Prognostic value of clinical and Doppler echocardiographic findings in children and adolescents with significant rheumatic valvular disease

Abstract

Introduction:The diagnosis of acute rheumatic fever (RF) is based on clinical findings. However, during the chronic phase of the disease, the clinical approach is not sufficient for the follow-up of the patients and the Doppler echocardiography is a tool for the diagnosis of cardiac involvement. Prognostic variables that influence long-term outcomes are not well known.Methods:462 patients with RF according to Jones criteria were studied, and followed-up from the initial attack to 13.6 ± 4.6 years. All patients underwent clinical assessment and Doppler echocardiography for the detection of heart valve involvement in the acute and chronic phases. Multivariate logistic regression analysis was used to identify the factors influencing long-term heart valve disease.Results:Carditis occurred in 55.8% and subclinical valvulitis in 35.3% patients. In the chronic phase, 33% of the patients had significant valvular heart disease. No normal Doppler echocardiography exam was observed on patients who had severe valvulitis, although heart auscultation had become normal in 13% of these. In the multivariate analysis, only the severity of carditis and the mitral and/or aortic valvulitis were associated with significant valvular heart disease. Chorea or arthritis were protective factors for significant valvular heart disease, odds ratio 0.41 (95% C.I. 0.22 – 0.77) and 0.43 (95% C.I. 0.23 – 0.82), respectively.Conclusions:Our study suggests that the use of Doppler echocardiography during RF helps to identify prognostic factors regarding the development of significant valvular heart disease. Initial severe carditis is an important factor in the long-term prognosis of chronic RHD, whereas arthritis and chore during the initial episode of RF appears to be protective. Strict secondary prophylaxis should be mandatory in high risk patients.

Acute rheumatic fever and rheumatic heart disease

“…In one study, the prevalence of subclinical carditis following the first episode of ARF was 18% and half of the patients had persistence or deterioration of disease 2–23 months later 178 . Studies by Araujo and colleagues 179 and Pekpak and colleagues 180 reported that the proportion of patients with subclinical ARF who had persistence of carditis at least 1 year later was 72% and 55%, respectively.…”

Improvement of Rheumatic Valvular Heart Disease in Patients Undergoing Prolonged Antibiotic Prophylaxis

“…In Brazil, 462 rheumatic patients were followed up for 13.6 years. More than one third of them presented recurrences by non-adherence to secondary prophylaxis ( 26 ).…”

Cardiovascular Statistics – Brazil 2023

“…198 In another study involving 258 children and adolescents with ARF followed up from 2 to 15 years, valve lesions healed in 25% of the patients with mild carditis, in 2.5% of those with moderate carditis, while no healing was observed in those with severe carditis. 199 • According to the GBD 2017, from 1990 to 2017, the agestandardized prevalence of RHD had a slight 3.0% (95% UI, 1.6 -4.3) increase, from 721.4 (95% UI, 688.7 -754.5) to 743.2 (95% UI, 709 -778.6) per 100 000 inhabitants, remaining higher in women than in men throughout the whole period (Table 5-1 and Chart 5-1.A). Although small for both sexes, the percent increase was numerically more pronounced in women (4.4%) than in men.…”