Rheumatic heart disease screening by echocardiography: the inadequacy of World Health Organization criteria for optimizing the diagnosis of subclinical disease.
BACKGROUND
Early case detection is vital in rheumatic heart disease (RHD) in children to minimize the risk of advanced valvular heart disease by preventive measures. The currently utilized World Health Organization (WHO) criteria for echocardiographic diagnosis of subclinical RHD emphasize the presence of pathological valve regurgitation but do not include valves with morphological features of RHD without pathological regurgitation. We hypothesized that adding morphological features to diagnostic criteria might have significant consequences in terms of case detection rates.


RESULTS
We screened 2170 randomly selected school children aged 6 to 17 years in Maputo, Mozambique, clinically and by a portable ultrasound system. Two different echocardiographic sets of criteria for RHD were assessed: "WHO" (exclusively Doppler-based) and "combined" (Doppler and morphology-based) criteria. Independent investigators reviewed all suspected RHD cases using a higher-resolution, nonportable ultrasound system. On-site echocardiography identified 18 and 124 children with suspected RHD according to WHO and combined criteria, respectively. After consensus review, 17 were finally considered to have definite RHD according to WHO criteria, and 66 had definite RHD according to combined criteria, giving prevalence rates of 7.8 (95% confidence interval, 4.6 to 12.5) and 30.4 (95% confidence interval, 23.6 to 38.5) per 1000 children, respectively (P<0.0001, exact McNemar test).


CONCLUSIONS
Important consideration should be given to echocardiographic criteria for detecting subclinical RHD because the number of cases detected may differ importantly according to the diagnostic criteria utilized. Currently recommended WHO criteria risk missing up to three quarters of cases of subclinically affected and therefore potentially treatable children with RHD.
Marijon
Eloi
E
Université Paris Descartes, AP-HP, Hôpital Européen Georges Pompidou, France. eloi_marijon@yahoo.fr
Celermajer
David S
DS
Tafflet
Muriel
M
El-Haou
Saïd
S
Jani
Dinesh N
DN
Ferreira
Beatriz
B
Mocumbi
Ana-Olga
AO
Paquet
Christophe
C
Sidi
Daniel
D
Jouven
Xavier
X
D000293:Adolescent; D002648:Child; D042241:Early Diagnosis; D004452:Echocardiography / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods* / Q000706:statistics & numerical data; D015588:Observer Variation; D015995:Prevalence; D012214:Rheumatic Heart Disease / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000517:prevention & control*; D012307:Risk Factors; D012720:Severity of Illness Index; D017678:Sex Distribution; D014944:World Health Organization