title: Are minor echocardiographic changes associated with an increased risk of acute rheumatic fever or progression to rheumatic heart disease?
abstract: BACKGROUND
  The World Heart Federation criteria for the echocardiographic diagnosis of rheumatic heart disease (RHD) include a category "Borderline" RHD which may represent the earliest evidence of RHD. We aimed to determine the significance of minor heart valve abnormalities, including Borderline RHD, in predicting the future risk of acute rheumatic fever (ARF) or RHD.
  
  
  METHODS
  A prospective cohort study of Aboriginal and Torres Strait Islander children aged 8 to 18 years was conducted. Cases comprised children with Borderline RHD or other minor non-specific valvular abnormalities (NSVAs) detected on prior echocardiography. Controls were children with a prior normal echocardiogram. Participants underwent a follow-up echocardiogram 2.5 to 5 years later to assess for progression of valvular changes and development of Definite RHD. Interval diagnoses of ARF were ascertained.
  
  
  RESULTS
  There were 442 participants. Cases with Borderline RHD were at significantly greater risk of ARF (incidence rate ratio 8.8, 95% CI 1.4-53.8) and any echocardiographic progression of valve lesions (relative risk 8.19, 95% CI 2.43-27.53) than their Matched Controls. Cases with Borderline RHD were at increased risk of progression to Definite RHD (1 in 6 progressed) as were Cases with NSVAs (1 in 10 progressed).
  
  
  CONCLUSIONS
  Children with Borderline RHD had an increased risk of ARF, progression of valvular lesions, and development of Definite RHD. These findings provide support for considering secondary antibiotic prophylaxis or ongoing surveillance echocardiography in high-risk children with Borderline RHD.
authors.affiliation: James Cook University, Cairns, QLD, Australia. Electronic address: marc.remond@my.jcu.edu.au.
authors.forename: Marc
authors.initials: M
authors.lastname: Rémond
authors.affiliation: Rural Clinical School of Western Australia, The University of Western Australia, Broome, WA, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Atkinson
authors.affiliation: James Cook University, Townsville, QLD, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: White
authors.affiliation: South Australian Health and Medical Research Institute, Adelaide, SA, Australia.
authors.forename: Alex
authors.initials: A
authors.lastname: Brown
authors.affiliation: Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Carapetis
authors.affiliation: Menzies School of Health Research, Darwin, NT, Australia.
authors.forename: Bo
authors.initials: B
authors.lastname: Remenyi
authors.affiliation: Menzies School of Health Research, Darwin, NT, Australia.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Roberts
authors.affiliation: Baker IDI Heart and Diabetes Institute, Alice Springs, NT, Australia.
authors.forename: Graeme
authors.initials: G
authors.lastname: Maguire
mesh_terms: D000293:Adolescent; D016022:Case-Control Studies; D002648:Child; D015331:Cohort Studies; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012213:Rheumatic Fever / Q000000981:diagnostic imaging / Q000208:ethnology; D012214:Rheumatic Heart Disease / Q000000981:diagnostic imaging* / Q000208:ethnology*; D012307:Risk Factors; D014463:Ultrasonography
keywords: Acute rheumatic fever; Diagnosis; Echocardiography; Rheumatic heart disease; Screening