The natural history of latent rheumatic heart disease in a 5 year follow-up study: a prospective observational study.

BACKGROUND: Latent rheumatic heart disease (RHD) occurs in asymptomatic individuals with echocardiographic evidence of RHD and no history of acute rheumatic fever. The natural history of latent RHD is unclear but has important clinical and economic implications about whether these children should receive penicillin prophylaxis or not. We performed a 5-year prospective study of this question. METHODS: In August 2013 through September 2014, we conducted a follow-up study of latent RHD among school pupils using the World Heart Federation (WHF) echocardiographic criteria. Contingency tables were used to assess progression, persistence or regression of latent RHD. RESULTS: Forty two borderline and 13 definite cases of RHD (n 55) were identified, 44 (80%; mean age 13.8 ± 4.0 years; 29 (65.9%) female) of whom were available for echocardiographic examination at a median follow-up of 60.8 months (interquartile range 51.3-63.5). Over the follow-up period, half the participants (n = 23; 52.3%) improved to normal or better WHF category (regressors), a third (n = 14, 31.8%) remained in the same category (persistors), while seven others (15.9%) progressed from borderline to definite RHD (progressors). In total, 21 subjects (47.7%) reverted to a normal status, nine (20.4%) either improved from definite to borderline or remained in the borderline category, and 14 (31.8%) either remained definite or progressed from borderline to a definite status. Two cases (20%) progressed to symptomatic disease. CONCLUSIONS: Latent RHD has a variable natural history that ranges from regression to normal in nearly half of cases, to persistence, progression or development of symptoms in the remainder of subjects.

Evaluation of a focussed protocol for hand-held echocardiography and computer-assisted auscultation in detecting latent rheumatic heart disease in scholars.

UNLABELLED: Introduction Echocardiography is the diagnostic test of choice for latent rheumatic heart disease. The utility of echocardiography for large-scale screening is limited by high cost, complex diagnostic protocols, and time to acquire multiple images. We evaluated the performance of a brief hand-held echocardiography protocol and computer-assisted auscultation in detecting latent rheumatic heart disease with or without pathological murmur. METHODS: A total of 27 asymptomatic patients with latent rheumatic heart disease based on the World Heart Federation criteria and 66 healthy controls were examined by standard cardiac auscultation to detect pathological murmur. Hand-held echocardiography using a focussed protocol that utilises one view - that is, the parasternal long-axis view - and one measurement - that is, mitral regurgitant jet - and a computer-assisted auscultation utilising an automated decision tool were performed on all patients. RESULTS: The sensitivity and specificity of computer-assisted auscultation in latent rheumatic heart disease were 4% (95% CI 1.0-20.4%) and 93.7% (95% CI 84.5-98.3%), respectively. The sensitivity and specificity of the focussed hand-held echocardiography protocol for definite rheumatic heart disease were 92.3% (95% CI 63.9-99.8%) and 100%, respectively. The test reliability of hand-held echocardiography was 98.7% for definite and 94.7% for borderline disease, and the adjusted diagnostic odds ratios were 1041 and 263.9 for definite and borderline disease, respectively. CONCLUSION: Computer-assisted auscultation has extremely low sensitivity but high specificity for pathological murmur in latent rheumatic heart disease. Focussed hand-held echocardiography has fair sensitivity but high specificity and diagnostic utility for definite or borderline rheumatic heart disease in asymptomatic patients.

Prevalence of rheumatic heart disease in 4720 asymptomatic scholars from South Africa and Ethiopia.

BACKGROUND: In Africa, screening for asymptomatic rheumatic heart disease (RHD) has been conducted in single communities using non-standardised echocardiographic criteria. The use of different diagnostic criteria has led to widely variable estimates of the prevalence of RHD in the same communities. METHODS: Randomly selected school pupils, from 4 to 24 years of age in Bonteheuwel and Langa communities of Cape Town, South Africa, and Jimma, Ethiopia, respectively, were screened for RHD according to standardised evidence-based echocardiographic diagnostic criteria of the World Heart Federation (WHF). RESULTS: We screened 4720 scholars. In South Africa (n=2720), 1604 (58.9%) were female and the mean age was 12.2±4.2 years. In Ethiopia (n=2000), 1012 (50.6%) were female and the mean age was 10.7±2.5 years. Echocardiographic screening revealed 55 cases of definite and borderline RHD by WHF criteria in South Africa and 61 cases in Ethiopia, corresponding to a prevalence of 20.2 cases per 1000 (95% CI 15.3 to 26.2) and 31 cases per 1000 (95% CI 23.4 to 39.0), respectively. The odds of detecting a scholar with RHD in Ethiopia were 1.5 times higher than in South Africa (OR 1.5; 95% CI 1.04 to 2.2, p=0.02). The prevalence of RHD was 27 cases per 1000 (95% CI 19.3 to 36.8) in Langa, and 12.5 cases per 1000 (95% CI 7.1 to 20.2) in Bonteheuwel. The odds of detecting a schoolchild with RHD in Langa compared with Bonteheuwel were 2.2 (OR 2.2; 95% CI 1.2 to 4.2, p=0.0071). INTERPRETATION: There were significant differences in detecting asymptomatic RHD in school pupils of different countries and in different communities within a country in sub-Saharan Africa. The variation in the prevalence of RHD between countries and communities has important implications for the modelling of the global burden of RHD.