No abstract

R heumatic heart disease (RHD) has been eradicated in many areas, but remains a major public health problem in the developing world with >345 000 related deaths each year. [1][2][3][4] RHD is the consequence of valvular damage caused by an exaggerated immune response to group A streptococcal infections, usually during infancy and childhood. Disease control is based on the administration of penicillin for primary prevention (ie, the treatment of group A streptococcal sore throat) and for secondary prevention (ie, at regular intervals to avoid further exposure to group A streptococcal infections that trigger the autoimmune response). See Clinical PerspectiveBecause penicillin prevents RHD progression when initiated in a timely fashion (ie, secondary prevention), early detection has been emphasized to be of particular interest. 1The World Health Organization had recommended active surveillance in the past. There are, however, no guidelines as how screening should be undertaken. A 2-step approach involving clinical examination followed by echocardiography has proven to be of low sensitivity and specificity when compared with echocardiography alone.5 Indeed, echocardiography detects 3 to 25 times more cases than auscultation alone in endemic regions.6-10 The World Heart Federation (WHF) has, therefore, provided guidelines to optimize echocardiographic RHD diagnosis. 11,12 There are certain issues that may prevent implementation of active surveillance by echocardiography in regions where RHD prevalence is highest.13 Cost-effectiveness and ethical issues arise when considering echocardiographybased screening as a public health policy in deprived regions. Concerns also include the cost of comprehensive portable Background-Rheumatic heart disease (RHD) remains a major public health problem worldwide. Although early diagnosis by echocardiography may potentially play a key role in developing active surveillance, systematic evaluation of simple approaches in resource poor settings are needed. Methods and Results-We prospectively compared focused cardiac ultrasound (FCU) to a reference approach for RHD screening in a school children population. FCU included (1) the use of a pocket-sized echocardiography machine, (2) nonexpert staff (2 nurses with specific training), and (3) a simplified set of echocardiographic criteria. The reference approach used standardized echocardiographic examination, reviewed by an expert cardiologist, according to 2012 World Heart Federation criteria. Among the 6 different echocardiographic criteria, first tested in a preliminary phase, mitral regurgitation jet length ≥2 cm or any aortic regurgitation was considered best suited to be FCU criteria. Of the 1217 subjects enrolled (mean, 9.6±1 years; 49.6% male), 49 (4%) were diagnosed with RHD by the reference approach.