Prevalence and progression of rheumatic heart disease: a global systematic review and meta-analysis of population-based echocardiographic studies

Handheld echocardiography for the screening and diagnosis of rheumatic heart disease: a systematic review to inform WHO guidelines

BACKGROUND

Early detection and diagnosis of acute rheumatic fever and rheumatic heart disease are key to preventing progression, and echocardiography has an important diagnostic role. Standard echocardiography might not be feasible in high-prevalence regions due to its high cost, complexity, and time requirement. Handheld echocardiography might be an easy-to-use, low-cost alternative, but its performance in screening for and diagnosing acute rheumatic fever and rheumatic heart disease needs further investigation.

METHODS

In this systematic review and meta-analysis, we searched Embase, MEDLINE, LILACS, and Conference Proceedings Citation Index-Science up to Feb 9, 2024, for studies on the screening and diagnosis of acute rheumatic fever and rheumatic heart disease using handheld echocardiography (index test) or standard echocardiography or auscultation (reference tests) in high-prevalence areas. We included all studies with useable data in which the diagnostic performance of the index test was assessed against a reference test. Data on test accuracy in diagnosing rheumatic heart disease, acute rheumatic fever, or carditis with acute rheumatic fever (primary outcomes) were extracted from published articles or calculated, with authors contacted as necessary. Quality of evidence was appraised using GRADE and QUADAS-2 criteria. We summarised diagnostic accuracy statistics (including sensitivity and specificity) and estimated 95% CIs using a bivariate random-effects model (or univariate random-effects models for analyses including three or fewer studies). Area under the curve (AUC) was calculated from summary receiver operating characteristic curves. Heterogeneity was assessed by visual inspection of plots. This study was registered with PROSPERO (CRD42022344081).

FINDINGS

Out of 4868 records we identified 11 studies, and two additional reports, comprising 15 578 unique participants. Pooled data showed that handheld echocardiography had high sensitivity (0·87 [95% CI 0·76-0·93]), specificity (0·98 [0·71-1·00]), and overall high accuracy (AUC 0·94 [0·84-1·00]) for diagnosing rheumatic heart disease when compared with standard echocardiography (two studies; moderate certainty of evidence), with better performance for diagnosing definite compared with borderline rheumatic heart disease. High sensitivity (0·79 [0·73-0·84]), specificity (0·85 [0·80-0·89]), and overall accuracy (AUC 0·90 [0·85-0·94]) for screening rheumatic heart disease was observed when pooling data of handheld echocardiography versus standard echocardiography (seven studies; high certainty of evidence). Most studies had a low risk of bias overall. Some heterogeneity was observed for sensitivity and specificity across studies, possibly driven by differences in the prevalence and severity of rheumatic heart disease, and level of training or expertise of non-expert operators.

INTERPRETATION

Handheld echocardiography has a high accuracy and diagnostic performance when compared with standard echocardiography for diagnosing and screening of rheumatic heart disease in high-prevalence areas.

FUNDING

World Health Organization.

TRANSLATIONS

For the Chinese, French, Italian, Persian, Portuguese, Spanish and Urdu translations of the abstract see Supplementary Materials section.

Prevalence of rheumatic heart disease diagnosed according to the echocardiographic criteria of the World Heart Federation in Africa: A systematic review and meta-analysis

Rheumatic heart disease (RHD) is a chronic complication arising from acute rheumatic fever (ARF), an autoimmune response triggered by group A streptococcal infection. It primarily affects children and young adults in developing countries. RHD continues to show substantial global heterogeneity. Socioeconomic factors lead the virtual disappearance of RHD in industrialized countries with the introduction of penicillin. By contrast, RHD is still endemic in Africa, Asia, South America, and developing communities of Australasia. We provide an estimate of the current prevalence of latent RHD in Africa using the echocardiographic diagnostic criteria of the World Heart Federation (WHF). Systematic review and meta-analysis of 21 studies reporting the prevalence of RHD, encompassing 40.639 patients. Estimated prevalence of RHD was 25.5 cases per 1000 population (P ≤0.02; 95 % CI, 18.1-32.9 per 1000): definite RHD 13.1 cases per 1000 population (95 % CI, 7.7-18.5 per 1000): and borderline 12,4 cases per 1000 population (95 % CI, 7.7-17.0 per 1000). The prevalence of definite RHD was a significantly higher in adults (M = 28.2, SD = 6.1) compared to children (M = 10.3, SD = 9.2), t(17) = 2.6, p = .0179. Prevalence of definite RHD in schools was 7,92 cases per 1000 population (95 % CI, 4,49-11,35 per 1000) and in community was 26,17 cases per 1000 population (95 % CI, 12,27-40,06 per 1000). This meta-analysis may have produced a better estimate of the prevalence of RHD in Africa using only studies performed according to the 2012 WHF, and clearly showed the high prevalence of RHD in the community and in adults.

Follow-up echocardiographic changes in children and youth aged <25 years with latent rheumatic heart disease: A systematic review and meta-analysis of global data

OBJECTIVES

To estimate progression, regression and persistence rates for borderline and mild-definite latent RHD in children and youth diagnosed at age < 25 years.

METHODS

A review was conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Electronic databases were searched for latent RHD echocardiography follow-up studies which used World Heart Federation diagnostic criteria. A meta-analysis of outcomes was conducted for borderline and mild-definite disease subcategories.

RESULTS

Data for 1618 individuals from 12 studies were included. For borderline cases, 48.51% regressed (95%CI 45.10-51.93), 13.99% progressed (95%CI 9.72-18.25), and 38.61% had persistent (unchanged) disease at follow-up (95%CI 29.68-47.54). For mild-definite cases, 34.01% regressed (95%CI 28.88-39.15), 8.06% progressed (95%CI 3.65-16.90), and 60.23% had persistent disease (95%CI 55.08-67.38).

CONCLUSIONS

Borderline and mild-definite latent RHD show variable evolution following initial diagnosis. While 8% of mild-definite and 14% borderline cases had signs of disease progression at follow-up, a third of mild-definite and half of borderline cases had disease regression, even with sub adequate antibiotic prophylaxis. The significant variability between study cohorts suggests latent RHD natural history is likely variable between different endemic regions globally. Future research is needed to identify those individuals who would most benefit from antibiotic prophylaxis and determine regional natural history of latent RHD.

2023 World Heart Federation guidelines for the echocardiographic diagnosis of rheumatic heart disease

Rheumatic heart disease (RHD) is an important and preventable cause of morbidity and mortality among children and young adults in low-income and middle-income countries, as well as among certain at-risk populations living in high-income countries. The 2012 World Heart Federation echocardiographic criteria provided a standardized approach for the identification of RHD and facilitated an improvement in early case detection. The 2012 criteria were used to define disease burden in numerous epidemiological studies, but researchers and clinicians have since highlighted limitations that have prompted a revision. In this updated version of the guidelines, we incorporate evidence from a scoping review, an expert panel and end-user feedback and present an approach for active case finding for RHD, including the use of screening and confirmatory criteria. These guidelines also introduce a new stage-based classification for RHD to identify the risk of disease progression. They describe the latest evidence and recommendations on population-based echocardiographic active case finding and risk stratification. Secondary antibiotic prophylaxis, echocardiography equipment and task sharing for RHD active case finding are also discussed. These World Heart Federation 2023 guidelines provide a concise and updated resource for clinical and research applications in RHD-endemic regions.

Outcomes of latent rheumatic heart disease: External validation of a simplified score in patients with and without secondary prophylaxis

BACKGROUND

Secondary antibiotic prophylaxis reduces progression of latent rheumatic heart disease (RHD) but not all children benefit. Improved risk stratification could refine recommendations following positive screening. We aimed to evaluate the performance of a previously developed echocardiographic risk score to predict mid-term outcomes among children with latent RHD.

METHODS

We included children who completed the GOAL, a randomized trial of secondary antibiotic prophylaxis among children with latent RHD in Uganda. Outcomes were determined by a 4-member adjudication panel. We applied the point-based score, consisting of 5 variables (mitral valve (MV) anterior leaflet thickening (3 points), MV excessive leaflet tip motion (3 points), MV regurgitation jet length ≥ 2 cm (6 points), aortic valve focal thickening (4 points) and any aortic regurgitation (5 points)), to panel results. Unfavorable outcome was defined as progression of diagnostic category (borderline to definite, mild definite to moderate/severe definite), worsening valve involvement or remaining with mild definite RHD.

RESULTS

799 patients (625 borderline and 174 definite RHD) were included, with median follow-up of 24 months. At total 116 patients (14.5%) had unfavorable outcome per study criteria, 57.8% not under prophylaxis. The score was strongly associated with unfavorable outcome (HR = 1.26, 95% CI 1.16-1.37, p < 0.001). Unfavorable outcome rates in low (≤6 points), intermediate (7-9 points) and high-risk (≥10 points) children at follow-up were 11.8%, 30.4%, and 42.2%, (p < 0.001) respectively (C-statistic = 0.64 (95% CI 0.59-0.69)).

CONCLUSIONS

The simple risk score provided an accurate prediction of RHD status at 2-years, showing a good performance in a population with milder RHD phenotypes.

Temporal trend analysis of rheumatic heart disease burden in high-income countries between 1990 and 2019

AIMS

To assesses trends in rheumatic heart disease (RHD) burden in high-income, European Union 15+ (EU15+) countries between 1990 and 2019.

METHODS AND RESULTS

Cross-sectional analysis of the incidence and mortality of RHD was conducted using data from the Global Burden of Disease (GBD) Study database. Age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs) were extracted for EU15+ countries per sex for each of the years from 1990 to 2019, inclusive, and mortality-to-incidence indices (MII) were computed. Joinpoint regression analysis was used for the description of trends. Over 29 years, an overall declining trend in RHD incidence and mortality across EU 15+ nations were observed. There was significant variability in RHD incidence and mortality rates across high-income countries. However, both RHD incidence and mortality were higher among females compared with males across EU15+ countries over the observed period. The most recent incidence trend, starting predominantly after 2014, demonstrated a rise in RHD incidence in most countries for both sexes. The timing of this RHD resurgence corresponds temporally with an influx of migrants and refugees into Europe. The recent increasing RHD incidence rates ranged from +0.4% to +24.7% for males, and +0.6% to +11.4% for females.

CONCLUSION

More than half of EU15+ nations display a recent increase in RHD incidence rate across both sexes. Possible factors associated with this rise are discussed and include increase in global migration from nations with higher RHD prevalence, host nation factors such as migrants' housing conditions, healthcare access, and migrant health status on arrival.

Agreement between Handheld and Standard Echocardiography for Diagnosis of Latent Rheumatic Heart Disease in Brazilian Schoolchildren from High-Prevalence Settings (Agreement between Screening and Standard Echo for RHD)

Introduction: Handheld echocardiography (echo) is the tool of choice for rheumatic heart disease (RHD) screening. We aimed to assess the agreement between screening and standard echo for latent RHD diagnosis in schoolchildren from an endemic setting. Methods: Over 14 months, 3 nonphysicians used handheld machines and the 2012 WHF Criteria to determine RHD prevalence in consented schoolchildren from Brazilian low-income public schools. Studies were interpreted by telemedicine by 3 experts (Brazil, US). RHD-positive children (borderline/definite) and those with congenital heart disease (CHD) were referred for standard echo, acquired and interpreted by a cardiologist. Agreement between screening and standard echo, by WHF subgroups, was assessed. Results: 1390 students were screened in 6 schools, with 110 (7.9%, 95% CI 6.5-9.5) being screen positive (14 ± 2 years, 72% women). Among 16 cases initially diagnosed as definite RHD, 11 (69%) were confirmed, 4 (25%) reclassified to borderline, and 1 to normal. Among 79 cases flagged as borderline RHD, 19 (24%) were confirmed, 50 (63%) reclassified to normal, 8 (10%) reclassified as definite RHD, and 2 had mild CHD. Considering the 4 diagnostic categories, kappa was 0.18. In patients with borderline RHD reclassified to non-RHD, the most frequent WHF criterion was B (isolated mitral regurgitation, 64%), followed by A (2 mitral valve morphological features, 31%). In 1 patient with definite RHD reclassified to normal, the WHF criterion was D (borderline RHD in aortic and mitral valves). After standard echo, RHD prevalence was 3.2% (95% CI 2.3-4.2). Conclusions: Although practical, RHD screening with handheld devices tends to overestimate prevalence.

Manifestations of Rheumatic Carditis, Regression of Valvular Regurgitation, and Independent Predictors of Mitral Regurgitation Improvement After Rheumatic Carditis in Thai Children

Background

Acute rheumatic fever (ARF) with carditis can lead to the development of rheumatic heart disease in children and young adults.

Objective

This study aimed to investigate the manifestations of rheumatic carditis, clinically significant regression of valvular regurgitation as assessed by echocardiography, and the independent predictors of mitral regurgitation (MR) improvement after rheumatic carditis in Thai children.

Method

Children diagnosed with rheumatic carditis during 2005-2020 at Siriraj Hospital (Bangkok, Thailand) were retrospectively enrolled. Trivial, and mild regurgitation were grouped as non-clinically significant (NCS) regurgitation. Valvular regression was defined moderate-severe regurgitation improving to NCS regurgitation.

Results

Eighty-one patients (mean age: 10 years, range: 8-12 years) were included. At presentation, 59 (72.8%) patients had combined mitral regurgitation (MR) and aortic regurgitation (AR), 20 (24.6%) patients had MR alone, and 2 (2.4%) patients had AR alone. Concerning severity, 28 (34.6%) and 30 (37%) patients presented with severe and moderate MR, respectively. Severe and moderate AR was found in 9 (11.1%) and 16 (19.8%) patients, respectively. At the one-year follow-up, 43.4% of moderate-severe MR, and 41.7% of moderate-severe AR improved to NCS regurgitation. Multivariate analysis revealed high erythrocyte sedimentation rate (ESR) (p = 0.01) and severe carditis (p = 0.05) at presentation to be independent predictors of MR improvement.

Conclusion

Thai children with rheumatic carditis had a high incidence of valvular regurgitation; however, the valvular damage was improved in most patients. High ESR and severe carditis independently predict MR improvement.

[Rheumatic cardiopathies and its risk factors: about 50 cases]

INTRODUCTION

Acute rheumatic fever (ARF) is a multi-systemic disease, in which cardiac involvement is the most serious major manifestation of disease. The aim of this study was to analyse cardiac involvement in children with ARF and his risk factors.

MATERIALS AND METHODS

It were a retrospective study including all children under the age of 14 years who were hospitalized for ARF in the pediatric department of the CHU Hédi Chaker of Sfax, during a period of twelve years (2010-2022).

RESULTS

We collected 50 cases (31 boys and 19 girls). Twenty-two patients (44%) developed cardiac lesions. The mean age at diagnosis was 9.6 years [5-14 years]. A pathological heart murmur was detected in 14 cases (n = 14/22) was classified as mild carditis in 15 cases, moderate carditis in 5 cases and severe in 2 cases. The median follow-up time was 3,3 years. Nineteen patients developed valvular sequelae Risk factors of cardiac lesions was: age more than 8 years, heart murmur, allonged PR, CRP > 100 mg/l and VS > 100 mm.

CONCLUSION

CR is still a public health problem in Tunisia. It is a serious pathology that can cause serious increases in morbidity rates. Thus, we must strengthen preventive strategies.

Echocardiographic Screening of Rheumatic Heart Disease: Current Concepts and Challenges

The incidence of acute rheumatic fever (ARF), which most commonly affects children aged 5-15 years after group A Streptococcus (GAS) infection, ranges from 8 to 51 per 100 000 people worldwide. Rheumatic heart disease (RHD), which occurs when patients with ARF are inappropriately treated or not given regular prophylaxis, is the most common cause of non-congenital heart disease in children and young adults in low-income countries. Timely treatment of GAS infection can prevent ARF, and penicillin prophylaxis can prevent recurrence of ARF. Secondary prophylaxis with benzathine penicillin G has been shown to decrease the incidence of RHD and is a key aspect of RHD control. The most important factor determining the prognosis of RHD is the severity of cardiac involvement. Although approximately 70% of patients with carditis in the acute phase of the disease recover without sequelae, carditis is important because it is the only complication of ARF that causes sequelae. One-third of patients with ARF are asymptomatic. Patients with mild symptoms of recurrent ARF and silent RHD will develop severe morbidities within 5-10 years if they do not receive secondary preventive treatments. A new screening program should be established to prevent cardiac morbidities of ARF in moderate- and highrisk populations. In the present study, we examined the applicability of echocardiographic screening programs for RHD. Cite this article as: Topçu S, Uçar T. Echocardiographic screening of rheumatic heart disease: Current concepts and challenges. Turk Arch Pediatr. 2024;59(1):3-12.

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.

Regional variations in heart failure: a global perspective

Heart failure (HF) is a global public health concern that affects millions of people worldwide. While there have been significant therapeutic advancements in HF over the last few decades, there remain major disparities in risk factors, treatment patterns and outcomes across race, ethnicity, socioeconomic status, country and region. Recent research has provided insight into many of these disparities, but there remain large gaps in our understanding of worldwide variations in HF care. Although the majority of the global population resides across Asia, Africa and South America, these regions remain poorly represented in epidemiological studies and HF trials. Recent efforts and registries have provided insight into the clinical profiles and outcomes across HF patterns globally. The prevalence of HF and associated risk factors has been reported and varies by country and region ranges, with minimal data on regional variations in treatment patterns and long-term outcomes. It is critical to improve our understanding of the different factors that contribute to global disparities in HF care so we can build interventions that improve our general cardiovascular health and mitigate the social and economic cost of HF. In this narrative review, we hope to provide an overview of the global and regional variations in HF care and outcomes.

Systematic review of first-in-human and early phase clinical trials for surgically implantable biological mitral valve substitutes

BACKGROUND

The aim of this review was the creation of uniform protocols to carry out and disclose First-In-Human and preliminary clinical trials of biological mitral valve replacement. The need for consistent methodology in these early trials was highlighted by the observation of significant variability in the methods and protocols used across different research.

METHODS

An extensive search through six major databases was carried out to retrieve First-In-Human (FIH) clinical studies evaluating surgically implanted bio-prostheses in the mitral position.

RESULTS

Following the PRISMA guideline, a systematic search identified 2082 published articles until March 2023. After removing duplicates (189), 1862 citations were screened, resulting in 22 eligible studies with 3332 patients for analysis. The mitral valve prostheses in these studies ranged from 21 to 37 mm, with the 29 mm size being most prevalent. Patient numbers varied, with the FIH subgroup including 31 patients and the older subgroup including 163 patients. Average study durations differed: the older subgroup lasted 4.57 years, the FIH subgroup 2.85 years, and the early phase studies spanned 8.05 years on average.

CONCLUSION

FIH clinical report is essential to assess the significance of clinical data required for a "de novo" surgical implant. In addition, understanding the performance of the device, and recognizing the difficulties associated with the innovation constitute important lessons. These insights could be beneficial for the development of bioprosthetic heart valves and formulating a protocol for an FIH clinical trial.

Analysis and comparison of the trends in burden of rheumatic heart disease in China and worldwide from 1990 to 2019

OBJECTIVES

This study aimed to describe the temporal trends in age and gender burdens of rheumatic heart disease (RHD) in China from 1990 to 2019, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs), and to compare them with the global burden of the disease.

METHODS

Using open data from the Global Burden of Disease (GBD) database from 1990 to 2019, this study analyzed the characteristics of RHD burden in China and worldwide, including changes in incidence, prevalence, mortality, and DALYs. Joinpoint was used to calculate the average annual percentage change (AAPC) and the corresponding 95% confidence interval (95% CI) to reflect the trends in the burden of RHD. A comprehensive comparative analysis of the differences in RHD burden between China and the rest of the world was conducted from multiple dimensions, including age, gender, and time periods.

RESULTS

From 1990 to 2019, the age-standardized incidence rate (ASIR) of RHD in China decreased from 29.62/100,000 to 23.95/100,000, while the global ASIR increased from 32.69/100,000 to 37.40/100,000. The age-standardized prevalence rate (ASPR) in China decreased from 446.15/100,000 to 390.24/100,000, while the global ASPR increased from 451.56/100,000 to 513.68/100,000. The age-standardized rates of mortality (ASMR) in China decreased from 18.11/100,000 to 4.04/100,000, while the global ASMR decreased from 8.94/100,000 to 3.85/100,000. The age-standardized DALY rate (ASDR) in China decreased from 431.45/100,000 to 93.73/100,000, while the global ASDR decreased from 283.30/100,000 to 132.88/100,000. The AAPC of ASIR, ASPR, ASMR, and ASDR in China was - 0.73%, -0.47%, -5.10%, and - 5.21%, respectively, while the AAPC of the global burden of RHD was 0.48%, 0.45%, -2.87%, and - 2.58%, respectively. The effects of age and gender on the burden of RHD were different. ASIR generally decreased with increasing age, while ASPR increased first and then decreased. ASMR and ASDR increased with increasing age. Women had higher incidence and mortality rates of RHD than men.

CONCLUSION

From 1990 to 2019, the incidence, prevalence, mortality, and DALYs of RHD in China decreased, indicating a relative reduction in the burden of RHD in China. The burden of RHD is age-related, with a higher prevalence observed in the younger population, a peak incidence among young adults, and a higher mortality rate among the elderly population. Women are more susceptible to RHD and have a higher risk of mortality than men. Given China's large population and aging population, RHD remains a significant public health challenge in China.

The prevalence of rheumatic heart disease in Ethiopia: a systematic review and meta-analysis

Globally, more than 33 million people are living with rheumatic heart disease (RHD). A high prevalence of the disease is observed in people with poor socio-economic status, overcrowding, and low access to medical facilities. Even though different studies have been conducted in different settings, there is no reliable data regarding RHD prevalence. Therefore, the aim of this systematic review and meta-analysis was to estimate the pooled prevalence of RHD in Ethiopia. PubMed/Medline, SCOPUS, HINARI, and Google Scholar databases were used to search for peer-reviewed articles. Articles published in English between the years 1992 and 2022 September were considered. The pooled prevalence of RHD was calculated using a random-effect model at a 95% confidence interval, including the weight of each study. Finally, statistical meta-analysis STATA version 16.0 software was used to calculate the pooled prevalence of RHD.A total of twelve cross-sectional studies were included in the meta-analysis. Individual study prevalence ranges from 0.32 to 32.78%. The pooled prevalence of RHD was 3.19% (95% CI: 1.46-5.56%). The prevalence was higher among the population who visited hospitals at 5.42% (95% CI: 1.09-12.7%) compared to schoolchildren at 0.73% (95% CI: 0.30-1.34%) and community-based studies at 3.83% (95% CI: 3.16-4.55%). Addis Ababa had the lowest prevalence of RHD (0.75% (95% CI: 0.38-1.25%), whereas the highest prevalence was observed in the Amhara region (8.95% (95% CI: 7.21-11.06%). A significant variation in the overall estimated prevalence of RHD was not observed between males and females.Trial registration Protocol registration (PROSPERO): CRD42021251553, Date of registration May 28 2021.

Pediatric Rheumatic Fever With Acute Fulminant Carditis: A Case Report

Acute rheumatic fever (ARF) is a multi-system inflammatory autoimmune disease. It is a significant cause of heart disease and early death worldwide, especially in children in developing countries. We present a case of acute fulminant rheumatic carditis in a child with no obvious predisposing factors, who resided in a developed country where this disease is not endemic. After pathological examination, a diagnosis of ARF with pancarditis was confirmed. This disease was not suspected before the pathological examination because of its low prevalence in Belgium.

Rheumatic Heart Disease in East Africa: A Systematic Review and Meta-Analysis

Background

Despite being a grave problem, there is little information on rheumatic heart disease's prevalence in East Africa. Therefore, the purpose of this systematic review and meta-analysis was to estimate the pooled prevalence of rheumatic heart disease in East Africa.

Materials and Methods

A computerized systematic search of using multiple database searching engines was performed in search of relevant English articles from the inception of the databases to December 2019. It was done in accordance with the preferred reporting items for systematic review and meta-analysis (PRISMA) standard. The funnel plot was used to assess publication bias. R and RStudio for Windows were used for all statistical analysis. The random-effect model was used for calculating the pooled estimate of the prevalence of rheumatic heart disease.

Results

The database search retrieved 1073 papers, and 80 articles (78 cross-sectional and two cohort study designs) with a total of 184575 individuals were found to be appropriate for the review. In East Africa, the overall prevalence of rheumatic heart disease was 14.67% (95% CI: 13.99% to 15.35%). In Ethiopia, Uganda, Tanzania, and Sudan, respectively, the subgroup analysis of rheumatic heart disease pooled prevalence was 22% (95% CI: 13% to 36%), 11% (95%t CI: 5% to 20%), 9% (95%t CI: 5% to 16%), and 3% (95%t CI: 1% to 10%), while the pooled prevalence of rheumatic heart disease in adults was 20% (95% CI: 12% to 30%), and in children, it was 4% (95% CI: 2% to 8%).

Conclusions

From this report, the prevalence of rheumatic heart disease in East Africa is very high, affecting about one in seven people. Therefore, future strategies should emphasize preventive measures at appropriate times to minimize the burden of this type of preventable heart disease.

Initiating the first rheumatic heart disease clinic in Cameroon: A descriptive study

Background and Aim

Rheumatic heart disease (RHD) is a significant cause of heart failure in sub-Saharan Africa. The causes of death from RHD are multiple, many of which can be prevented with appropriate follow-up of patients and effective secondary prophylaxis. An RHD Clinic was initiated to attempt a solution in Yaoundé, Cameroon. Over 6 months, its impact was evaluated.

Methods

Two echocardiography registers were accessed, and patients diagnosed with RHD between 2005 and 2018 were contacted. Consenting carers and patients pioneered the first RHD Clinic. Activities of the clinic comprised health education, medical visits, and benzylpenicillin G (BPG) injections. Text messages and phone calls were used to remind patients of their monthly appointments.

Results

Out of 1200 first-time cardiac ethnographies, 70 patients (5.83%) had been diagnosed with RHD. The case fatality rate of RHD was 16.67%. Twenty-three patients were successfully registered and followed-up by the clinic, 70% of whom were female. The age range was 4-22 years. Fifty-three percent had an NYHA score of 2 or more at the time of admission into the clinic. There was an increase in adherence to secondary prophylaxis with BPG from 42.9% at baseline to 87%-95% in the last 3 months.

Conclusion

Our short experience running an RHD Clinic was marked by increased treatment adherence among persons living with RHC.

Population-based assessment of cardiovascular complications of rheumatic heart disease in Fiji: a record-linkage analysis

OBJECTIVE

To determine population-based rates of non-fatal complications of rheumatic heart disease (RHD).

DESIGN

Retrospective cohort study based on multiple sources of routine clinical and administrative data amalgamated by probabilistic record-linkage.

SETTING

Fiji, an upper-middle-income country, where most of the population has access to government-funded healthcare services.

PARTICIPANTS

National cohort of 2116 patients with clinically apparent RHD aged 5-69 years during 2008 and 2012.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was hospitalisation for any of heart failure, atrial fibrillation, ischaemic stroke and infective endocarditis. Secondary outcomes were first hospitalisation for each of the complications individually in the national cohort as well as in hospital (n=1300) and maternity (n=210) subsets. Information on outcomes was obtained from discharge diagnoses coded in the hospital patient information system. Population-based rates were obtained using relative survival methods with census data as the denominator.

RESULTS

Among 2116 patients in the national cohort (median age, 23.3 years; 57.7% women), 546 (25.8%) were hospitalised for an RHD complication, a substantial proportion of all cardiovascular admissions in the country during this period in those aged 0-40 years (heart failure, 210/454, 46.3%; ischaemic stroke 31/134, 23.1%). Absolute numbers of RHD complications peaked during the third decade of life with higher population-based rates in women compared with men (incidence rate ratio 1.4, 95% CI 1.3 to 1.6, p<0.001). Hospitalisation for any RHD complication was associated with substantially increased risk of death (HR 5.4, 95% CI 3.4 to 8.8, p<0.001), especially after the onset of heart failure (HR 6.6, 95% CI 4.8 to 9.1, p<0.001).

CONCLUSIONS

Our study defines the burden of RHD-attributable morbidity in the general population of Fiji, potentially reflecting the situation in low-income and middle-income countries worldwide. Hospitalisation for an RHD complication is associated with markedly increased risk of death, re-emphasising the importance of effective early prevention.

IgG2 rules: N-acetyl-β-D-glucosamine-specific IgG2 and Th17/Th1 cooperation may promote the pathogenesis of acute rheumatic heart disease and be a biomarker of the autoimmune sequelae of Streptococcus pyogenes

Antecedent group A streptococcal pharyngitis is a well-established cause of acute rheumatic fever (ARF) where rheumatic valvular heart disease (RHD) and Sydenham chorea (SC) are major manifestations. In ARF, crossreactive antibodies and T cells respond to streptococcal antigens, group A carbohydrate, N-acetyl-β-D-glucosamine (GlcNAc), and M protein, respectively, and through molecular mimicry target heart and brain tissues. In this translational human study, we further address our hypothesis regarding specific pathogenic humoral and cellular immune mechanisms leading to streptococcal sequelae in a small pilot study. The aims of the study were to (1) better understand specific mechanisms of pathogenesis in ARF, (2) identify a potential early biomarker of ARF, (3) determine immunoglobulin G (IgG) subclasses directed against GlcNAc, the immunodominant epitope of the group A carbohydrate, by reaction of ARF serum IgG with GlcNAc, M protein, and human neuronal cells (SK-N-SH), and (4) determine IgG subclasses deposited on heart tissues from RHD. In 10 pediatric patients with RHD and 6 pediatric patients with SC, the serum IgG2 subclass reacted significantly with GlcNAc, and distinguished ARF from 7 pediatric patients with uncomplicated pharyngitis. Three pediatric patients who demonstrated only polymigrating arthritis, a major manifestation of ARF and part of the Jones criteria for diagnosis, lacked the elevated IgG2 subclass GlcNAc-specific reactivity. In SC, the GlcNAc-specific IgG2 subclass in cerebrospinal fluid (CSF) selectively targeted human neuronal cells as well as GlcNAc in the ELISA. In rheumatic carditis, the IgG2 subclass preferentially and strongly deposited in valve tissues (n = 4) despite elevated concentrations of IgG1 and IgG3 in RHD sera as detected by ELISA to group A streptococcal M protein. Although our human study of ARF includes a very small limited sample set, our novel research findings suggest a strong IgG2 autoantibody response against GlcNAc in RHD and SC, which targeted heart valves and neuronal cells. Cardiac IgG2 deposition was identified with an associated IL-17A/IFN-γ cooperative signature in RHD tissue which displayed both IgG2 deposition and cellular infiltrates demonstrating these cytokines simultaneously. GlcNAc-specific IgG2 may be an important autoantibody in initial stages of the pathogenesis of group A streptococcal sequelae, and future studies will determine if it can serve as a biomarker for risk of RHD and SC or early diagnosis of ARF.

Neutrophil-Lymphocyte Ratio and Red Blood Cell Distribution Width in Patients with Atrial Fibrillation and Rheumatic Valve Disease

The lifetime risk of developing atrial fibrillation (AF) is 1 in 3 adults, resulting in a prevalence of 2-4%. Rheumatic heart disease (RHD) is a frequent aetiology of valvular heart disease in lowand middle-income countries. Between 21% and 80% of patients with mitral valve disease, especially with stenosis, may have AF. Both these conditions, AF and RHD, present a state of persistent inflammation. In turn, inflammation is a frequent cause of anisocytosis, which can be evidenced through the parameter RDW (red bold cell distribution width). Factors associated with increased RDW are also known as risk factors associated with a higher incidence of AF. RDW may have an independent role in the pathogenesis of AF and the increased propensity of both thromboembolic and bleeding events. Another marker involved in the incidence of AF is the neutrophil-lymphocyte ratio. This is also a marker of oxidative stress and inflammation and is associated with a higher rate of AF recurrence. This review will evaluate these biomarkers and their association with cardiovascular events in patients with AF and RHD. The hypotheses and current debates about the relationship of biomarkers with the severity of chronic valve dysfunction, with acute rheumatic carditis in the paediatric population, and with the presence of thrombus in the left atrium will be discussed.

Current Situation of Acute Rheumatic Fever and Rheumatic Heart Disease in Latin America and the Caribbean: A Systematic Review

Background:

Rheumatic heart disease (RHD) disproportionately affects low-income and middle-income countries. Latin America and the Caribbean (LAC) have been less represented in scientific literature. We aimed to describe the epidemiology, burden and implemented screening and prevention strategies of RHD in LAC.

Methods:

We systematically searched PubMed, Embase, LILACS, and SciELO from 1990 to April 2021. Observational and experimental studies that described data on the epidemiology, burden, or prevention/screening strategies of RHD, regardless of age or language, were included. The risk of bias was assessed by previously published tools depending on their study design. Pre-specified data were independently extracted and presented by each topic (epidemiology, burden, prevention/screening). PROSPERO registration number: CRD42021250043.

Results:

Forty-eight studies out of 1692 non-duplicate records met the eligibility criteria. They were mainly from Brazil, observational in design, and hospital-based. Data on the epidemiology of acute rheumatic fever (ARF) was not recent (most before 2000) with studies describing decreasing incidence through the years. The prevalence of RHD was described in six studies, ranging from 0.24 to 48 per 1,000 among studies evaluating schoolchildren. Nine studies described data based on admissions, ranging from 0.04% to 7.1% in single-center studies. Twenty-four studies assessed the burden of RHD with most of them reporting mortality rates/proportions and complications such as the need for intervention, atrial fibrillation, or embolism. Six preventive strategies were identified that included educational, register-based, and/or secondary prophylaxis strategies. Three well-established echocardiographic screening studies in Brazil and Peru were identified.

Conclusions:

Most ARF/RHD research in LAC comes from a single country, Brazil where preventive/screening efforts have been conducted. There was a paucity of data from several countries in the region, reflecting the need for epidemiological studies from more countries in LAC which will provide a better picture of the current situation of ARF/RHD and guide the implementation of preventive strategies.

Chronic rheumatic heart disease with recrudescence of acute rheumatic fever on histology: a case report

Background

Rheumatic heart disease (RHD) is endemic in sub-Saharan Africa where it is the leading cause of cardiovascular mortality in the young. Rheumatic heart disease results from recurrent episodes of acute rheumatic fever (ARF), which are often difficult to diagnose clinically. Acute rheumatic fever may be diagnosed based on the revised Jones Criteria 2015 for the diagnosis of ARF. Histologically, acute rheumatic valvulitis manifests with active inflammation characterized by lymphocytic infiltration, Aschoff bodies, and Anitschkow cells. Chronic rheumatic valvulitis is associated with neovascularization, and/or dystrophic calcification. The combination of histological features of both ARF and chronic RHD is a rare finding.

Case summary

Here we report on a case of a 59-year-old woman with mixed aortic and mitral valve disease of probable rheumatic aetiology (elevated C-reactive protein and prolonged PR interval) and with histological evidence of lymphocytic infiltration, Aschoff bodies, and fibrinoid necrosis admixed with features of chronic RHD.

Discussion

Cases of chronic RHD admixed with ARF are very rare; however, they should be considered in regions with a high prevalence of RHDs.

Rheumatic Heart Disease Is a Neglected Disease Relative to Its Burden Worldwide: Findings From Global Burden of Disease 2019

Background

Rheumatic heart disease (RHD) takes a heavy toll in low‐ and middle‐income countries. We aimed to present worldwide estimates for the burden of the RHD during 1990 to 2019 using the GBD (Global Burden of Disease) study.

Methods and Results

Sociodemographic index (SDI) and age‐period‐cohort analysis were used to assess inequity. The age‐standardized death, disability‐adjusted life years, incidence, and prevalence rates of RHD were 3.9 (95% uncertainty interval, 3.3–4.3), 132.9 (95% uncertainty interval, 115.0–150.3), 37.4 (28.6–46.7), and 513.7 (405.0–636.3) per 100 000 in 2019, respectively. The age‐standardized incidence and prevalence rates increased by 14.4% and 13.8%, respectively. However, disability‐adjusted life years and death rates decreased by 53.1% and 56.9%, respectively. South Asia superregion had the highest age‐standardized disability‐adjusted life years and deaths. Sub‐Saharan Africa had the highest age‐standardized incidence and prevalence rates. There was a steep decline in RHD burden among higher‐SDI countries. However, only age‐standardized deaths and disability‐adjusted life years rates decreased in lower‐SDI countries. The age‐standardized years of life lost and years lived with disability rates for RHD significantly declined as countries' SDI increased. The coefficients of birth cohort effect on the incidence of RHD showed an increasing trend from 1960 to 1964 to 2015 to 2019; however, the birth cohort effect on deaths attributable to RHD showed unfailingly decreasing trends from 1910 to 1914 to 2015 to 2019.

Conclusions

There was a divergence in the burden of RHD among countries based on SDI levels, which calls for including RHD in global assistance and funding. Indeed, many countries are still dealing with an unfinished infectious disease agenda, and there is an urgency to act now to prevent an increase in future RHD burden.

Rheumatic heart disease prevalence in Namibia: a retrospective review of surveillance registers

Background

Rheumatic heart disease (RHD) is the most commonly acquired heart disease in children and young people in low and middle-income settings. Fragile health systems and scarcity of data persist to limit the understanding of the relative burden of this disease. The aims of this study were to estimate the prevalence of RHD and to assess the RHD-related health care systems in Namibia.

Methods

Data was retrieved from outpatient and inpatient registers for all patients diagnosed and treated for RHD between January 2010 to December 2020. We used descriptive statistics to estimate the prevalence of RHD. Key observations and engagement with local cardiac clinicians and patients helped to identify key areas of improvement in the systems.

Results

The outpatient register covered 0.032% of the adult Namibian population and combined with the cumulative incidence from the inpatient register we predict the prevalence of clinically diagnosed RHD to be between 0.05% and 0.10% in Namibia. Young people (< 18 years old) are most affected (72%), and most cases are from the north-eastern regions. Mitral heart valve impairment (58%) was the most common among patients. We identified weaknesses in care systems i.e., lack of patient unique identifiers, missing data, and clinic-based prevention activities.

Conclusion

The prevalence of RHD is expected to be lower than previously reported. It will be valuable to investigate latent RHD and patient follow-ups for better estimates of the true burden of disease. Surveillance systems needs improvements to enhance data quality. Plans for expansions of the clinic-based interventions must adopt the “Awareness Surveillance Advocacy Prevention” framework supported by relevant resolutions by the WHO.

Global burden of rheumatic heart disease: trends from 1990 to 2019

Background

Rheumatic heart disease (RHD) is a critical public health issue worldwide, and its epidemiological patterns have changed over the decades. This article aimed to estimate the global trends of RHD, and attributable risks from 1990 to 2019.

Methods

Data on RHD burden were explored from the Global Burden of Disease Study 2019. Trends of the RHD burden were estimated using the estimated annual percentage change (EAPC) and age-standardized rate (ASR).

Results

During 1990–2019, increasing trends in the ASR of incidence and prevalence of RHD were observed worldwide, with the respective EAPCs of 0.58 (95% confidence interval [CI] 0.52 to 0.63) and 0.57 (95%CI 0.50 to 0.63). Meanwhile, increasing trends commonly occurred in low and middle Socio-Demographic Index (SDI) regions and countries. The largest increasing trends in the ASR of incidence and prevalence were seen in Fiji, with the respective EAPCs being 2.17 (95%CI 1.48 to 2.86) and 2.22 (95%CI 1.53 to 2.91). However, death and disability-adjusted life years (DALYs) due to RHD showed pronounced decreasing trends of ASR globally, in which the EAPCs were − 2.98 (95%CI − 3.03 to − 2.94) and − 2.70 (95%CI − 2.75 to − 2.65), respectively. Meanwhile, decreasing trends were also observed in all SDI areas and geographic regions. The largest decreasing trends of death were observed in Thailand (EAPC = − 9.55, 95%CI − 10.48 to − 8.61). Among the attributable risks, behavioral risk-related death and DALYs caused by RHD had pronounced decreasing trends worldwide and in SDI areas.

Conclusions

Pronounced decreasing trends of death and DALYs caused by RHD were observed in regions and countries from 1990 to 2019, but the RHD burden remains a substantial challenge globally. The results would inform the strategies for more effective prevention and control of RHD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02829-3.

A systematic framework for prioritising burden of disease data required for vaccine development and implementation: the case for group A streptococcal diseases

Vaccine development and implementation decisions need to be guided by accurate and robust burden of disease data. We developed an innovative systematic framework outlining the properties of such data that are needed to advance vaccine development and evaluation, and prioritize research and surveillance activities. We focus on 4 objectives—advocacy, regulatory oversight and licensure, policy and post-licensure evaluation, and post-licensure financing—and identify key stakeholders and specific requirements for burden of disease data aligned with each objective. We apply this framework to group A Streptococcus, a pathogen with an underrecognized global burden, and give specific examples pertinent to 8 clinical endpoints. This dynamic framework can be adapted for any disease with a vaccine in development and can be updated as vaccine candidates progress through clinical trials. This framework will also help with research and innovation priority setting of the Immunization Agenda 2030 (IA2030) and accelerate development of future vaccines.

[Rheumatic mitral aggression. Usefulness of 3d transesophageal echocardiography]

Rheumatic heart disease is the leading cause of cardiovascular disease in children under 25 years of age worldwide, with the highest prevalence in low-income countries. The usual and distinctive finding of rheumatic aggression is mitral stenosis, which leads to serious cardiovascular consequences. International guidelines establish transthoracic echocardiography (TTE) as the diagnostic test for rheumatic heart disease; however, it has limitations in the measurement of planimetry and those inherent to Doppler. Transesophageal 3D echocardiography (TTE-3D) is a new modality that shows realistic images of the mitral valve and has the added value of accurately locating the plane of maximum stenosis and better determining commissural involvement.

European Society of Cardiology: cardiovascular disease statistics 2021

AIMS

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries.

METHODS AND RESULTS

Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures.

CONCLUSION

Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.

Prevalence of rheumatic heart disease in adults from the Brazilian Amazon Basin

BACKGROUND

Rheumatic heart disease (RHD) continues to be a burden in low- and middle-income countries and prevalence estimates are lacking from South America. We aimed to determine the prevalence of RHD in the Brazilian Amazon Basin.

METHODS

We examined a random sample of adults (≥18 years) from the general population, who underwent echocardiographic image acquisition by a medical doctor. All images were analyzed according to (i) the 2012 World Heart Federation criteria and (ii) a simplified algorithm for RHD from a previously validated risk score (categories: low-, medium-, high-risk) which involved assessment of the mitral valve (leaflet thickening and excessive motion, regurgitation jet length) and aortic valve (thickening and any regurgitation).

RESULTS

A total of 488 adults were screened (mean age 40 ± 15 years, 38% men). The prevalence of RHD was 39/1000 adults (n = 17 definite and n = 2 borderline). Fourteen (74%) had pathological mitral regurgitation, four (21%) mitral stenosis, 0 (0%) pathological aortic regurgitation and six (32%) both mitral and aortic valve disease. None had a prior diagnosis of RHD, 10 (53%) had positive cardiac auscultation and two (11%) reported a history of rheumatic fever. The simplified algorithm identified four (21%) adults as low-risk, six (32%) as intermediate, and nine (47%) as high-risk.

CONCLUSIONS

The prevalence of RHD was 39/1000 in adults from the Brazilian Amazon Basin, indicating the need for screening programs in remote areas. A simplified model was only able to categorize every second case of RHD as high-risk. External validation of simplified screening models to increase feasibility in clinical practice are encouraged.

Rheumatic heart disease control: the time for a paradigm shift

Rheumatic heart disease (RHD) is a completely preventable, life-threatening complication of group A streptococcal pharyngitis and the commonest cause of acquired heart disease in children and young adults in low- and middle-income countries. Conventional control measures are faced with many obstacles including the difficulty of early diagnosis of bacterial pharyngitis and acute rheumatic fever (ARF) leading to late presentation with established RHD which is not curable. Recent evidence confirmed the role of echocardiography screening of asymptomatic children in the early detection of 'latent' RHD. Benzathine penicillin prophylaxis was shown to be effective in halting the progression of latent RHD. There is enough evidence to warrant the implementation of control strategies that use lower thresholds for the diagnosis of group A streptococcal infection and ARF and we believe that it is high time to introduce an echocardiography screen-to-treat policy in endemic areas.

Pediatric cardiac services in Sudan: Achievements, challenges, and future perspectives (2004-2021)

Pediatric cardiology (PC) is a rapidly advancing specialty addressing a large population of children as well as adults with congenital heart disease. It requires huge technical and financial resources; therefore, establishing, maintaining, and developing such services in limited resource settings are challenging. A PC program that includes clinical aspects, echocardiography, diagnostic and interventional cardiac catheterization and cardiac surgery, and rheumatic heart disease control was established in Sudan in 2004. There are currently three public centers with facilities to evaluate and treat children with heart disease: two in Khartoum and one in Wad Medani. Major obstacles include the shortage of trained personnel and operation rooms, the deficiency of intensive care facilities, and the financial burden of interventional procedures. This paper details the establishment and progress of the program, its challenges, potential solutions, and future perspectives for PC programs in Sudan and African countries.

Mitral valve-in-valve implantation during pregnancy

A 32-year-old, 11-week pregnant African woman with known rheumatic heart disease presented to the emergency department with worsening shortness of breath on exertion. She had undergone a double bioprosthetic valve replacement and left atrial appendage resection 8 years prior for severe mitral stenosis, moderate mitral regurgitation and moderate aortic regurgitation. A transo-oesophageal echocardiography at this presentation confirmed a morphologically calcified and stenosed mitral bioprosthesis, with moderate stenosis of her aortic bioprosthesis. Her multidisciplinary team, including cardiologists, cardiothoracic surgeons and obstetricians, came to a consensus decision to proceed with a transseptal transcatheter valve implantation within the mitral valve prosthesis (valve-in-valve implantation). Transthoracic echocardiography performed 2 months post procedure showed satisfactory mitral valve gradients and at 30 weeks' gestation, she successfully delivered her fifth child. 2 years later, the valve in valve complex is still functioning well.

Long-term outcomes following rheumatic heart disease diagnosis in Australia

Aims 

Rheumatic heart disease (RHD) is a major contributor to cardiac morbidity and mortality globally. This study aims to estimate the probability and predictors of progressing to non-fatal cardiovascular complications and death in young Australians after their first RHD diagnosis.

Methods and results 

This retrospective cohort study used linked RHD register, hospital, and death data from five Australian states and territories (covering 70% of the whole population and 86% of the Indigenous population). Progression from uncomplicated RHD to all-cause death and non-fatal cardiovascular complications (surgical intervention, heart failure, atrial fibrillation, infective endocarditis, and stroke) was estimated for people aged <35 years with first-ever RHD diagnosis between 2010 and 2018, identified from register and hospital data. The study cohort comprised 1718 initially uncomplicated RHD cases (84.6% Indigenous; 10.9% migrant; 63.2% women; 40.3% aged 5–14 years; 76.4% non-metropolitan). The composite outcome of death/cardiovascular complication was experienced by 23.3% (95% confidence interval: 19.5–26.9) within 8 years. Older age and metropolitan residence were independent positive predictors of the composite outcome; history of acute rheumatic fever was a negative predictor. Population group (Indigenous/migrant/other Australian) and sex were not predictive of outcome after multivariable adjustment.

Conclusion 

This study provides the most definitive and contemporary estimates of progression to major cardiovascular complication or death in young Australians with RHD. Despite access to the publically funded universal Australian healthcare system, one-fifth of initially uncomplicated RHD cases will experience one of the major complications of RHD within 8 years supporting the need for programmes to eradicate RHD.

Rheumatic Heart Disease Screening Based on Phonocardiogram

Rheumatic heart disease (RHD) is one of the most common causes of cardiovascular complications in developing countries. It is a heart valve disease that typically affects children. Impaired heart valves stop functioning properly, resulting in a turbulent blood flow within the heart known as a murmur. This murmur can be detected by cardiac auscultation. However, the specificity and sensitivity of manual auscultation were reported to be low. The other alternative is echocardiography, which is costly and requires a highly qualified physician. Given the disease's current high prevalence rate (the latest reported rate in the study area (Ethiopia) was 5.65%), there is a pressing need for early detection of the disease through mass screening programs. This paper proposes an automated RHD screening approach using machine learning that can be used by non-medically trained persons outside of a clinical setting. Heart sound data was collected from 124 persons with RHD (PwRHD) and 46 healthy controls (HC) in Ethiopia with an additional 81 HC records from an open-access dataset. Thirty-one distinct features were extracted to correctly represent RHD. A support vector machine (SVM) classifier was evaluated using two nested cross-validation approaches to quantitatively assess the generalization of the system to previously unseen subjects. For regular nested 10-fold cross-validation, an f1-score of 96.0 ± 0.9%, recall 95.8 ± 1.5%, precision 96.2 ± 0.6% and a specificity of 96.0 ± 0.6% were achieved. In the imbalanced nested cross-validation at a prevalence rate of 5%, it achieved an f1-score of 72.2 ± 0.8%, recall 92.3 ± 0.4%, precision 59.2 ± 3.6%, and a specificity of 94.8 ± 0.6%. In screening tasks where the prevalence of the disease is small, recall is more important than precision. The findings are encouraging, and the proposed screening tool can be inexpensive, easy to deploy, and has an excellent detection rate. As a result, it has the potential for mass screening and early detection of RHD in developing countries.

Outcomes of Echocardiography-Detected Rheumatic Heart Disease: Validating a Simplified Score in Cohorts From Different Countries

Background The natural history of latent rheumatic heart disease (RHD) detected by echocardiography remains unclear. We aimed to assess the accuracy of a simplified score based on the 2012 World Heart Federation criteria in predicting mid-term RHD echocardiography outcomes in children from 4 different countries. Methods and Results Patient-level baseline and follow-up data of children with latent RHD from 4 countries (Australia, n=62; Brazil, n=197; Malawi, n=40; New Zealand, n=94) were combined. A simplified echocardiographic scoring system previously developed from Brazilian and Ugandan cohorts, consisting of 5 point-based variables with respective weights, was applied: mitral valveanterior leaflet thickening (weight=3), excessive leaflet
tip motion (3), regurgitation jet length ≥2 cm (6), aortic valve
focal thickening (4), and any regurgitation (5). Unfavorable outcome was defined as worsening diagnostic category, persistent definite RHD or development/worsening of valve regurgitation/stenosis. The score model was updated using methods for recalibration. 393 patients (314 borderline, 79 definite RHD) with median follow-up of 36 (interquartile range, 25-48) months were included. Median age was 14 (interquartile range, 11-16) years and secondary prophylaxis was prescribed to 16%. The echocardiographic score model applied to this external population showed significant association with unfavorable outcome (hazard ratio, 1.10; 95% CI, 1.04-1.16; P=0.001). Unfavorable outcome rates in low (≤5 points), intermediate (6-9), and high-risk (≥10) children at 3-year follow-up were 14.3%, 20.8%, and 38.5% respectively (P<0.001). The updated score model showed good performance in predicting unfavorable outcome. Conclusions The echocardiographic score model for predicting RHD outcome was updated and validated for different latent RHD populations. It has potential utility in the clinical and screening setting for risk stratification of latent RHD.

Diagnosing rheumatic heart disease: where are we now and what are the challenges?

INTRODUCTION

Rheumatic heart disease (RHD), a sequela of acute rheumatic fever (ARF), affects 40.5 million people worldwide. The burden of disease disproportionately falls on low- and middle-income countries (LMIC) and sub-populations within high-income countries (HIC). Advances have been made in earlier detection of RHD, though several barriers to ideal management persist.

AREAS COVERED

This article reviews the current burden of RHD, highlighting the disparate impact of disease. It also reviews the clinical and echocardiographic presentation of RHD, as some may present in late stages of disease with associated complications. Finally, we review the advances which have been made in echocardiographic screening to detect latent RHD, highlighting the challenges which remain regarding secondary prophylaxis management and uncertainty of best practices for treatment of latent RHD.

EXPERT OPINION

Advances in technology and validation of portable echocardiography have made screening and identifying latent RHD feasible in the most burdened regions. However, uncertainty remains around best management of those with latent RHD and best methods to ensure ideal secondary prophylaxis for RHD. Research regarding latent RHD management, as well as continued work on innovative solutions (such as group A streptococcal vaccine), are promising as efforts to improve outcomes of this preventable disease persist.

Safety and Efficacy of Ibutilide for Acute Pharmacological Cardioversion of Rheumatic Atrial Fibrillation

INTRODUCTION

Ibutilide is indicated for acute cardioversion of nonvalvular atrial fibrillation (AF). However, its efficacy and safety in the pharmacological cardioversion of rheumatic AF are unknown.

METHODS

Patients with mild-to-moderate rheumatic mitral valve (MV) disease with symptomatic, paroxysmal, or persistent AF were included in the analysis. Intravenous ibutilide was administered at doses tailored to body weight (0.5-2.0 mg) for over 10 min. The primary end point was efficacy, assessed as the rate of conversion of AF to sinus rhythm. The secondary end point was safety, including arrhythmic events and death within 24 h of drug initiation.

RESULTS

From June 2016 to October 2018, 165 patients (94 with mitral stenosis, 23 with mitral regurgitation, 11 with mixed MV disease, and 37 with MV replacement) received ibutilide (mean dose 0.90 ± 0.54 mg). Ibutilide successfully converted AF to sinus rhythm in 127/165 (76.9%) patients, with a conversion time of 7.9 ± 4.1 min. The QTc increased from 419.9 ± 15.8 to 487.5 ± 34 ms after ibutilide administration (p < 0.001). The mean change in QTc after ibutilide administration (∆QTc) was 72.01 ± 36.03. There were no deaths, but 3 patients (1.8%) developed torsades de pointes (TdP) requiring defibrillation 55 ± 37 min after infusion.

CONCLUSION

Ibutilide cardioverted 77% of rheumatic AF to sinus rhythm, indicating its potential as a clinically useful option for pharmacological cardioversion of rheumatic AF. TdP is a potentially serious adverse event that requires careful monitoring.

Persisting burden and challenges of rheumatic heart disease

Rheumatic heart disease (RHD) is the result of episodes of acute rheumatic fever with valvular (and other cardiac) damage caused by an abnormal immune response to group A streptococcal infections, usually during childhood and adolescence. As a result of improved living conditions and the introduction of penicillin, RHD was almost eradicated in the developed world by the 1980s. However, being a disease of poverty, its burden remains disproportionately high in the developing world, despite being a fundamentally preventable disease. Rheumatic heart disease generates relatively little attention from the medical and science communities, in contrast to other common infectious problems (such as malaria, HIV, tuberculosis), despite the major cardiovascular morbidity/mortality burden imposed by RHD. This relative neglect and paucity of funding have probably contributed to limited fundamental medical advances in this field for over 50 years. Given the importance of prevention before the onset of major valvular damage, the main challenges for RHD prevention are improving social circumstances, early diagnosis, and effective delivery of antibiotic prophylaxis. Early identification through ultrasound of silent, subclinical rheumatic valve lesions could provide an opportunity for early intervention. Simple echocardiographic diagnostic criteria and appropriately trained personnel can be valuable aids in large-scale public health efforts. In addition, a better understanding of the immunogenic determinants of the disease may provide potential routes to vaccine development and other novel therapies.

Preventive interventions to reduce the burden of rheumatic heart disease in populations at risk: a systematic review protocol

BACKGROUND

Rheumatic heart disease is preventable, yet associated with significant health burden, mostly in low-resourced settings. It is prevalent among children and young adults living in impoverished areas. Primordial, primary, and secondary preventive measures have been recommended through health interventions and comprehensive programmes, although most implemented interventions are the high-resourced settings. The proposed review aims to synthesise the evidence of prevention effectiveness of implemented health interventions for the prevention of rheumatic heart disease.

METHODS AND DESIGN

This article describes a protocol for a systematic review. A predefined search strategy will be used to search for relevant literature published from the year 2000 to present. Electronic databases Medline, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials will be searched for the studies, as well as reference lists of relevant studies included. Risk of bias and quality appraisal will be done for the included studies using ROBINS-I tool and Cochrane tool for assessing risk of bias in randomised control trials. Findings will be analysed in subgroups based on the level of intervention and prevention strategy implemented. We will present the findings in descriptive formats with tables and flow diagrams.

DISCUSSION

This review will provide evidence on the prevention effectiveness of interventions or strategies implemented for the prevention of RHD. The findings of this will be significant for policy, practice, and research in countries planning to implement interventions.

REGISTRATION

PROSPERO ID: CRD42020170503.

The "Cairo Accord"- Towards the Eradication of RHD: An Update

Rheumatic heart disease (RHD) is the most common cause of acquired heart disease in children and young adults. It continues to be prevalent in many low- and middle-income countries where it causes significant morbidity and mortality. Following the 2017 Cairo conference "Rheumatic Heart Disease: from Molecules to the Global Community," experts from 21 countries formulated an approach for addressing the problem of RHD: "The Cairo Accord on Rheumatic Heart Disease." The Accord attempts to set policy priorities for the eradication of acute rheumatic fever (ARF) and RHD and builds on a recent series of policy initiatives and calls to action. We present an update on the recommendations of the Cairo Accord and discuss recent progress toward the eradication of RHD, including contributions from our own Aswan Rheumatic Heart Disease Registry (ARGI).

Inflammatory Responses with Left Ventricular Compromise after Induction of Myocardial Infarcts in Sheep (Ovis aries)

Ischemic myocardial disease is a major cause of death among humans worldwide; it results in scarring and pallor of the myocardium and triggers an inflammatory response that contributes to impaired left ventricular function. This response includes and is evidenced by the production of several inflammatory cytokines including TNFα, IL1β, IL4, IFNγ, IL10 and IL6. In the current study, myocardial infarcts were induced in 6 mo old male castrated sheep by ligation of the left circumflex obtuse marginal arteries (OM 1 and 2). MRI was used to measure parameters of left ventricular function that include EDV, ESV, EF, SVI, dp/dt max and dp/dt min at baseline and at 4 wk and 3 mo after infarct induction. We also measured serum concentrations of an array of cytokines. Postmortem histologic findings corroborate the existence of left ventricular myocardial injury and deterioration. Our data show a correlation between serum cytokine concentrations and the development of myocardial damage and left ventricular functional compromise.

Prevalence of rheumatic heart disease among school children in East Africa: a systematic review and meta-analysis

Introduction

conducting researches and estimating the prevalence of rheumatic heart disease in school children is crucial to develop school-based strategies targeted to decrease the prevalence of this disease. Therefore, this systematic review and meta-analysis were aimed to estimate the overall prevalence of rheumatic heart disease (RHD) among school children in East Africa.

Methods

PubMed/MEDLINE, Google Scholar, Cochrane review, African Journals Online and African Index Medicus databases were searched to identify relevant research articles. The overall prevalence of rheumatic heart disease was pooled based on the weighted inverse variance random-effects model at a 95% confidence interval. The presence of heterogeneity, sensitivity analysis and presence of publication bias was tested. Results were presented with narrative synthesis, tables and forest plots.

Results

a total of thirteen research articles were included in the final analysis. The pooled prevalence of rheumatic heart disease in East African school children was 1.79% (17.9 cases per 1000 children (95% CI=11.6, 24.2; I²=95.1%; p<0.001)). From the subgroup analysis conducted by publication year, a lower prevalence of RHD in school children was reported among studies published after 2015 (six studies; overall prevalence=1.17% (11.7 cases per 1000 school children); with 95% CI=0.60, 1.73%; I²=88.8%; p<0.001). Additionally, the horn of Africa was found to have the lowest prevalence of RHD in school children among East African countries (six studies; overall prevalence=1.59% (15.9 cases per 1000 school children); with 95% CI=0.68, 2.51%; I²=94.2%; p<0.001).

Conclusion

the prevalence of rheumatic heart disease (RHD) among school children in East Africa was considerably higher than the results from high-income countries. Therefore, community education on strep throat and its complications should be implemented through mass media. Rheumatic heart disease preventive strategies should be integrated with schools to reduce the prevalence of RHD among school children.

Atrial Fibrillation in Valvular Heart Disease

Rheumatic heart disease results in significant remodeling of the atria that provides the milieu for maintaining atrial fibrillation. Some electrical remodeling is reversible and hence early intervention may prove useful. Active screening for atrial fibrillation in high-risk subset and instituting anticoagulation may reduce the devastating complications that follow. Age older than 50 years, NYHA functional class II symptoms, left atrial dimension >4.0 cm on echocardiogram in parasternal long-axis view, and gradients across the mitral valve >10 mm Hg are clinical indicators that identify the high-risk subset. Ablation strategy in this population may differ compared with the nonvalvular group.

Generating Evidence From Contextual Clinical Research in Low- to Middle Income Countries: A Roadmap Based on Theory of Change

Along with inadequate access to high-quality care, competing health priorities, fragile health systems, and conflicts, there is an associated delay in evidence generation and research from LMICs. Lack of basic epidemiologic understanding of the disease burden in these regions poses a significant knowledge gap as solutions can only be developed and sustained if the scope of the problem is accurately defined. Congenital heart disease (CHD), for example, is the most common birth defect in children. The prevalence of CHD from 1990 to 2017 has progressively increased by 18.7% and more than 90% of children with CHD are born in Low and Middle-Income Countries (LMICs). If diagnosed and managed in a timely manner, as in high-income countries (HICs), most children lead a healthy life and achieve adulthood. However, children with CHD in LMICs have limited care available with subsequent impact on survival. The large disparity in global health research focus on this complex disease makes it a solid paradigm to shape the debate. Despite many challenges, an essential aspect of improving research in LMICs is the realization and ownership of the problem around paucity of local evidence by patients, health care providers, academic centers, and governments in these countries. We have created a theory of change model to address these challenges at a micro- (individual patient or physician or institutions delivering health care) and a macro- (government and health ministries) level, presenting suggested solutions for these complex problems. All stakeholders in the society, from government bodies, health ministries, and systems, to frontline healthcare workers and patients, need to be invested in addressing the local health problems and significantly increase data to define and improve the gaps in care in LMICs. Moreover, interventions can be designed for a more collaborative and effective HIC-LMIC and LMIC-LMIC partnership to increase resources, capacity building, and representation for long-term productivity.

Experimental Rodent Models of Cardiovascular Diseases

Cardiovascular diseases, as the most common non-communicable disease in the world, cause a high mortality rate today and bring a serious medical burden to countries worldwide, especially in low- and middle-income countries. Experimental rodent models are widely used for cardiovascular diseases researches due to the effective simulation of human cardiovascular diseases, strong reproductive ability, and easy detection. Herein, we will summarize the pathological manifestations of common cardiovascular diseases and illustrate the establishment of corresponding experimental rodent models in detail.

Echocardiographic screening to determine progression of latent rheumatic heart disease in endemic areas: A systematic review and meta-analysis

BACKGROUND

The World Health Organisation previously recommended routine screening in school-aged children in countries with a high prevalence of rheumatic heart disease (RHD); however, it is unclear if screening-detected (latent) valve disease will inevitably evolve to a pathological lesion. Understanding the natural history of latent RHD is essential prior to recommendation of screening in endemic areas. Studies documenting the progression of latent RHD have had contrasting conclusions about the pathogenicity of latent valvular lesions. This review provides estimates of rates of progression of latent RHD.

METHODS AND FINDINGS

In this systematic review and meta-analysis, we searched EMBASE, MEDLINE, Global Index Medicus, Africa Wide, Cochrane Database of Systematic Reviews and Global Health Database for studies published before April 30, 2019. Study data were extracted from all studies which reported follow-up data on progression of latent valve lesions. Studies with control cohorts were used to calculate comparative prevalence ratios. This study is registered with PROSPERO, number CRD42019119427. We identified 12 studies reporting follow-up data on latent RHD for 950 people in 9 countries. The estimated pooled prevalence rate for progression per year of latent RHD was 5%/year (95% CI 2-8). Eight studies reported on the progression of borderline latent RHD with an estimated pooled prevalence of 2%/year (95% CI 0-4). Three studies included control groups. There was a significant increase in the risk of progression of valvular disease in the latent group compared with controls (RR = 3.57 (95%CI = 1.65-7.70, P = 0.001). The overall risk of bias was low. Given most studies included penicillin administration we were unable to document the natural history of latent RHD. Furthermore, we were unable to perform a sensitivity analysis to determine the effect of administering penicillin prophylaxis on progression of valve disease given prescription of penicillin was not standardised.

CONCLUSION

Latent RHD has a slow rate of progression but it is significantly higher compared to controls, with definite latent RHD having a higher rate of progression compared with borderline latent disease. There are a massive number of individuals at risk for RHD in the developing world as well as logistical challenges of screening and delivering penicillin prophylaxis. The low rate of progression from untargeted screening may be an important consideration in resource-constrained environments.