB finished (P <0. 05, P <0. 01). R and K values obviously decreased in treatment group 1 hour after CPB finished (P <0. 05), while a angle, MA, CI, and PLT increased (P <0. 05, P <0. 01). hs-CRP and IL-6 decreased in the treatment group 1 h and 24 h after CPB finished (P <0.05), while IL-10 increased (P <0.05). The count of PLT increased 24 h after CPB finished in the treatment group (P <0. 05).

CONCLUSION

LH had certain protection effect on the vascular endothelium undergoing CPB, and lower excessive activation of coagulation reaction and inflammation reaction in patients undergoing CPB.

Rheumatic heart disease in pregnancy: cardiac and obstetric outcomes

BACKGROUND

Rheumatic heart disease (RHD) remains an important health issue for indigenous women of child-bearing age in northern Australia. However, the influence of RHD on maternal outcomes with current clinical practice is unclear.

AIMS

To determine maternal cardiac complications and obstetric outcomes in patients with RHD.

METHODS

Retrospective case note analysis of women with RHD who received obstetric care between July 1999 and May 2010 at Cairns Base Hospital in north Queensland. Outcome measures were obstetric interventions and outcomes, cardiac interventions and complications, stratified according to a cardiac risk score (CRS).

RESULTS

Ninety-five confinements occurred in 54 patients, of whom 52 were Indigenous Australians. There were no maternal or neonatal deaths. With a CRS of 0, cardiac complications occurred in 0 of 70 confinements; with a CRS of 1, complications occurred in 5 of 17 confinements (29%); with a CRS of >1, complications occurred in 2 of 4 confinements (50%). Another four patients were first diagnosed with RHD after developing acute pulmonary oedema during the peripartum period.

CONCLUSIONS

  RHD has a major impact on maternal cardiac outcomes. However, with current management practices, maternal and fetal mortality are low, and the incidence of complications is predictable based on known risk factors.

Improvement in rheumatic fever and rheumatic heart disease management and prevention using a health centre-based continuous quality improvement approach

BACKGROUND

Rheumatic heart disease (RHD) remains a major health concern for Aboriginal Australians. A key component of RHD control is prevention of recurrent acute rheumatic fever (ARF) using long-term secondary prophylaxis with intramuscular benzathine penicillin (BPG). This is the most important and cost-effective step in RHD control. However, there are significant challenges to effective implementation of secondary prophylaxis programs. This project aimed to increase understanding and improve quality of RHD care through development and implementation of a continuous quality improvement (CQI) strategy.

METHODS

We used a CQI strategy to promote implementation of national best-practice ARF/RHD management guidelines at primary health care level in Indigenous communities of the Northern Territory (NT), Australia, 2008-2010. Participatory action research methods were employed to identify system barriers to delivery of high quality care. This entailed facilitated discussion with primary care staff aided by a system assessment tool (SAT). Participants were encouraged to develop and implement strategies to overcome identified barriers, including better record-keeping, triage systems and strategies for patient follow-up. To assess performance, clinical records were audited at baseline, then annually for two years. Key performance indicators included proportion of people receiving adequate secondary prophylaxis (≥80% of scheduled 4-weekly penicillin injections) and quality of documentation.

RESULTS

Six health centres participated, servicing approximately 154 people with ARF/RHD. Improvements occurred in indicators of service delivery including proportion of people receiving ≥40% of their scheduled BPG (increasing from 81/116 [70%] at baseline to 84/103 [82%] in year three, p = 0.04), proportion of people reviewed by a doctor within the past two years (112/154 [73%] and 134/156 [86%], p = 0.003), and proportion of people who received influenza vaccination (57/154 [37%] to 86/156 [55%], p = 0.001). However, the proportion receiving ≥80% of scheduled BPG did not change. Documentation in medical files improved: ARF episode documentation increased from 31/55 (56%) to 50/62 (81%) (p = 0.004), and RHD risk category documentation from 87/154 (56%) to 103/145 (76%) (p < 0.001). Large differences in performance were noted between health centres, reflected to some extent in SAT scores.

CONCLUSIONS

A CQI process using a systems approach and participatory action research methodology can significantly improve delivery of ARF/RHD care.

Undetected rheumatic heart disease revealed using portable echocardiography in a population of school students in Tairawhiti, New Zealand

AIM

The aim of this programme was to find undetected rheumatic heart disease (RHD) in students from selected schools in the Tairawhiti region (eastern part of the North Island) of New Zealand.

METHOD

Portable echocardiography was used to scan students in 5 urban and rural schools in Tairawhiti where the population is predominantly Maori. The age range of students in the urban schools was 10-13 years and in the rural schools 5-17 years. Those with abnormal echocardiograms were referred for a paediatric consultation, with hospital-based echocardiography if required for the clarification of diagnoses and further management.

RESULTS

A total of 685 students, representing over 95% of the schools' students, consented to having echocardiographic scanning. After repeat hospital based echocardiography for 11 students, a total of 52 scans were regarded as abnormal. In this population definite (n=4) or probable (n=7) RHD was found in 11 students a prevalence of 1.61% (95%CIs 0.80-2.85). Possible RHD was found in 19 students. Previously undetected confirmed (n=1) or probable (n=7) RHD was found in 8 students a prevalence of 1.17% (95%CIs 0.51-2.29). Congenital heart defects (CHD) were found in 22 students a prevalence of 3.21% (95%CIs 2.02-4.83).

CONCLUSION

Echocardiography was a popular modality and detected a significant burden of previously unknown RHD in this young Maori population who are now receiving penicillin. However, echocardiography detected a greater prevalence of possible RHD for which optimum management is at present uncertain. Echocardiography also detected students with a range of severity of CHD. Screening with echocardiography for RHD would involve a significant use of public health, paediatric and cardiac resources with 7.6% of students and their families requiring clinical consultations and ongoing management of the abnormal echocardiographic results.

Echocardiography screening for rheumatic heart disease in Ugandan schoolchildren

BACKGROUND

Historically, sub-Saharan Africa has had the highest prevalence rates of clinically detected rheumatic heart disease (RHD). Echocardiography-based screening improves detection of RHD in endemic regions. The newest screening guidelines (2006 World Health Organization/National Institutes of Health) have been tested across India and the Pacific Islands, but application in sub-Saharan Africa has, thus far, been limited to Mozambique. We used these guidelines to determine RHD prevalence in a large cohort of Ugandan school children, to identify risk factors for occult disease, and to assess the value of laboratory testing.

METHODS AND RESULTS

Auscultation and portable echocardiography were used to screen randomly selected schoolchildren, 5 to 16 years of age, in Kampala, Uganda. Disease likelihood was defined as definite, probable, or possible in accordance with the 2006 National Institutes of Health/World Health Organization guidelines. Ninety-seven percent of eligible students received screening (4869 of 5006). Among them, 130 children (2.7%) had abnormal screening echocardiograms. Of those 130, secondary evaluation showed 72 (55.4%) with possible, probable, or definite RHD; 18 (13.8%) with congenital heart disease; and 40 (30.8%) with no disease. Echocardiography detected 3 times as many cases of RHD as auscultation: 72 (1.5%) versus 23 (0.5%; P<0.001). Children with RHD were older (10.1 versus 9.3 years; P=0.002). Most cases (98%) involved only the mitral valve. Lower socioeconomic groups had more RHD (2.7% versus 1.4%; P=0.036) and more advanced disease (64% versus 26%; P<0.001). Antistreptolysin O titers were elevated in children with definite RHD.

CONCLUSIONS

This is one of the largest single-country childhood RHD prevalence studies and the first to be conducted in sub-Saharan Africa. Our data support inclusion of echocardiography in screening protocols, even in the most resource-constrained settings, and identify lower socioeconomic groups as most vulnerable. Longitudinal follow-up of children with echocardiographically diagnosed subclinical RHD is needed.

Anti-inflammatory treatment for carditis in acute rheumatic fever

BACKGROUND

Rheumatic heart disease remains an important cause of acquired heart disease in developing countries. Although the prevention of rheumatic fever and the management of recurrences is well established, the optimal management of active rheumatic carditis is still unclear. This is an update of a review published in 2003 and previously updated in 2009.

OBJECTIVES

To assess the effects of anti-inflammatory agents such as aspirin, corticosteroids, immunoglobulin and pentoxifylline for preventing or reducing further heart valve damage in patients with acute rheumatic fever.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2011), MEDLINE (1966 to Aug 2011), EMBASE (1998 to Sept 2011), LILACS (1982 to Sept 2011), Index Medicus (1950 to April 2001) and references lists of identified studies. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins, pentoxifylline) with placebo or controls, or comparing any of the anti-inflammatory agents with one another, in adults and children with acute rheumatic fever diagnosed according to the Jones, or modified Jones criteria. The presence of cardiac disease one year after treatment was the major outcome criteria selected.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data. Risk of bias was assessed using methodology outlined in the Cochrane handbook.

MAIN RESULTS

No new studies were included in this update. Eight randomised controlled trials involving 996 people were included. Several steroidal agents corticotrophin, cortisone, hydrocortisone, dexamethasone and prednisone, and intravenous immunoglobulin were compared to aspirin, placebo or no treatment in the various studies. Six of the trials were conducted between 1950 and 1965, one study was done in 1990, and the final study was published in 2001. Overall there was no significant difference in the risk of cardiac disease at one year between the corticosteroid-treated and aspirin-treated groups (six studies, 907 participants, relative risk 0.87, 95% confidence interval 0.66 to 1.15). Similarly, use of prednisone (two studies, 212 participants, relative risk 1.13, 95% confidence interval 0.52 to 2.45) compared to aspirin did not reduce the risk of developing heart disease after one year. Adverse events were not reported in five studies. The three studies reporting on adverse events all reported substantial adverse events. However, all results should be interpreted with caution due to the age of the studies and to substantial risk of bias.

AUTHORS' CONCLUSIONS

There is little evidence of benefit from using corticosteroids or intravenous immunoglobulins to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. Additionally there was substantial risk of bias, so results should be viewed with caution. New randomised controlled trials in patients with acute rheumatic fever to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisolone, and other new anti-inflammatory agents are warranted. Advances in echocardiography will allow for more objective and precise assessments of cardiac outcomes.

Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered.

METHODS

The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.

RESULTS

In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm(2) (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm(2), we recommend early surgery (Grade 2C).

CONCLUSIONS

These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.

[Case of rheumatic fever complicating carditis detected by a newly-developed systolic murmur in an adult woman]

A 62-year-old woman presented to a primary care doctor on January 2006 due to a sore throat and high fever, and had received medication for a common cold. She was referred to our hospital in February 2006 because of additional manifestations such as painful rashes on the lower limb similar to erythema nodosum and polyarthralgia on her feet, shoulder and finger joints. She was initially treated with an anti-inflammatory drug (NSAID) for polyarthritis but the symptoms did not improved. In addition, the serum level of anti-streptolysin O antibody (ASO) was elevated at the second visit more than that at the first visit. She was diagnosed to have rheumatic fever (RF) based on the polyarthritis, inflammatory data and an increase of the ASO level. She was treated with 10 mg a day of prednisolone (PSL) and sultamicillin tosilate. However, a systolic murmur that had been never noticed by previous auscultation appeared after the third hospital day and the mitral regurgitation was also detected on echocardiogram. She was then treated with 40 mg a day of PSL because of an appearance of the carditis due to RF. The increased PSL dose promptly improved the systolic murmur as well as the arthritis. This report presented an RF case with carditis detected by an development of the systolic murmur in an adult female.

Infective endocarditis: an update on the role of echocardiography

The evaluation of valvular and nonvalvular structures is of central importance in the diagnosis, management, and treatment of infective endocarditis (IE). The incidence of IE has remained constant due to changing substrate, with notably higher prevalence observed in the elderly. Mortality and morbidity continue to remain high, despite advances in medical and surgical treatment. This article reviews the technical and practical aspects of the use of echocardiography to evaluate patients with suspected IE.

[Iatrogeny in paediatrics: reconsider attitudes]

Iatrogeny is a pathologic condition caused in a patient in the different stages of a medical act. In the United States, it is the fourth cause of death but in Portugal, data are not yet available. Though different from medical error, it is still a taboo subject for health care providers. The authors report a case of relational, diagnostic and therapeutic iatrogeny with serious consequences for the patient. Doctors have a fundamental role in reducing morbidity and mortality due to iatrogenic causes; they have the duty to question and reconsider diagnosis and treatments, keeping an alert attitude and self-criticism in order to identify potential iatrogenic interventions or to correct it as soon as possible.

Cardiac tamponade as a rare form of presentation of rheumatic carditis

In this article the authors describe a clinical case of acute rheumatic fever (according to revised Jones criteria, American Heart Association [AHA], 1992) with cardiac tamponade, emphasizing this uncommon presentation. An adolescent patient with a clinical picture of cardiac tamponade was seen in the emergency department. Clinical progression and tests demonstrated rheumatic carditis with an initial manifestation of pericarditis with cardiac tamponade. This report aims to warn physicians about the diagnosis of rheumatic carditis in an unusual clinical presentation, in cases of cardiac tamponade, particularly in school-aged children and adolescents in countries with a high prevalence of rheumatic fever. The literature contains only two documented cases of cardiac tamponade related to acute rheumatic fever, and this case represents a third.

[Comparison of amiodarone plus irbesartan regimen versus amiodarone alone on maintaining sinus rhythm in rheumatic heart disease patients with persistent atrial fibrillation post valve replacement and cardioversion]

OBJECTIVE

To compare the efficacy of combined amiodarone and irbesartan use versus amiodarone alone on maintaining sinus rhythm in rheumatic heart disease patients with persistent atrial fibrillation (AF) post valve replacement and cardioversion.

METHODS

Patients were randomly divided into amiodarone group (A, n = 31) and amiodarone plus irbesartan group (AI, n = 32) and all patients received Warfarin (INR 2.0 - 3.0). For patients in group A, intravenous amiodarone (600 mg/d) was applied for 10 days and oral amiodarone (200 mg, b.i.d.) was given on the 7th day for 3 days. For patients in group AI, irbesartan (150 mg/d) was added on top of amiodarone at the study begin. Electric cardioversion was performed for patients still with AF on day 10. Amiodarone (200 mg, b.i.d. for 1 week, then 200 mg, q.d. till study end) with or without irbesartan (150 mg/d) was continued thereafter. Patients were followed up for 12 months after sinus rhythm recovery. The primary end points are first recurrence of symptomatic and asymptomatic AF.

RESULTS

Twelve months post therapy, number of patients on sinus rhythm was significantly higher (68.7% vs. 41.9%, P<0.05) and left atrium diameter (LAD) was significantly smaller [(48.6 +/- 4.6) mm vs. (51.5 +/- 4.2) mm, P<0.05] in group AI than those in group A. LAD (OR 1.242) and use of irbesartan (OR 0.226) are associated with the AF recurrence.

CONCLUSION

Combined amiodarone and irbesartan use is superior to amiodarone alone for maintaining sinus rhythm in rheumatic heart disease patients with persistent AF post valve replacement and cardioversion.

Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics

Primary prevention of acute rheumatic fever is accomplished by proper identification and adequate antibiotic treatment of group A beta-hemolytic streptococcal (GAS) tonsillopharyngitis. Diagnosis of GAS pharyngitis is best accomplished by combining clinical judgment with diagnostic test results, the criterion standard of which is the throat culture. Penicillin (either oral penicillin V or injectable benzathine penicillin) is the treatment of choice, because it is cost-effective, has a narrow spectrum of activity, and has long-standing proven efficacy, and GAS resistant to penicillin have not been documented. For penicillin-allergic individuals, acceptable alternatives include a narrow-spectrum oral cephalosporin, oral clindamycin, or various oral macrolides or azalides. The individual who has had an attack of rheumatic fever is at very high risk of developing recurrences after subsequent GAS pharyngitis and needs continuous antimicrobial prophylaxis to prevent such recurrences (secondary prevention). The recommended duration of prophylaxis depends on the number of previous attacks, the time elapsed since the last attack, the risk of exposure to GAS infections, the age of the patient, and the presence or absence of cardiac involvement. Penicillin is again the agent of choice for secondary prophylaxis, but sulfadiazine or a macrolide or azalide are acceptable alternatives in penicillin-allergic individuals. This report updates the 1995 statement by the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee. It includes new recommendations for the diagnosis and treatment of GAS pharyngitis, as well as for the secondary prevention of rheumatic fever, and classifies the strength of the recommendations and level of evidence supporting them.

Consensus guidelines on pediatric acute rheumatic fever and rheumatic heart disease

JUSTIFICATION

Acute rheumatic fever and rheumatic chronic valvular heart disease is an important preventable cause of morbidity and mortality in suburban and rural India. Its diagnosis is based on clinical criteria. These criteria need verification and revision in the Indian context. Furthermore, there are glaring differences in management protocols available in literature. These facts prompted Indian Academy of Pediatrics to review the management of rheumatic fever.

PROCESS

Management of Rheumatic fever was reviewed and recommendation was formulated at national consultative meeting on 20th May 2007 at New Delhi.

OBJECTIVES

To formulate uniform guidelines on management of acute rheumatic fever and rheumatic heart disease in the Indian context. Guidelines were formulated for the management of streptococcal pharyngitis, acute rheumatic fever and its cardiac complication as well as secondary prophylaxis for recurrent episodes.

RECOMMENDATIONS

(1) Streptococcal eradication with appropriate antibiotics (Benzathine penicillin single dose or penicillin V oral or azithromycin). (2) Diagnosis of rheumatic fever based on Jones criteria. (3) Control inflammatory process with aspirin with or without steroids (total duration of treatment of 12 weeks). (4) Treatment of chorea according to severity (therapy to continue for 2-3 weeks after clinical improvement). (5) Protocol for managing cardiac complication like valvular heart disease, congestive heart failure and atrial fibrillation. (6) Secondary prophylaxis with benzathine penicillin and management of anaphylaxis.

Rheumatic fever diagnosis, management, and secondary prevention: a New Zealand guideline

AIM

The National Heart Foundation of New Zealand, and the Cardiac Society of Australia and New Zealand (CSANZ) recently launched an evidence-based review and guideline entitled New Zealand Guideline for Rheumatic Fever Diagnosis, Management, and Secondary Prevention. This paper is a brief summary.

METHOD

This Guideline was developed by a writing group comprising experts in the area. Relevant literature was identified and reviewed, and the Australian guideline for rheumatic fever and rheumatic heart disease was reviewed and adapted for the New Zealand context. A peer review and stakeholder consultation process followed the development of the draft document.

RESULTS

The final draft of the New Zealand guideline was endorsed by Te Hotu Manawa Maori, Pacific Islands Heart Beat, The Paediatric Society of New Zealand, and the Rheumatic Fever Trust of New Zealand--plus approved by a number of organisations including the Royal Australasian College of Physicians, the Australasian Society for Infectious Disease, the Pasifika Medical Association, and Te Ohu Rata o Aotearoa. Two subsequent New Zealand guidelines for rheumatic fever: Sore Throat Management and Primary Prevention are also in production. The complete guideline, and associated summary algorithms, can be downloaded from www.nhf.org.nz

CONCLUSION

A New Zealand Guideline for Rheumatic Fever Diagnosis, Management and Secondary Prevention of Acute Rheumatic Fever should result in improved consistency in the approach to this disease, and reduced mortality and morbidity from acute rheumatic fever and rheumatic heart disease.

[Comparative assessment of inotropic reaction of isolated myocardium of patients with ischemic and rheumatic heart disease after short-term periods of rest at the background of amiodarone]

We studied inotropic reaction of isolated myocardium of patients with heart failure induced by ischemic and rheumatic cardiac involvement after periods of rest at the background of amiodarone. The studies were carried out on muscular trabeculi separated from right atrial auricle during surgery. It was shown that inotropic reaction of insufficient myocardium could be of 2 types. In type I inotropic reaction first contraction after period of rest either exceeded basal contractions or remained at their level. Type 2 was characterized by significant lowering of amplitude of contractions relative to regular ones. Exposure of the myocardium to amiodarone (1 micro/L) led to significant potentiation of trabeculi contraction after periods of rest of muscles with type I reaction and did not affect response of muscles with type II reaction. These results allow to conclude that the state of calcium transporting systems of sarcoplasmic reticulum (SR) is different in ischemic and rheumatic heart failure and that realization of therapeutic effect of amiodarone depends on functional state of SR.

[Effects of cattle encephalon glycoside and ignotin injection on serum level of S100B protein and neuron specific enolase in patients undergoing cardiac valve replacement with cardiopulmonary bypass]

OBJECTIVE

To investigate the effects of cattle encephalon glycoside and ignotin injection on serum level of S100B protein and neuron specific enolase (NSE) during cardiac valve replacement with cardiopulmonary bypass (CPB).

METHODS

Forty patients undergoing cardiac valve replacement with CPB were randomly divided into two equal groups: cattle encephalon glycoside and ignotin injection group (Group A, injected intravenously with cattle encephalon glycoside and ignotin 20 ml after induction of anesthesia, and control group (Group B, injected intravenously with normal saline instead. Blood samples were taken from the jugular bulb after induction of anesthesia (T1), immediately, and 2 h, 6 h, and 24 h after the discontinuation of CPB (T2, T3, T4, and T5) for determination of serum levels of S100B protein and NSE.

RESULTS

The serum levels of S100B protein and NSE of both groups were significantly increased after CPB, and then gradually decreased. At the time point T5, the serum levels of S100B protein of both groups decreased to near the baseline levels (T1 levels), but the serum levels of NSE remained high in both groups. At the time points T2, T3, T4 and T5, the serum levels of S100B protein were significantly higher in Group B than in Group A (all P < 0.05). At the time points T2, T3, and T4, the serum levels of NSE was significantly higher in Group B than in Group A (all P < 0.05).

CONCLUSION

Cattle encephalon glycoside and ignotin injection decreases the serum levels of S100B protein and NSE and has cerebral protective effect during cardiac valve replacement with CPB to a certain degree.

Prevention of Ischemic Stroke: Antithrombotic Therapy in Cardiac Embolism

Ischemic stroke secondary to cardiac disease accounts for approximately 30% of all stroke subtypes and it may be due to a large list of conditions. Stroke secondary to heart disease causes more severe deficits, higher mortality, and increased costs that other stroke subtypes. Therefore, proper identification of cardioembolic stroke is crucial for adequate selection of optimal preventive strategies. Identification of stroke prone individuals with heart disease could also have an important therapeutic impact. This manuscript reviews the interaction between the heart and brain with a particularly emphasis in the current state of older and newer antithrombotic drugs for stroke prevention in patients with atrial fibrillation. Other neuro-cardiological issues reviewed include current antithrombotic strategies in patients with a host of heart conditions which include pacemakers, acute myocardial infarction, congestive heart failure, cardiac procedures, patent foramen ovale, valve disease, endocarditis, or cardiac tumours.