title: Handheld echocardiography versus auscultation for detection of rheumatic heart disease.
abstract: BACKGROUND
  Rheumatic heart disease (RHD) remains a major public health concern in developing countries, and routine screening has the potential to improve outcomes. Standard portable echocardiography (STAND) is far more sensitive than auscultation for the detection of RHD but remains cost-prohibitive in resource-limited settings. Handheld echocardiography (HAND) is a lower-cost alternative. The purpose of this study was to assess the incremental value of HAND over auscultation to identify RHD.
  
  
  METHODS
  RHD screening was completed for schoolchildren in Gulu, Uganda, by using STAND performed by experienced echocardiographers. Any child with mitral or aortic regurgitation or stenosis plus a randomly selected group of children with normal STAND findings underwent HAND and auscultation. STAND and HAND studies were interpreted by 6 experienced cardiologists using the 2012 World Heart Federation criteria. Sensitivity and specificity of HAND and auscultation for the detection of RHD and pathologic mitral or aortic regurgitation were calculated by using STAND as the gold standard.
  
  
  RESULTS
  Of 4773 children who underwent screening with STAND, a subgroup of 1317 children underwent HAND and auscultation. Auscultation had uniformly poor sensitivity for the detection of RHD or valve disease. Sensitivity was significantly improved by using HAND compared with auscultation for the detection of definite RHD (97.8% vs 22.2%), borderline or definite RHD (78.4% vs 16.4%), and pathologic aortic insufficiency (81.8% vs 13.6%).
  
  
  CONCLUSIONS
  Auscultation alone is a poor screening test for RHD. HAND significantly improves detection of RHD and may be a cost-effective screening strategy for RHD in resource-limited settings.
authors.affiliation: Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee; justin.godown@vanderbilt.edu.
authors.forename: Justin
authors.initials: J
authors.lastname: Godown
authors.affiliation: Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan;
authors.forename: Jimmy C
authors.initials: JC
authors.lastname: Lu
authors.affiliation: Division of Pediatric Cardiology, Children's National Medical Center, Washington, District of Columbia;
authors.forename: Andrea
authors.initials: A
authors.lastname: Beaton
authors.affiliation: Division of Pediatric Cardiology, Children's National Medical Center, Washington, District of Columbia;
authors.forename: Craig
authors.initials: C
authors.lastname: Sable
authors.affiliation: Joint Clinical Research Centre, Kampala, Uganda;
authors.forename: Grace
authors.initials: G
authors.lastname: Mirembe
authors.affiliation: Gulu University, Gulu, Uganda; and.
authors.forename: Richard
authors.initials: R
authors.lastname: Sanya
authors.affiliation: Gulu University, Gulu, Uganda; and.
authors.forename: Twalib
authors.initials: T
authors.lastname: Aliku
authors.affiliation: Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan;
authors.forename: Sunkyung
authors.initials: S
authors.lastname: Yu
authors.affiliation: Uganda Heart Institute, Kampala, Uganda.
authors.forename: Peter
authors.initials: P
authors.lastname: Lwabi
authors.affiliation: Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan;
authors.forename: Catherine L
authors.initials: CL
authors.lastname: Webb
authors.affiliation: Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan;
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Ensing
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D003906:Developing Countries; D004452:Echocardiography / Q000191:economics / Q000295:instrumentation*; D018618:Echocardiography, Doppler, Color / Q000295:instrumentation; D005260:Female; D006326:Heart Auscultation / Q000191:economics; D006349:Heart Valve Diseases / Q000175:diagnosis / Q000191:economics; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics; D019095:Point-of-Care Systems / Q000191:economics; D012214:Rheumatic Heart Disease / Q000175:diagnosis* / Q000191:economics; D012680:Sensitivity and Specificity; D014454:Uganda
keywords: aortic valve insufficiency; developing countries; handheld echocardiography; medically underserved area; mitral valve insufficiency; rheumatic heart disease; screening