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Rudiktyo E, Wind A, Doevendans P, Siswanto BB, Cramer MJ, Soesanto AM. Characteristics of patients with rheumatic heart disease in a national referral hospital in Indonesia. MEDICAL JOURNAL OF INDONESIA 2022. [DOI: 10.13181/mji.oa.226150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) is one of the most common cardiovascular problems in Indonesia. Comprehensive data regarding patient characteristics are critical in planning optimal treatment strategies to relieve the burden of RHD. This study aimed to describe the clinical and echocardiographic characteristics of patients across several types of valvular lesions in RHD in the Indonesian population.
METHODS This retrospective study was performed between January 2016 and June 2019 at the National Cardiovascular Center Harapan Kita, Jakarta, Indonesia. The study population comprised all patients with significant valve disease aged ≥18 years. Patient characteristics and echocardiographic parameters were collected retrospectively from medical records and hospital information systems. Patients were classified into several groups based on etiologies of valve disease.
RESULTS Of 5,482 patients with significant valve lesions, 2,333 (42.6%) were RHD patients. They were predominantly female (64.1%) and younger (mean [standard deviation] age 42.61 [12.01] years). Atrial fibrillation (AF) was the most frequent rhythm disorder observed in RHD (65.4%). Isolated mitral stenosis was the most common valve lesion in RHD patients (46.5%). Most patients with RHD had preserved left ventricular (LV) ejection fraction. Half of the patients with mitral stenosis had reduced right ventricular (RV) contractility (tricuspid annular plane systolic excursion <17 mm).
CONCLUSIONS Isolated mitral stenosis was the most observed condition of valve lesions in RHD. Characteristics of RHD patients in this study were predominantly female, younger age, had preserved LV function, reduced RV function, and high prevalence of AF.
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Vyas P, Hasit J, Dake R, Patel I, Patel K. A study of spectrum of rheumatic heart disease in children at a tertiary care hospital in Western India. JOURNAL OF CLINICAL AND PREVENTIVE CARDIOLOGY 2021. [DOI: 10.4103/jcpc.jcpc_49_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Khanra D, Soni S, Ola R, Duggal B. Acute attack of gout precipitated by concomitant use of aspirin and diuretic in a rheumatic mitral stenosis patient. BMJ Case Rep 2019; 12:12/9/e232085. [DOI: 10.1136/bcr-2019-232085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
Acute rheumatic fever is caused by an autoimmune response to throat infection with Streptococcus pyogenes. Cardiac involvement during acute rheumatic fever can result in rheumatic heart disease, which can cause heart failure and premature mortality. Poverty and household overcrowding are associated with an increased prevalence of acute rheumatic fever and rheumatic heart disease, both of which remain a public health problem in many low-income countries. Control efforts are hampered by the scarcity of accurate data on disease burden, and effective approaches to diagnosis, prevention, and treatment. The diagnosis of acute rheumatic fever is entirely clinical, without any laboratory gold standard, and no treatments have been shown to reduce progression to rheumatic heart disease. Prevention mainly relies on the prompt recognition and treatment of streptococcal pharyngitis, and avoidance of recurrent infection using long-term antibiotics. But evidence for the effectiveness of either approach is not strong. High-quality research is urgently needed to guide efforts to reduce acute rheumatic fever incidence and prevent progression to rheumatic heart disease.
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Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Luiza Guilherme
- Heart Institute (InCor), University of São Paulo, Institute for Investigation in Immunology, National Institute of Science and Technology, São Paulo, Brazil
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Bhutia E, Kumar D, Kundal M, Kishore S, Juneja A. Atypical Articular Presentations in Indian Children With Rheumatic Fever. Heart Lung Circ 2017; 27:199-204. [PMID: 28528779 DOI: 10.1016/j.hlc.2017.03.159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 01/02/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The objective of the study was to describe the clinical characteristics of atypical articular presentations during the initial outbreak and recurrence in patients with acute rheumatic fever (ARF) in the paediatric age group. METHODS This was a retrospective, observational study conducted between January 2012 and December 2014 on all suspected cases of acute rheumatic fever (ARF) fulfilling either WHO 2004 or Australian guidelines with atypical articular manifestations ie, presence of at least one of the following features: duration of symptoms more than 3 weeks; monoarthritis/arthralgia; involvement of small joints of hand and feet and/or cervical spine and/or hip joint; and, not responding to salicylates in 1 week. RESULTS 'Atypical' pattern was present in 63% (39/62) of patients with articular manifestations, of which arthralgia was a common manifestation (57%). Polyarticular afflictions were predominately non-migratory (additive) in both atypical (74%; 29/39) and typical (82%; 18/23) groups. Monoarticular (33%) affliction of the joints constituted a significant disease manifestation. Time from onset to diagnosis was >3 weeks in 79% of patients while small joints involvement and axial joint involvement occurred in half of the cases (51%). Inadequate response to NSAIDs was found in three (7%) cases. CONCLUSION Atypical manifestations in ARF may well be mistaken for a connective tissue disorder, post streptococcal reactive arthritis and septic arthritis. Physicians should be made aware of these features to prevent diagnostic dilemma, and to effect institution of appropriate management including penicillin prophylaxis.
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Affiliation(s)
- Euden Bhutia
- Department of Paediatrics, PGIMER and associated Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Dinesh Kumar
- Department of Paediatrics, PGIMER and associated Dr Ram Manohar Lohia Hospital, New Delhi, India.
| | - Mohan Kundal
- Department of Paediatrics, PGIMER and associated Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Sunil Kishore
- Department of Paediatrics, PGIMER and associated Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Atul Juneja
- Department of Biostatistics, National Institute of Medical Statistics, (ICMR), Delhi, India
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Laudari S, Subramanyam G. A study of spectrum of rheumatic heart disease in a tertiary care hospital in Central Nepal. IJC HEART & VASCULATURE 2017; 15:26-30. [PMID: 28616570 PMCID: PMC5458122 DOI: 10.1016/j.ijcha.2017.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/31/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Rheumatic heart disease is one of the most common cause for heart failure and associated mortalities/morbidities in the young population in developing countries like Nepal imparting huge familial, social and manpower burden. MATERIALS AND METHODS This is a hospital based descriptive cross-sectional study during June 2014 to April 2016 over a period of 22 months at College of Medical Sciences-Bharatpur including 235 patients with clinical and/or echocardiographic evidence of definite rheumatic heart disease. RESULTS The age of the patients ranged from 7 to 76 years with mean age 39.82 ± 4.2 years with female preponderance (F:M = 2.1:1) (p < 0.01). Majority of the rheumatic heart disease patients belonged to 30-44 years (28.78%) followed by 15-29 years (25.75%) and 45-59 years (25.00%). Majority belonged to the low socioeconomic status (60.60%) (p < 0.05). The predominantly involved isolated valve was mitral in 110 patients (46.80%) followed by isolated aortic valve in 22 patients (9.36%) and 79 (33.62%) had dual valvular involvement. The common rheumatic valvular lesions were pure mitral stenosis in 32 (13.61%), isolated mitral regurgitation in 58 (24.68%), combined mitral stenosis/regurgitation in 36 (15.32%), combined mitral/aortic regurgitation in 23 (9.78%) and combined aortic stenosis/regurgitation in 18 (7.66%) patients with few overlappings. The common complications encountered were heart failure in 90 (38.30%) and arrhythmias in 124 (51.00%) patients.130 patients (55.32%) received injectable benzathine penicillin whereas 45 patients (19.15%) preferred oral penicillin V. Surgical intervention was done in 54 (22.97%) patients. 12 (5.10%) expired in the CCU during the course of treatment. CONCLUSION RHD is a leading cause of heart failure among young populations with requirement of prolonged duration of medical treatment and many of them requiring surgery.
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Affiliation(s)
- S Laudari
- Department of Cardiology, College of Medical Sciences, TH, Bharatpur, Nepal
| | - G Subramanyam
- Department of Cardiology, College of Medical Sciences, TH, Bharatpur, Nepal
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Cannon J, Roberts K, Milne C, Carapetis JR. Rheumatic Heart Disease Severity, Progression and Outcomes: A Multi-State Model. J Am Heart Assoc 2017; 6:JAHA.116.003498. [PMID: 28255075 PMCID: PMC5523987 DOI: 10.1161/jaha.116.003498] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Rheumatic heart disease (RHD) remains a disease of international importance, yet little has been published about disease progression in a contemporary patient cohort. Multi‐state models provide a well‐established method of estimating rates of transition between disease states, and can be used to evaluate the cost‐effectiveness of potential interventions. We aimed to create a multi‐state model for RHD progression using serial clinical data from a cohort of Australian patients. Methods and Results The Northern Territory RHD register was used to identify all Indigenous residents diagnosed with RHD between the ages of 5 and 24 years in the time period 1999–2012. Disease severity over time, surgeries, and deaths were evaluated for 591 patients. Of 96 (16.2%) patients with severe RHD at diagnosis, 50% had proceeded to valve surgery by 2 years, and 10% were dead within 6 years. Of those diagnosed with moderate RHD, there was a similar chance of disease regression or progression over time. Patients with mild RHD at diagnosis were the most stable, with 64% remaining mild after 10 years; however, 11.4% progressed to severe RHD and half of these required surgery. Conclusions The prognosis of young Indigenous Australians diagnosed with severe RHD is bleak; interventions must focus on earlier detection and treatment if the observed natural history is to be improved. This multi‐state model can be used to predict the effect of different interventions on disease progression and the associated costs.
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Affiliation(s)
- Jeffrey Cannon
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Kathryn Roberts
- Menzies School of Health Research, Royal Darwin Hospital Campus, Darwin, Northern Territory, Australia
| | - Catherine Milne
- NT Rheumatic Heart Disease Register, Centre for Disease Control, Darwin, Northern Territory, Australia
| | - Jonathan R Carapetis
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
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Rheumatic Fever. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Kumar D, Bhutia E, Kumar P, Shankar B, Juneja A, Chandelia S. Evaluation of the American Heart Association 2015 revised Jones criteria versus existing guidelines. HEART ASIA 2016; 8:30-5. [PMID: 27326228 DOI: 10.1136/heartasia-2015-010709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/12/2016] [Accepted: 02/04/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To compare the diagnostic yield of acute rheumatic fever (ARF) by the American Heart Association/ American College of Cardiology (AHA/ACC) 2015 revised Jones criteria with the WHO 2004 and Australian guidelines 2012. METHODS Retrospective observational study in 93 cases of suspected ARF admitted to the Division of Paediatric Cardiology between January 2012 and December 2014. WHO 2004, Australian guidelines and AHA/ACC 2015 Jones criteria were applied to assess definite and probable ARF. RESULTS Of the 93 cases, 50 were diagnosed as the first episode of ARF and 43 as a recurrence of the condition. Subclinical carditis was a predominant presentation (38%) in the first episode group (p<0.01) whereas in the recurrence group carditis (88%) was the main presentation (p<0.01). Among the joint manifestations, the majority of patients in both the first episode group and the recurrence group presented with arthralgia. Of all the patients with suspected ARF (50), 34% of cases did not fulfil the standard Jones criteria 2004; however, 86% qualified as having ARF on applying the Australian and AHA/ACC 2015 criteria. Surprisingly in the recurrence group only 67% of the patients fulfilled AHA/ACC 2015 despite the modifications incorporated beyond WHO 2004; however, all the patients fulfilled the Australian guidelines either as definite (88.4%) or probable (11.6%). Inclusion of subclinical carditis, polyarthralgia and monoarthritis as major criteria influenced the diagnosis to definite ARF in 20%, 10% and 4% of patients, respectively. CONCLUSIONS The clinical manifestations of ARF, comprising subclinical carditis and arthralgia, are possibly milder in the Indian population; hence, inclusion of subclinical carditis, polyarthralgia and monoarthritis as major criteria in the newer guidelines has improved the diagnostic yield of ARF. In the absence of a gold standard for the diagnosis of ARF, it is not possible to comment on sensitivity and specificity.
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Affiliation(s)
- Dinesh Kumar
- Department of Paediatrics , PGIMER and associated Dr Ram Manohar Lohia Hospital , New Delhi , India
| | - Euden Bhutia
- Department of Paediatrics , PGIMER and associated Dr Ram Manohar Lohia Hospital , New Delhi , India
| | - Pradeep Kumar
- Department of Pediatrics and Neonatology , Rani Children's Hospital , Ranchi , India
| | - Binoy Shankar
- Department of Paediatrics , PGIMER and associated Dr Ram Manohar Lohia Hospital , New Delhi , India
| | - Atul Juneja
- Department of Biostatistics , National Institute of Medical Statistics (ICMR) , Delhi , India
| | - Sudha Chandelia
- Department of Paediatrics , PGIMER and associated Dr Ram Manohar Lohia Hospital , New Delhi , India
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Abstract
OBJECTIVES To project the cost-effectiveness of population-based echo screening to prevent rheumatic heart disease (RHD) consequences. BACKGROUND RHD is a leading cause of cardiovascular mortality and morbidity during adolescence and young adulthood in low- and middle-per capita income settings. Echocardiography-based screening approaches can dramatically expand the number of children identified at risk of progressive RHD. Cost-effectiveness analysis can inform public health agencies and payers about the net economic benefit of such large-scale population-based screening. METHODS A Markov model was constructed comparing a no-screen to echo screen approach. The echo screen program was modeled as a 2-staged screen of a cohort of 11-year-old children with initial short screening performed by dedicated technicians and follow-up complete echo by cardiologists. Penicillin RHD prophylaxis was modeled to only reduce rheumatic fever recurrence-related exacerbation. Quality-adjusted life years (QALYs) and societal costs (in 2010 Australian dollars) associated with each approach were estimated. One-way, two-way and probabilistic sensitivity analyses were performed on RHD prevalence and transition probabilities; echocardiography test characteristics; and societal level costs including supplies, transportation, and labor. RESULTS The incremental costs and QALYs of the screen compared to no screen strategy were -$432 (95% CI = -$1357 to $575) and 0.007 (95% CI = -0.0101 to 0.0237), respectively. The joint probability that the screen was both less costly and more effective exceeded 80%. Sensitivity analyses suggested screen strategy dominance depends mostly on the probability of transitioning out of sub-clinical RHD. CONCLUSION Two-stage echo RHD screening and secondary prophylaxis may achieve modestly improved outcomes at lower cost compared to clinical detection and deserves closer attention from health policy stakeholders.
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Affiliation(s)
- Justin P Zachariah
- Department of Cardiology, Boston Children's Hospital , Boston, MA , USA and
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Mota CCC, Meira ZMA, Graciano RN, Graciano FF, Araújo FDR. Rheumatic Fever prevention program: long-term evolution and outcomes. Front Pediatr 2015; 2:141. [PMID: 25610826 PMCID: PMC4285057 DOI: 10.3389/fped.2014.00141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 12/16/2014] [Indexed: 11/16/2022] Open
Abstract
This investigation aims to analyze the profile of long-term evolution of rheumatic fever in children and adolescents and outcomes after the control of recurrences. The cohort involved 702 patients followed from 1.3 to 16.9 years covering the two periods, before and after the implementation of a prevention program. Besides the establishment of the Reference Center in the State of Minas Gerais and the implementation of strategies to promote the compliance to prophylaxis, a project for education of health professionals was carried out in 23 cities. In addition to the clinical and epidemiological profile, the severity of the disease was analyzed. Mixed lesions were found in 27.1%, valvar regurgitation in 72.9%, and complete regression of the valvar lesions was seen in 34.4% of the patients, mostly presenting mild dysfunctions. The recurrence rate per patient-year was 0.058 and out of a total of 85 recurrences, 21.4% occurred in the first and 7.5% in the second period. More severe degrees of carditis and significant valvar sequels presented a higher prevalence in patients with recurrences. The comparative analysis between the two periods showed no changes regarding the age at the primary attack, gender, type, and site of valvar lesions and affected joints; however, important modifications in the indices of severity were observed after the control of recurrences. A significant decrease in the prevalence of severe carditis, obstructive valvar sequels, hospital admissions, surgical approach, and deaths was seen. This investigation showed that although the clinical profile of presentation remains unchanged, the control of repeated attacks can improve the morbimortality rates. In this context, the secondary prophylaxis should be the first priority in the control of the disease in developing countries, taking into account the difficulties found for effective primordial and primary prevention.
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Affiliation(s)
- Cleonice Carvalho Coelho Mota
- Department of Pediatrics, Hospital das Clínicas da UFMG, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Zilda Maria Alves Meira
- Department of Pediatrics, Hospital das Clínicas da UFMG, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Rosangela Nicoli Graciano
- Department of Pediatrics, Hospital das Clínicas da UFMG, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Fernando Felipe Graciano
- Department of Pediatrics, Hospital das Clínicas da UFMG, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
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Murdoch J, Davis S, Forrester J, Masuda L, Reeve C. Acute rheumatic fever and rheumatic heart disease in the Kimberley: using hospitalisation data to find cases and describe trends. Aust N Z J Public Health 2014; 39:38-43. [PMID: 25169025 DOI: 10.1111/1753-6405.12240] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/01/2014] [Accepted: 02/01/2014] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To describe the epidemiology of hospitalisations due to acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in the Kimberley region of Western Australia (WA) and use these data to improve completeness of the WA RHD Register. METHODS Retrospective analysis of Kimberley regional hospitalisation data for hospitalisations coded as ARF/RHD from 01/07/2002 to 30/06/2012, with individual follow-up of those not on the register. Annual age-standardised hospitalisation rates were calculated to determine hospitalisation trend. RESULTS There were 250 admissions among 193 individuals. Of these, 53 individuals (27%) with confirmed or probable ARF/RHD were not on the register. Males were less likely to be on the register (62% versus 79% of females, p<0.01), as were those hospitalised with ARF without heart involvement (68% versus 87% of other ARF diagnoses, p<0.01). ARF/RHD hospitalisation rates decreased by 8.8% per year (p<0.001, rate ratio = 0.91, 95%CI 0.87-0.96). CONCLUSIONS AND IMPLICATIONS Using hospitalisation data is an effective method of identifying cases of ARF/RHD not currently on the register. This process could be undertaken for initial case finding in areas with newly established registers, or as regular quality assurance in areas with established register-based programs. Reasons for the observed decrease in hospitalisation rates remain unclear and warrant further investigation.
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Choudhury SA, Exil V. Rheumatic heart disease in Tennessee: An overlooked diagnosis. SAGE Open Med Case Rep 2014; 2:2050313X14527589. [PMID: 27489643 PMCID: PMC4857350 DOI: 10.1177/2050313x14527589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 02/12/2014] [Indexed: 11/15/2022] Open
Abstract
Rheumatic heart disease, already a major burden in low- and middle-income countries, is becoming an emerging problem in high-income countries. Although acute rheumatic fever and rheumatic heart disease have almost been eradicated in areas with established economies, the emergence of this problem may be attributable to the migration from low-income to high-income settings. Between 2010 and 2012, we diagnosed a cluster of rheumatic heart disease cases in children from the Middle Tennessee area. The goal of this report is to increase awareness among clinicians as the incidence and prevalence of acute rheumatic fever remain relatively significant in large US metropolitan areas. Although acute rheumatic fever is seasonal, a high suspicion index may lead to the early diagnosis and prevention of its cardiac complications. Furthermore, screening procedures may be recommended for populations at risk for rheumatic heart disease in endemic areas, and active surveillance with echocardiography-based screening might become very important.
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Affiliation(s)
| | - Vernat Exil
- Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Children's Hospital At Vanderbilt University, Nashville TN, USA
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Tadele H, Mekonnen W, Tefera E. Rheumatic mitral stenosis in children: more accelerated course in sub-Saharan patients. BMC Cardiovasc Disord 2013; 13:95. [PMID: 24180350 PMCID: PMC4228389 DOI: 10.1186/1471-2261-13-95] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 10/28/2013] [Indexed: 11/28/2022] Open
Abstract
Background Mitral stenosis, one of the grave consequences of rheumatic heart disease, was generally considered to take decades to evolve. However, several studies from the developing countries have shown that mitral stenosis follows a different course from that seen in the developed countries. This study reports the prevalence, severity and common complications of mitral stenosis in the first and early second decades of life among children referred to a tertiary center for intervention. Methods Medical records of 365 patients aged less than 16 and diagnosed with rheumatic heart disease were reviewed. Mitral stenosis was graded as severe (mitral valve area < 1.0 cm2), moderate (mitral valve area 1.0-1.5 cm2) and mild (mitral valve area > 1.5 cm2). Results Mean age at diagnosis was 10.1 ± 2.5 (range 3–15) years. Of the 365 patients, 126 (34.5%) were found to have mitral stenosis by echocardiographic criteria. Among children between 6–10 years, the prevalence of mitral stenosis was 26.5%. Mean mitral valve area (n = 126) was 1.1 ± 0.5 cm2 (range 0.4-2.0 cm2). Pure mitral stenosis was present in 35 children. Overall, multi-valvular involvement was present in 330 (90.4%). NYHA functional class was II in 76% and class III or IV in 22%. Only 25% of patients remember having symptoms of acute rheumatic fever. Complications at the time of referral include 16 cases of atrial fibrillation, 8 cases of spontaneous echo contrast in the left atrium, 2 cases of left atrial thrombus, 4 cases of thrombo-embolic events, 2 cases of septic emboli and 3 cases of airway compression by a giant left atrium. Conclusion Rheumatic mitral stenosis is common in the first and early second decades of life in Ethiopia. The course appeared to be accelerated resulting in complications and disability early in life. Echocardiography-based screening programs are needed to estimate the prevalence and to provide support for strengthening primary and secondary prevention programs.
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Affiliation(s)
- Henok Tadele
- Department of Pediatrics & Child Health, School of Medicine, Hawassa University, Hawassa, Ethiopia.
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Roberts KV, Brown ADH, Maguire GP, Atkinson DN, Carapetis JR. Utility of auscultatory screening for detecting rheumatic heart disease in high-risk children in Australia's Northern Territory. Med J Aust 2013; 199:196-9. [PMID: 23909543 DOI: 10.5694/mja13.10520] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/11/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To evaluate the utility of auscultatory screening for detecting echocardiographically confirmed rheumatic heart disease (RHD) in high-risk children in the Northern Territory, Australia. DESIGN Cross-sectional screening survey. SETTING Twelve rural and remote communities in the NT between September 2008 and June 2010. PARTICIPANTS 1015 predominantly Indigenous schoolchildren aged 5-15 2013s. INTERVENTION All children underwent transthoracic echocardiography, using a portable cardiovascular ultrasound machine, and cardiac auscultation by a doctor and a nurse. Sonographers and auscultators were blinded to each others' findings and the clinical history of the children. Echocardiograms were reported offsite, using a standardised protocol, by cardiologists who were also blinded to the clinical findings. MAIN OUTCOME MEASURES Presence of a cardiac murmur as identified by nurses (any murmur) and doctors (any murmur, and "suspicious" or "pathological" murmurs), compared with echocardiogram findings. RHD was defined according to the 2012 World Heart Federation criteria for echocardiographic diagnosis of RHD. RESULTS Of the 1015 children screened, 34 (3.3%) had abnormalities identified on their echocardiogram; 24 met echocardiographic criteria for definite or borderline RHD, and 10 had isolated congenital anomalies. Detection of any murmur by a nurse had a sensitivity of 47.1%, specificity of 74.8% and positive predictive value (PPV) of 6.1%. Doctor identification of any murmur had 38.2% sensitivity, 75.1% specificity and 5.1% PPV, and the corresponding values for doctor detection of suspicious or pathological murmurs were 20.6%, 92.2% and 8.3%. For all auscultation approaches, negative predictive value was more than 97%, but the majority of participants with cardiac abnormalities were not identified. The results were no different when only definite RHD and congenital abnormalities were considered as true cases. CONCLUSIONS Sensitivity and positive predictive value of cardiac auscultation compared with echocardiography is poor, regardless of the expertise of the auscultator. Although negative predictive value is high, most cases of heart disease were missed by auscultation, suggesting that cardiac auscultation should no longer be used to screen for RHD in high-risk schoolchildren in Australia.
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Pilot study of nurse-led rheumatic heart disease echocardiography screening in Fiji--a novel approach in a resource-poor setting. Cardiol Young 2013; 23:546-52. [PMID: 23040535 DOI: 10.1017/s1047951112001321] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We designed a pilot study of a training module for nurses to perform rheumatic heart disease echocardiography screening in a resource-poor setting. The aim was to determine whether nurses given brief, focused, basic training in echocardiography could follow an algorithm to potentially identify cases of rheumatic heart disease requiring clinical referral, by undertaking basic two-dimensional and colour Doppler scans. Training consisted of a week-long workshop, followed by 2 weeks of supervised field experience. The nurses' skills were tested on a blinded cohort of 50 children, and the results were compared for sensitivity and specificity against echocardiography undertaken by an expert, using standardised echocardiography definitions for definite and probable rheumatic heart disease. Analysis of the two nurses' results revealed that when a mitral regurgitant jet length of 1.5 cm was used as the trigger for rheumatic heart disease identification, they had a sensitivity of 100% and 83%, respectively, and a specificity of 67.4% and 79%, respectively. This pilot supports the principle that nurses, given brief focused training and supervised field experience, can follow an algorithm to undertake rheumatic heart disease echocardiography in a developing country setting to facilitate clinical referral with reasonable accuracy. These results warrant further research, with a view to developing a module to guide rheumatic heart disease echocardiographic screening by nurses within the existing public health infrastructure in high-prevalence, resource-poor regions.
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Rayamajhi A, Sharma D, Shakya U. Clinical, laboratory and echocardiographic profile of acute rheumatic fever in Nepali children. ACTA ACUST UNITED AC 2013; 27:169-77. [PMID: 17716444 DOI: 10.1179/146532807x220271] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Acute rheumatic fever (RF) is a common, preventable health problem in developing countries. Sporadic outbreaks and the prevalence in some indigenous populations have renewed interest in RF in developed countries also. AIMS To describe the clinical, laboratory and echocardiographic features, outcome and value of echocardiography in detecting valvular disease in RF. METHODS A prospective, cross-sectional study was conducted over 2 years. Patients under 14 years admitted to the cardiology unit of Kanti Children's Hospital, Kathmandu with RF using the Jones criteria were recruited consecutively. RESULTS The median age (range) of the 51 patients was 11 (5-14) years, the male:female ratio was 1.6:1 and 39% had a history of a sore throat. Clinical and laboratory features detected were as follows: carditis 92%, arthritis 33%, chorea 8%, subcutaneous nodules 4%, fever 51%, arthralgia 37%, elevated antistreptolysin O titre 94%, elevated CRP 78%, prolonged PR interval 45%, pericardial effusion 22% and cardiac failure 28%. In total, 36 patients (71%) complained of joint pains. A murmur on auscultation was significantly associated with underlying diseased valves confirmed by echocardiography (p=0.001). A murmur was audible in 78.4% and diseased valves were confirmed by echocardiography in 88.2%. The mitral valve was the most commonly involved valve (82%) and mitral regurgitation the commonest lesion (24%). A thickened mitral valve predicted carditis (p=0.007). Five (10%) patients died. CONCLUSION Inclusion of echocardiographic evidence of carditis and possibly arthralgia as major criteria would improve case detection.
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Affiliation(s)
- Ajit Rayamajhi
- Cardiology Unit, Department of Paediatrics, National Academy of Medical Sciences, Kanti Children's Hospital, Kathmandu, Nepal.
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Use of Doppler echocardiography to support the decision to discontinue secondary prophylaxis for patients with rheumatic fever and normal cardiac auscultation. Pediatr Cardiol 2013; 34:1073-80. [PMID: 23239309 DOI: 10.1007/s00246-012-0601-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 11/29/2012] [Indexed: 10/27/2022]
Abstract
Secondary prophylaxis remains the safest way to prevent or minimize heart valve damage in patients with rheumatic fever. However, criteria to determine the duration of prophylaxis have not been well established. This study aimed to evaluate the clinical and Doppler echocardiographic profile of patients with rheumatic fever and a normal clinical examination at least 5 years after the first episode and to discuss the contribution of Doppler echocardiography in supporting the decision to discontinue secondary prophylaxis. An observational longitudinal study analyzing 183 patients with rheumatic fever and a normal clinical examination 5 years or more after the initial attack was conducted. The patients underwent Doppler echocardiography to study the severity of mitral or aortic valvular disease. Of the 183 patients, 77 (42 %) had clinical carditis. Subclinical chronic heart disease occurred for 79 % of the patients with previous clinical carditis and for 25 % of the patients without clinical carditis. Of the 35 patients with previous clinical carditis who were in the period of discontinued prophylaxis, residual valvular heart disease was observed in all, whereas of the 62 patients without clinical carditis, only 27 % showed residual valvular heart disease. Considering Doppler echocardiographic criteria, prophylaxis would be continued for 13 (34 %) of the patients with previous clinical carditis and for only 2 (3 %) of those without clinical carditis. Return of cardiac auscultation to normal is not always accompanied by return of Doppler echocardiographic findings to normal. Criteria regarding Doppler echocardiographic findings and valve morphology should be evaluated by the time secondary prophylaxis is discontinued. However, further studies are needed to demonstrate whether prolonged prophylaxis provides any benefit to patients with persistent echocardiographic findings.
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Abstract
Rheumatic heart disease (RHD) is a leading cause of cardiac disease among children in developing nations, and in indigenous populations of some industrialized countries. In endemic areas, RHD has long been a target of screening programmes that, historically, have relied on cardiac auscultation. The evolution of portable echocardiographic equipment has changed the face of screening for RHD over the past 5 years, with greatly improved sensitivity. However, concerns have been raised about the specificity of echocardiography, and the interpretation of minor abnormalities poses new challenges. The natural history of RHD in children with subclinical abnormalities detected by echocardiographic screening remains unknown, and long-term follow-up studies are needed to evaluate the significance of detecting these changes at an early stage. For a disease to be deemed suitable for screening from a public health perspective, it needs to fulfil a number of criteria. RHD meets some, but not all, of these criteria. If screening programmes are to identify additional cases of RHD, parallel improvements in the systems that deliver secondary prophylaxis are essential.
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Abstract
Rheumatic heart disease, often neglected by media and policy makers, is a major burden in developing countries where it causes most of the cardiovascular morbidity and mortality in young people, leading to about 250,000 deaths per year worldwide. The disease results from an abnormal autoimmune response to a group A streptococcal infection in a genetically susceptible host. Acute rheumatic fever--the precursor to rheumatic heart disease--can affect different organs and lead to irreversible valve damage and heart failure. Although penicillin is effective in the prevention of the disease, treatment of advanced stages uses up a vast amount of resources, which makes disease management especially challenging in emerging nations. Guidelines have therefore emphasised antibiotic prophylaxis against recurrent episodes of acute rheumatic fever, which seems feasible and cost effective. Early detection and targeted treatment might be possible if populations at risk for rheumatic heart disease in endemic areas are screened. In this setting, active surveillance with echocardiography-based screening might become very important.
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Affiliation(s)
- Eloi Marijon
- Paris Cardiovascular Research Centre, INSERM U970, European Georges Pompidou Hospital, Paris, France; Department of Cardiology, European Georges Pompidou Hospital, Paris, France; Paris Descartes University, Paris, France; Maputo Heart Institute (ICOR), Maputo, Mozambique.
| | - Mariana Mirabel
- Paris Cardiovascular Research Centre, INSERM U970, European Georges Pompidou Hospital, Paris, France; Paris Descartes University, Paris, France; University College London, London, UK
| | | | - Xavier Jouven
- Paris Cardiovascular Research Centre, INSERM U970, European Georges Pompidou Hospital, Paris, France; Department of Cardiology, European Georges Pompidou Hospital, Paris, France; Paris Descartes University, Paris, France; Maputo Heart Institute (ICOR), Maputo, Mozambique
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Steer AC, Colquhoun S, Kado J, Carapetis JR. Secondary prophylaxis is important for the prevention of recurrent rheumatic fever in the Pacific. Pediatr Cardiol 2011; 32:864-5. [PMID: 21479911 DOI: 10.1007/s00246-011-9966-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Spinetto H, Lennon D, Horsburgh M. Rheumatic fever recurrence prevention: a nurse-led programme of 28-day penicillin in an area of high endemnicity. J Paediatr Child Health 2011; 47:228-34. [PMID: 21470327 DOI: 10.1111/j.1440-1754.2010.01942.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate safety and effectiveness of 28-day long-acting penicillin to prevent recurrences of acute rheumatic fever (ARF). METHODS Historical cohort study using the regional RF register for Auckland, New Zealand, in a 5-14-year-old population with ARF rates of ~40-80/100,000. Consented patients were referred to a population-based delivery programme of free benzathine penicillin every 28 days by community nurses with discharge after the longer of 10 years of treatment or aged 21 years. First-episode and recurrent ARF cases classified as definite (Jones criteria 1992) or probable (Jones criteria 1956) were the main outcome measures. RESULTS Of the 360 cases meeting the case definitions, 20 recurrences occurred in 19 people (median age 21 years). The age at first episode was 2-52 years (mode 11 years), median age 21.3 (8-40). ARF recurred 0-21 years after penicillin was discontinued. Seventy-two per cent of recurrent cases occurred within 5 years, and 12% between 5 years and 10 years. The 4-weekly long-acting penicillin failure rate (n= 1) was 0.07/100 patient years. The programme failure rate (Auckland residents) was 1.4/100 patient years (n= 20). Patient non-adherence accounted for 55% of recurrences. Two recurrences after discharge from prophylaxis as per the New Zealand guidelines occurred 3 years and 13 years later. CONCLUSIONS In this environment, 28-day long-acting penicillin prophylaxis for at least 10 years delivered by community nurses is safe and effective for patients with no or mild cardiac disease by auscultation at discharge off penicillin. Penicillin delivery every 21 days (as suggested by a recent Cochrane review) would add to costs and complexity.
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Burden of disease and barriers to the diagnosis and treatment of group a beta-hemolytic streptococcal pharyngitis for the prevention of rheumatic heart disease in Dar Es Salaam, Tanzania. Pediatr Infect Dis J 2010; 29:1135-7. [PMID: 21155123 DOI: 10.1097/inf.0b013e3181edf475] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To understand patient and clinician attitudes toward Streptococcus pharyngitis and rheumatic heart disease prevention in Tanzania, data from 3 sources were obtained: a survey of 119 clinicians, outpatient rapid test screening, and interviews with 17 rheumatic heart disease patients. Patients do not seek care for sore throat. Clinicians stated that identifying and treating Streptococcus pharyngitis is not prioritized.
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Pastore S, De Cunto A, Benettoni A, Berton E, Taddio A, Lepore L. The resurgence of rheumatic fever in a developed country area: the role of echocardiography. Rheumatology (Oxford) 2010; 50:396-400. [PMID: 21047802 DOI: 10.1093/rheumatology/keq290] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The annual incidence of ARF ranges from 5 to 51/100, 000 population worldwide in the 5- to 15-year age group. In the past, there was a decline in the incidence of ARF; however, focal outbreaks have been reported. This study evaluated the incidence of ARF in 2007-08 in a region of a developed country compared with the previous decade. METHODS A retrospective review of all admission records for ARF in Trieste between January 2007 and December 2008 was undertaken. The diagnosis of ARF was established by the Jones criteria according to the 1992 revision. RESULTS Between January 2007 and December 2008: 13 cases of ARF were recorded, 11 females and 2 males. The estimated incidence was 23 and 27/100, 000 population new cases each year, respectively, in the 5- to 15-year age group. Migratory polyarthritis occurred in 6/13, chorea in 7/13 and clinical carditis in 5/13 cases. Five out of 13 patients had only echocardiographic abnormalities, with no clinical cardiac manifestations. Another two patients did not fulfil diagnostic criteria for ARF, presenting with only three minor criteria, but they revealed silent carditis at echocardiography evaluation. During the follow-up, in one case the carditis receded and in the other it significantly improved. CONCLUSIONS Our experience underlines that ARF has not yet disappeared in industrialized countries. We observed a high incidence of chorea, always associated with mild carditis. Echocardiographic assessment should be routinely performed in all patients with suspected ARF in order to identify those subclinical cases of valvulitis that would otherwise pass undiagnosed without receiving proper prophylaxis.
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Affiliation(s)
- Serena Pastore
- Department of Pediatrics, IRCCS Burlo Garofolo - University of Trieste, Italy.
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Steer AC, Carapetis JR. Acute rheumatic fever and rheumatic heart disease in indigenous populations. Pediatr Clin North Am 2009; 56:1401-19. [PMID: 19962028 DOI: 10.1016/j.pcl.2009.09.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acute rheumatic fever and rheumatic heart disease are diseases of socioeconomic disadvantage. These diseases are common in developing countries and in Indigenous populations in industrialized countries. Clinicians who work with Indigenous populations need to maintain a high index of suspicion for the potential diagnosis of acute rheumatic fever, particularly in patients presenting with joint pain. Inexpensive medicines, such as aspirin, are the mainstay of symptomatic treatment of rheumatic fever; however, antiinflammatory treatment has no effect on the long-term rate of progression or severity of chronic valvular disease. The current focus of global efforts at prevention of rheumatic heart disease is on secondary prevention (regular administration of penicillin to prevent recurrent rheumatic fever), although primary prevention (timely treatment of streptococcal pharyngitis to prevent rheumatic fever) is also important in populations in which it is feasible.
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Affiliation(s)
- Andrew C Steer
- Department of Paediatrics, Centre for International Child Health, University of Melbourne, Flemington Road, Parkville, 3052, Melbourne, Victoria, Australia.
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Steer AC, Carapetis JR. Prevention and treatment of rheumatic heart disease in the developing world. Nat Rev Cardiol 2009; 6:689-98. [DOI: 10.1038/nrcardio.2009.162] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
BACKGROUND There is a great need for echocardiographic criterions for accurate diagnosis of carditis in acute rheumatic fever. AIM To test the efficacy of proposed echocardiographic criterions for the diagnosis of carditis. MATERIALS AND METHODS We studied 333 patients suspected of having acute rheumatic fever, undertaking detailed clinical examination, laboratory tests and meticulous echocardiography in each case. We used previously established echocardiographic criterions for the diagnosis of carditis and subclinical valvitis. In 220 cases (66.06%), both the echo criterions, and the Jones' criterions, gave positive results. In 52 cases (15.61%), we found evidence of subclinical carditis, in that clinically no murmur was heard, meaning the Jones' criterions were negative, but the echocardiographic evaluation was positive. In 4 patients clinically diagnosed as having carditis, the Jones' criterions were positive, but echocardiographic evaluation showed them to have congenitally malformed hearts. In another 57 cases (17.11%), the Jones' criterions were negative, as were the results of echocardiographic evaluation. These patients were taken as control subjects. On this basis, the echocardiographic criterions had sensitivity of 81% and specificity of 93%. CONCLUSION Using our echocardiographic criterions, it is possible to make a precise diagnosis of carditis or subclinical valvitis. Hence, echocardiography should, in future, be included as a major criterion in the Jones' system.
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Eissa S, Lee R, Binns P, Garstone G, McDonald M. Assessment of a register-based rheumatic heart disease secondary prevention program in an Australian Aboriginal community. Aust N Z J Public Health 2006; 29:521-5. [PMID: 16366062 DOI: 10.1111/j.1467-842x.2005.tb00243.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess specific performance indicators relating to a register-based acute rheumatic fever and rheumatic heart disease (ARF/RHD) prevention program in a remote Australian Aboriginal community in order to identify the most appropriate avenues for improvements in delivery of services. METHODS Information kept on the central ARF/RHD register was compared with an amalgamated dataset from three other sources. The community clinic charts of identified patients were reviewed for information regarding accuracy of diagnosis and the number of doses of benzathine penicillin received in the last year. Specific follow-up arrangements were assessed and compared with practice guidelines. RESULTS The central ARF/RHD register contained the names of 58 of the 72 (81%) people identified in the community as eligible for inclusion. Only 42% (22/52) of people receiving antibiotic prophylaxis had received 80% or more of the recommended doses in the previous year; service delivery was significantly better for females than males (p = 0.004). Individuals in priority category 1 (most severe disease) were found to be receiving follow-up and investigation according to guidelines. About half the people in categories 2 (moderate disease) and 3 (mild disease) had been inadequately investigated and/or missed out on follow-up appointments. CONCLUSIONS The ARF/RHD prevention program in this large remote Aboriginal community is struggling to deliver services to a substantial proportion of people who require them. Specific interventions, especially those related to men's health, may be required to correct the problems.
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Affiliation(s)
- Sabry Eissa
- Royal Free and University College London Medical School, University College London, United Kingdom
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Reddy A, Jatana SK, Nair M. Clinical Evaluation Versus Echocardiography in the Assessment of Rheumatic Heart Disease. Med J Armed Forces India 2004; 60:255-8. [PMID: 27407645 PMCID: PMC4923052 DOI: 10.1016/s0377-1237(04)80058-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) is still a common form of heart disease among children and young adults, especially in developing countries like India. Between 1940 and 1983, the prevalence rate of RHD varied from 1.8 to 11 per 1000 (national average 6 per 1000), while between 1984 and 1995 the rate varied from 1 to 5.4 per 1000 [1]. The study was carried out to assess the accuracy of a medical student's clinical evaluation of valvular heart disease and compare it with that of an echocardiographic evaluation and to determine the sensitivity, specificity and predictive values of clinical examination as compared to echocardiography for the various lesions in RHD patients. METHOD 50 children between the ages of 5-16 years, attending the out patient department or admitted in a large teaching hospital, satisfying the criteria of RHD, were included in the study. Each patient underwent detailed clinical evaluation and relevant investigations including echocardiography. RESULTS Mitral valve was involved most often both by echocardiography and clinically. Isolated aortic valve involvement was rare. The most common lesion was mitral regurgitation (MR) both by auscultation and by echo. Mixed lesions were seen more often than pure lesions. Mitral stenosis (MS) had the highest sensitivity while tricuspid regurgitation (TR) had the highest specificity. MR had the highest positive predictive value and MS the highest negative predictive value. Sensitivity and specificity of aortic regurgitation (AR) was very low when compared to earlier studies. There was a statistically significant difference between echo diagnosis and clinical diagnosis (p < 0.05). CONCLUSION It is recommended that echocardiography be done routinely for the diagnosis of cardiac lesions in patients of RHD as clinical examination alone can miss various lesions, especially when the lesions are mild or when multiple lesions are present.
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Affiliation(s)
- Ashwin Reddy
- Ex-Medical Cadet, Department of Paediatrics, Armed Forces Medical College, Pune-411 040
| | - S K Jatana
- Associate Professor, Department of Paediatrics, Armed Forces Medical College, Pune-411 040
| | - Mng Nair
- Professor & Head, Department of Paediatrics, Armed Forces Medical College, Pune-411 040
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Abstract
We designed a multi-hospital prospective study of children less than 12 years to determine the comparative clinical profile, severity of carditis, and outcome on follow up of patients suffering an initial and recurrent episodes of acute rheumatic fever. The study extended over a period of 3 years, with diagnosis based on the Jones criteria. We included 161 children in the study, 57 having only one episode and 104 with recurrent episodes. Those seen in the first episode were differentiated from those with recurrent episodes on the basis of the history. The severity of carditis was graded by clinical and echocardiographic means. In those suffering their first episode, carditis was significantly less frequent (61.4%) compared to those having recurrent episodes (96.2%). Arthritis was more marked in the first episode (61.4%) compared to recurrent episodes (36.5%). Chorea was also significantly higher in the first episode (15.8%) compared to recurrent episodes (3.8%). Sub-cutaneous nodules were more-or-less the same in those suffering the first (7%) as opposed to recurrent episodes (5.8%), but Erythema marginatum was more marked during the first episode (3.5%), being rare in recurrent episodes at 0.9%. Fever was recorded in approximately the same numbers in first (45.6%) and recurrent episodes (48.1%). Arthralgia, in contrast, was less frequent in first (21.1%) compared to recurrent episodes (32.7%). A history of sore throat was significantly increased amongst those suffering the first episode (54.4%) compared to recurrent episodes (21.2%). When we compared the severity of carditis in the first versus recurrent episodes, at the start of study mild carditis was found in 29.8% versus 10.6%, moderate carditis in 26.3% versus 53.8%, and severe carditis in 5.3% versus 31.8% of cases, respectively. At the end of study, 30.3% of patients suffering their first episode were completely cured of carditis, and all others showed significant improvement compared to those with recurrent episodes, where only 6.8% were cured, little improvement or deterioration being noted in the remainder of the patients. We conclude that the clinical profile of acute rheumatic fever, especially that of carditis, is milder in those suffering their first attack compared to those with recurrent episodes.
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Abstract
To describe the epidemiology and clinical features of Sydenham's chorea in the Aboriginal population of northern Australia a review was conducted of 158 episodes in 108 people: 106 were Aborigines, 79 were female, and the mean age was 10.9 years at first episode. Chorea occurred in 28% of cases of acute rheumatic fever, carditis occurred in 25% of episodes of chorea, and arthritis in 8%. Patients with carditis or arthritis tended to have raised acute phase reactants and streptococcal serology. Two episodes lasted at least 30 months. Mean time to first recurrence of chorea was 2.1 years compared with 1.2 years to second recurrence. Established rheumatic heart disease developed in 58% of cases and was more likely in those presenting with acute carditis, although most people who developed rheumatic heart disease did not have evidence of acute carditis with chorea. Differences in the patterns of chorea and other manifestations of acute rheumatic fever in different populations may hold clues to its pathogenesis. Long term adherence to secondary prophylaxis is crucial following all episodes of acute rheumatic fever, including chorea, to prevent recurrence.
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Affiliation(s)
- J R Carapetis
- Division of Infectious Diseases, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.
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Kassem AS, el-Walili TM, Zaher SR, Ayman M. Reversibility of mitral regurgitation following rheumatic fever: clinical profile and echocardiographic evaluation. Indian J Pediatr 1995; 62:717-23. [PMID: 10829950 DOI: 10.1007/bf02825126] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The clinical disappearance of the murmur of rheumatic mitral regurgitation after period of time has been documented by many researchers. However no studies have related the disappearance of the murmur with the functional or anatomical state of the mitral valve. This study was done to elucidate the mitral valve status using doppler and color coded echocardiography among those children who have lost their apical pansystolic murmur on auscultation following a documented attack of rheumatic fever. The study sample consisted of 51 patients including 31 patients in whom the murmur has disappeared (group I), and 20 patients with persistent isolated mitral regurgitation (group II). Patients of group I had significantly lower grades of murmur intensity, lower incidence of cardiomegaly, and had no heart failure in the initial attack. They were more compliant with prophylaxis and had less recurrences than patients of group II. The murmur disappeared in patients of group I from 1/2 to 14 years after the initial attack. Echocardiography revealed that such patients had a normal mitral valve apparatus, and a normal heart size and function. Only 5 patients of this group had a significant regurgitant jet demonstrated by colour doppler. We concluded that recovery of the mitral valve and return of cardiac functions to normal is possible in patients who had mitral regurgitation following rheumatic fever. Some of them may still have an inaudible mild regurgitation. Patients who have lost their murmur may be allowed to exercise freely, yet penicillin prophylaxis should not be discontinued.
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Affiliation(s)
- A S Kassem
- Department of Pediatrics, Faculty of Medicine, University of Alexandria, Egypt
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Long-term outcome of patients with rheumatic fever receiving benzathine penicillin G prophylaxis every three weeks versus every four weeks. The journal The Journal of Pediatrics 1994. [DOI: 10.1016/s0022-3476(06)80188-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
The close relationship between Group A beta Hemolytic Streptococci (GABS) and rheumatic fever is a well established one. However, the concept of the streptococcus as the sole etiologic agent of the rheumatic heart disease (RHD) has been challenged over the past years. Since coxsackievirus group B (CVB) has long been proposed as a cause of acquired valvular disease simulating rheumatic fever, we attempted in this study to document infections with this group of viruses in patients with rheumatic fever. We obtained blood samples from 106 patients with old (quiescent) rheumatic fever/rheumatic heart disease [group I], 94 patients with acute rheumatic fever (ARF) [group II], and 74 normal matched controls. We tested for the presence of neutralizing antibodies to the 6 serotypes of CVB by a micro neutralization test. We have found that infection with CVB, especially types B2 and B4, was common in the studied population. Forty-two percent of normal individuals had evidence of infection with any of the 6 serotypes of CVB. Patients of group I had significantly more frequent infections with CVB 2. Patients in group II had significantly more frequent infections with CVB 2 and CVB 6. There was no clear correlation between such infections and the clinical course of rheumatic fever. There was no difference in the incidence of CVB infections between patients with definite ARF, and patients with suspected ARF. We set a low order association between rheumatic fever and infection with CVB types B2 and B6. We emphasize the importance of pursuing the investigation of the role of CVB in relation to RHD.
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Affiliation(s)
- S R Zaher
- Department of Pediatrics, University of Alexandria, Egypt
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Kassem AS, Zaher SR. An international comparison of the prevalence of streptococcal infections and rheumatic fever in children. Pediatr Ann 1992; 21:835, 839-42. [PMID: 1480438 DOI: 10.3928/0090-4481-19921201-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Differences in the socioeconomic standards of living remain an important and feasible partial explanation for the difference in incidence of rheumatic fever following GABHS infection in Egyptian compared with American children. However, past and ongoing studies of the epidemiology, diagnosis, and treatment of GABHS infections in Egypt, the United States, and elsewhere suggest other significant factors are relevant. Additional knowledge about the rheumatogenic GABHS serotypes that are most prevalent in all countries is an important area where additional research is needed. Streptococcal research will help not only in improving the quality of primary prevention of rheumatic fever, but also in developing streptococcal vaccines.
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Affiliation(s)
- A S Kassem
- Department of Pediatrics, University of Alexandria, Egypt
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Kassem AS, Madkour AA, Massoud BZ, Zaher SR. Benzathine penicillin G for rheumatic fever prophylaxis: 2-weekly versus 4-weekly regimens. Indian J Pediatr 1992; 59:741-8. [PMID: 1340864 DOI: 10.1007/bf02859412] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Rheumatic fever is still one of the major public health problems in Egypt and the developing countries. It is characterized by a high tendency to recur following streptococcal infections. The use of long acting penicillin for prophylaxis against strep infections was a good achievement in this field, yet, recurrences have been reported in patients following monthly prophylactic programs. Clinical experience in Alexandria have shown for a long time that giving penicillin every 2 weeks is followed by less recurrences of rheumatic fever. Recently, reports came showing that effective penicillin levels are not maintained except for 2 to 3 weeks after the injection. In the present study, we compared two regimens of prophylaxis with 190 patients in the 2-weekly regimen, and 170 patients in the 4-weekly regimen being followed up for 2 consecutive years. Two hundred and sixty nine streptococcal infections occurred during this period. Although the streptococcal infection rate was equal in both groups, the rheumatic fever recurrence rate and the RF attack rate were significantly higher in the group of patients on the 4-weekly schedule. The results of this study have shown the superiority of the 2-weekly schedule in the adequate control of RF recurrences. We suggest that this schedule should be implemented for secondary prophylaxis of rheumatic fever in Egypt and other areas with severe RF.
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Affiliation(s)
- A S Kassem
- Department of Pediatrics, University of Alexandria, Egypt
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Abstract
Fulminating active rheumatic carditis has been observed for over 3 decades in this environment with no recent alteration in either the incidence or the pattern of presentation. Patients are black, seldom older than 20 years and are usually in their early teens but may occasionally be as young as five years. Heart failure is prevalent but occurs only when a haemodynamically important left-sided valve lesion supervenes. Regurgitation is the predominant valve lesion and involves principally the mitral valve. Mitral annular dilatation is the initial pathology and predisposes to lengthening--or rupture--of chordae tendineae and prolapse of the anterior leaflet. The resultant cardiac work-overload apparently perpetuates the rheumatic activity. Heart failure, whether caused by or associated with active rheumatic carditis, makes surgical management of the valve lesion mandatory as a life-saving measure. Mitral valve repair, rather than replacement, is the surgical procedure of choice but is not always practicable when the rheumatic activity is fulminant, significant aortic regurgitation associated or the surgeon relatively inexperienced. Aggressive medical therapy for heart failure, which should include vasodilator drugs, provides temporary improvement only. Contrary to ongoing doctrine, treatment with steroid drugs is neither life-saving nor beneficial. Varying degrees of left ventricular dysfunction are encountered pre-operatively and may be a sequel of the severe regurgitant valve lesion rather than of a rheumatic 'myocardial factor'.
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Affiliation(s)
- J B Barlow
- Mitral Valve Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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Majeed HA, Batnager S, Yousof AM, Khuffash F, Yusuf AR. Acute rheumatic fever and the evolution of rheumatic heart disease: a prospective 12 year follow-up report. J Clin Epidemiol 1992; 45:871-5. [PMID: 1624969 DOI: 10.1016/0895-4356(92)90070-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Sixty four children who presented with the initial attack of acute rheumatic fever and maintained continuous regular secondary prophylaxis, were followed up prospectively for 12.3 years (an observation period of 775 patient-years). The prevalence rate of rheumatic heart disease in the 29 children who had carditis in the initial attack and in the 35 children who had no carditis initially was 49 vs 0%, respectively. The overall prevalence rate of rheumatic heart disease was 20%. Mitral incompetence developed in 11 patients (17%), aortic incompetence in 2 (3%) and mitral stenosis in 2 (3%). None of the patients developed aortic stenosis. Two recurrences developed with a recurrence rate of 0.003 per patient per year. One patient needed cardiac surgery and there was no mortality. These data strongly suggest that continuous regular secondary prophylaxis can prevent or significantly reduce the development of mitral and aortic valve stenosis, the prevalence rate of rheumatic heart disease and mortality.
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Affiliation(s)
- H A Majeed
- Department of Pediatrics, Faculty of Medicine, University of Kuwait, Safat
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42
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Affiliation(s)
- E M Ayoub
- Department of Pediatrics, University of Florida, Gainesville 32610
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43
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44
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Sanyal SK, Abu-Melha A. Is there a need to modify the "revised" Jones diagnostic criteria of acute rheumatic fever? Indian J Pediatr 1988; 55:9-14. [PMID: 3288562 DOI: 10.1007/bf02722554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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45
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Sanyal SK, Saleh MA, Abu-Melha A. Infective endocarditis during infancy and childhood: current status. Indian J Pediatr 1988; 55:51-79. [PMID: 3288561 DOI: 10.1007/bf02722559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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46
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Lue HC, Wu MH, Hsieh KH, Lin GJ, Hsieh RP, Chiou JF. Rheumatic fever recurrences: controlled study of 3-week versus 4-week benzathine penicillin prevention programs. J Pediatr 1986; 108:299-304. [PMID: 3511209 DOI: 10.1016/s0022-3476(86)81009-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To compare the merits of 3-week versus 4-week injections of benzathine penicillin G in preventing recurrence of rheumatic fever, 179 patients aged 4 to 19 years were assigned to one of the two programs. Age, weight, cardiac status, and streptococcal infections among the patients and their family members studied in each program were comparable. Eight-two patients and their family members were monitored for streptococcal infections. Compliance in the two programs was comparable. Of the 63 patients who stayed in the 4-week program, RF recurred in six, as a result of prophylaxis failure in five and associated with partial compliance in one. Of the 90 patients in the 3-week program, RF recurred in one, associated with partial compliance; no failures occurred (P = 0.01). We recommended that for RF chemoprophylaxis in individuals at great risk, regardless of age, benzathine penicillin injections should be administered every 3 rather than every 4 weeks.
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Majeed HA, Yousof AM, Khuffash FA, Yusuf AR, Farwana S, Khan N. The natural history of acute rheumatic fever in Kuwait: a prospective six year follow-up report. JOURNAL OF CHRONIC DISEASES 1986; 39:361-9. [PMID: 3700577 DOI: 10.1016/0021-9681(86)90122-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
One hundred and twenty-six children with the initial attack of acute rheumatic fever were followed up prospectively for 6 years. Sixty-six children maintained regular secondary prophylaxis (regular group) and 60 were irregular (irregular group). Two recurrences developed in the regular group with a recurrence rate of 0.005/patient/year follow-up, and 71 recurrences developed in the irregular group with a recurrence rate of 0.2/patient/year follow-up. These findings demonstrate the effect of secondary prophylaxis in reducing the frequency of recurrences. The prevalence rate of rheumatic heart disease in children who had carditis in the initial attack was 42% in the regular group vs 70% in the irregular group (p less than 0.05). These findings demonstrate the deleterious effect of recurrences in the evolution of rheumatic heart disease. The prevalence rate of rheumatic heart disease in children who maintained regular secondary prophylaxis, was 42% in those children who had carditis in the initial attack and 6% in those who had no carditis (p less than 0.05). These findings demonstrate the prognostic significance of presence or absence of carditis during the initial attack, in the subsequent evolution of rheumatic heart disease. The prevalence rate of rheumatic heart disease in the 66 children who maintained regular prophylaxis was 23%. Comparison of these data with those of similarly designed studies shows that the evolution of rheumatic heart disease following the initial attack of acute rheumatic fever, seems to behave similarly in the tropics and subtropics as it did in temperate climates.
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