Echocardiographic screening for rheumatic heart disease

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RHD affects ≈20 million people worldwide
highest in developing countries
significant morbidity and mortality
Subclinical detection adds to of secondary prophylaxis
echocardiographic definitions evolving
In 2012, the WHF published evidence-based
guidelines for the echocardiographic diagnosis of RHD
but these criteria have not yet been applied

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  • RHD remains a source of substantial morbidity and mortality in developing countries. Efforts to decrease the incidence of rheumatic fever (RF) and the severity of RHD involve reduced exposure to group A streptococcus (sometimes termed primordial prevention), appropriate treatment of streptococcal pharyngitis (primary prevention), and prevention of RF recurrence (secondary prophylaxis). Because many cases of RF are subclinical, accurate detection of existing RHD is of importance for appropriate secondary prevention. Probably approximately 90% of cases of RHD are silent on physical examination and detectable only by echocardiography. In 2012, the WHF published echo/Doppler criteria for the diagnosis of RHD, establishing diagnoses of definite RHD and borderline RHD, and attempting in part to differentiate mild RHD from normal findings (Reméyni B, et al. Nat Rev Cardiol 2012;9:297-309). The present study confirms that the WHF criteria used for the diagnosis of definite RF appear valid. It is more difficult to judge the WHF criteria for borderline RHD, with no ‘gold standard’ other than the eventual progression and development of clinical valve disease.
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Echocardiographic screening for rheumatic heart disease

  1. 1. Echocardiographic Screening for Rheumatic Heart Disease World Heart Federation Criteria for the Echocardiographic Diagnosis of RHD in Individuals Aged ≤20 Years
  2. 2. Clinical Perspective  RHD affects ≈20 million people worldwide  highest in developing countries  significant morbidity and mortality  Subclinical detection adds to of secondary prophylaxis  echocardiographic definitions evolving  In 2012, the WHF published evidence-based  guidelines for the echocardiographic diagnosis of RHD  but these criteria have not yet been applied
  3. 3. Effective evaluation Echocardiography search Clinical search 90% RHD detection 10% of detection
  4. 4. Definite echocardiographic Criteria for RHD  A) Pathologic MR and at least 2 morphologic features of RHD of the MV  B) MS mean gradient ≥4 mm Hg  C) Pathological AR and at least 2 morphological features of RHD of the AV  D) Borderline disease of both the AV and MV
  5. 5. Keywords  Definite RHD  Pathological MS  Pathological MR  Pathological AR  Borderline RHD  Morphological RHD
  6. 6. Borderline RHD (A, B, or C)  A) At least 2 morphologic features of RHD of the MV without pathologic MR or MS  B) Pathologic MR  C) Pathologic AR
  7. 7. Echocardiographic criteria for pathologic regurgitation (all 4 Doppler criteria must be met) Pathological MR Pathological AR 1. Seen in 2 views 2. In at least 1 view jet length ≥2 cm 3. Peak velocity ≥3 m/s for 1 complete Envelope in systole 4. Pansystolic jet in at least 1 envelope Seen in 2 views 2. In at least 1 view jet length ≥1 cm 3. Peak velocity ≥3 m/s for 1 complete Envelope in diastole 4. Pandiastolic jet in at least 1 envelope
  8. 8. Morphologic features of RHD Features in the MV Features in the AV 1. AMVL thickening ≥3 mm 2. Chordal thickening 3. Restricted leaflet motion 4. Excessive leaflet tip motion during systole 1. Irregular or focal thickening 2. Coaptation defect 3. Restricted leaflet motion 4. Prolapse
  9. 9. Reference Reményi B, Wilson N, Steer A, Ferreira B, Kado J, Kumar K, Lawrenson J, Maguire G, Marijon E, Mirabel M, Mocumbi AO, Mota C, Paar J, Saxena A, Scheel J, Stirling J, Viali S, Balekundri VI, Wheaton G, Zühlke L, Carapetis J. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease–an evidence-based guideline. Nat Rev Cardiol. 2012;9:297–309.
  10. 10. Clinical application  http://circ.ahajournals.org/content/early/2014/03/12/CIRCULATIONAHA.113 .003495.abstract
  11. 11. Hard work adds comfortable orientation

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