Echo Screening for Rheumatic Heart Disease
2019; Lippincott Williams & Wilkins; Volume: 12; Issue: 2 Linguagem: Inglês
10.1161/circimaging.118.008818
ISSN1942-0080
Autores Tópico(s)Antimicrobial Resistance in Staphylococcus
ResumoHomeCirculation: Cardiovascular ImagingVol. 12, No. 2Echo Screening for Rheumatic Heart Disease Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBEcho Screening for Rheumatic Heart DiseaseAre We There Yet? Chris T. Longenecker, MD Chris T. LongeneckerChris T. Longenecker Chris T. Longenecker, MD, Assistant Professor of Medicine, Case Western Reserve University School of Medicine, University Hospitals Harrington Heart and Vascular Institute, 2103 Cornell Rd, WRB Room 4–533, Cleveland, OH 44106. Email: E-mail Address: [email protected] University Hospitals Harrington Heart & Vascular Institute and Case Western Reserve University School of Medicine, Cleveland, OH. Originally published1 Feb 2019https://doi.org/10.1161/CIRCIMAGING.118.008818Circulation: Cardiovascular Imaging. 2019;12:e008818This article is a commentary on the followingSimplified Echocardiography Screening Criteria for Diagnosing and Predicting Progression of Latent Rheumatic Heart DiseaseSee Article by Nunes et alEncountering for the first time a child suffering from rheumatic heart disease (RHD) is often a life-altering event for those who seek to improve cardiovascular care in low-income countries around the world. How can a disease that is so rarely seen in the United States still affect 33 million people and cause 319 000 annual deaths globally?1 Isn't there something we can do? There is. And in May of 2018 a growing awareness about what can be done led to a landmark resolution on RHD control and prevention at the World Health Assembly.2 The resolution lays out a number of concrete things for member states to do such as identifying high-risk sub-populations, effectively treating strep pharyngitis to prevent rheumatic fever, and implementing effective monitoring and treatment programs for those with established RHD.Seeking another way to do something, various groups—including our own RHD Action Uganda coalition—have been screening children for RHD using echocardiography for over a decade.3–7 The World Heart Federation (WHF) criteria,8 established in 2012, have been largely effective at standardizing methods. Using these criteria, echo screening for RHD is more sensitive than auscultation and can serve 2 main purposes: (1) to estimate the potential burden of disease in populations and (2) to actively find cases of mild RHD that might be treated early to prevent clinical complications. Although the goal of improving epidemiological estimates of the disease has proven useful for advocacy, whether the strategy of active case finding using echo improves outcomes or is cost-effective is not at all clear. Some short-term longitudinal studies using the WHF criteria have been published4,9,10; however, the natural history of latent disease and clinical predictors of outcomes are incompletely understood, particularly for those with borderline disease. We also know that giving a child a diagnosis of latent RHD decreases his or her quality of life,11 which may alter the risk-benefit ratio of large screening programs. For these reasons, the late Bongani Mayosi—a tireless advocate for investment in RHD—and Liesl Zuhlke cautioned us against using echo screening outside of research until more studies of its impact on disease progression could be done.12The landmark study by Nunes et al13 published in this issue of Circulation: Cardiovascular Imaging moves the field forward in some important ways. Using large screening studies from Brazil and Uganda, they have identified the key components of the WHF criteria that have the strongest predictive value for definite RHD. It has long been suspected that certain components of the WHF criteria such as spectral Doppler do not add substantially to a screening study and are not practical for front-line health workers to employ. Thus, simplified criteria without spectral Doppler have been developed for hand-held ultrasound.14 Nunes et al13 have now gone further to show that only 5 simple components of the WHF criteria (anterior mitral valve thickening, excessive mitral leaflet motion, regurgitant mitral jet >2 cm, irregular aortic valve thickening, and any aortic regurgitation), weighted according to their ability to differentiate rheumatic changes from normal, are necessary to identify definite RHD. An even more important finding is that a risk score derived from these weighted components may predict disease progression on echo. Ultimately, these simplified criteria could facilitate larger screening programs that would require the use of nonexperts to be cost-effective and logistically viable.There are important limitations of the study, many of which are recognized by the study authors. For example, there is no gold standard definition of echo detected latent RHD—all we have are the WHF criteria. It is, therefore, not surprising that a score made of component parts of the WHF criteria would have an incredibly high C statistic (>0.99 in both derivation and validation cohorts!) for predicting definite RHD as defined by WHF criteria. The C statistics is more modest for predicting progression of echo findings (0.811). Ultimately, though, the most important question is whether this new risk score predicts progression to clinically relevant outcomes such as heart failure, endocarditis, atrial fibrillation, or stroke. Does it matter if one has valvular changes consistent with definite RHD as an adolescent if those changes never progress to clinically relevant disease over the course of a lifetime? It may be necessary to incorporate clinical variables such as age, gender, socioeconomic status, and household size to predict the risk of true clinical progression.Similarly, proof that a medical intervention such as benzathine penicillin alters progression of disease is necessary before screening is implemented on a larger scale. The GOAL trial (Gwoko Adunu pa Lutino; clinicaltrials.gov No. NCT03346525) will test the hypothesis that benzathine penicillin prophylaxis will reduce the rate of echo progression by 50% over 2 years of follow-up. This ambitious trial of nearly 1000 children with echo detected latent RHD is being conducted in Uganda and is led by several of the coauthors of this paper. It will be interesting to see whether the effectiveness of benzathine penicillin prophylaxis in this trial varies according to the echo risk score at baseline.It will also be important to validate the performance of this risk score in large screening cohorts from other groups, perhaps from Australia or the Pacific. Although separated by the Atlantic Ocean, the derivation and validation cohorts used in this study are not entirely independent, since the same investigators served as the expert readers for both studies or taught expert readers for the other study. The RHD echo screening community is not large, and many of the same experts have contributed to training efforts and dissemination of the WHF criteria. Nonetheless, a more robust validation cohort would be one in which the expert readers are from a more independent research group.Finally, the risk score developed in this paper has only 3 categories—low, intermediate, and high-risk. Missing is normal, which is perhaps the most important category. In order for latent RHD criteria to be applied as a screening tool in large populations, we must be able to tell the vast majority of children (and their parents) that they do not have evidence of RHD. I propose we think of this as being analogous to the power of zero which is now a well-recognized phenomenon in the coronary artery calcium literature. For example, a 65-year-old man with a calcium score of zero may not need a statin, even if his LDL (low-density lipoprotein) cholesterol is a bit high. In a similar fashion, could scarce resources dedicated to strep pharyngitis and RHD prevention be diverted away from those with a normal echo at age 15, with a goal of focusing on those at highest risk?So much work has been done in the field of echo screening for RHD over the past decade, and we have come a long way, but can you hear the children in the backseat screaming, Are we there yet? Should echo screening be used for active case finding outside of research? Unfortunately, I fear we still have a long way to go. But as anyone who has driven long distances with young kids can attest, I am very eager to get there. The children at risk in Uganda and other RHD endemic countries are waiting.DisclosuresC T. Longenecker has received a program grant from the Medtronic Foundation.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circimagingChris T. Longenecker, MD, Assistant Professor of Medicine, Case Western Reserve University School of Medicine, University Hospitals Harrington Heart and Vascular Institute, 2103 Cornell Rd, WRB Room 4–533, Cleveland, OH 44106. Email: [email protected]eduReferences1. 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Nunes MCP, Sable C, Nascimento BR, Lima EM, da Silva JLP, Diamantino AC, Oliveira KKB, Okello E, Aliku T, Lwabi P, Colosimo EA, Ribeiro ALP, Beaton AZ. Simplified echocardiography screening criteria for diagnosing and predicting progression of latent rheumatic heart disease.Circ Cardiovasc Imag. 2019; 12:e007928. doi: 10.1161/CIRCIMAGING.118.007928LinkGoogle Scholar14. Ploutz M, Lu JC, Scheel J, Webb C, Ensing GJ, Aliku T, Lwabi P, Sable C, Beaton A. Handheld echocardiographic screening for rheumatic heart disease by non-experts.Heart. 2016; 102:35–39. doi: 10.1136/heartjnl-2015-308236CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Hunter L, Pecoraro A, Doubell A, Monaghan M, Lloyd G, Lombard C, Herbst P and Bäck M (2021) Screening for subclinical rheumatic heart disease: addressing borderline disease in a real-world setting, European Heart Journal Open, 10.1093/ehjopen/oeab041, 1:3, Online publication date: 27-Nov-2021. Rizvi A, Botsa E and Whyte Oshodi A (2019) Letter by Rizvi et al Regarding Article, "Cardiovascular Imaging—Echo Screening for Rheumatic Heart Disease: Are We There Yet?", Circulation: Cardiovascular Imaging, 12:4, Online publication date: 1-Apr-2019. Kaminstein D, Kuhn W, Huang D and Burleson S (2019) Perspectives on Point-of-Care Ultrasound Use in Pediatric Tropical Infectious Disease, Clinical Pediatric Emergency Medicine, 10.1016/j.cpem.2019.06.003, 20:2, (128-140), Online publication date: 1-Jun-2019. Related articlesSimplified Echocardiography Screening Criteria for Diagnosing and Predicting Progression of Latent Rheumatic Heart DiseaseMaria Carmo P. Nunes, et al. Circulation: Cardiovascular Imaging. 2019;12 February 2019Vol 12, Issue 2 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.118.008818PMID: 30704284 Originally publishedFebruary 1, 2019 KeywordsechocardiographyEditorialsmitral valvepharyngitisrheumatic heart diseaseauscultationPDF download Advertisement SubjectsEchocardiographyRheumatic Heart Disease
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