Letter by Kothari Regarding Article, “Rheumatic Heart Disease Screening by Echocardiography: The Inadequacy of World Health Organization Criteria for Optimizing the Diagnosis of Subclinical Disease”
To the Editor:
I read with interest the article on the prevalence of rheumatic heart disease (RHD) using combined World Health Organization and echocardiographic criteria.1 As the authors point out, the number of cases of RHD detected depends on the criteria used for diagnosis. For doctors working in parts of the world where RHD is still a problem, a 10-fold increase in the prevalence of the disease comes as an unwelcome surprise. Fortunately, this increase seems to be the result of the differing ascertainment of the “subclinical” disease rather than a true reflection of the problem. The assertions that such prevalence data represent the true public health problem of RHD and that these methods of diagnosis would help reduce the burden of the disease are presumptive. Even in the prepenicillin era, regression of cases with mild murmurs was well recorded.2 In those studies, the new-onset mitral stenosis occurred on follow-up in some patients even in the absence of another obvious episode of rheumatic fever, but mostly in patients with chorea. As such, identifying a thickening of the valve with a trivial regurgitation and labeling the patient as having rheumatic heart disease does not serve any purpose other than inflating the prevalence figure. Should these patients be offered penicillin prophylaxis in the hope that the next episode of rheumatic fever might not damage the valve further? The answer is not known because the secondary prophylaxis studies were not conducted in patients with subclinical RHD. In addition, the clinicians working with large numbers of patients with RHD do not estimate the prevalence of RHD to be up to 3% of schoolchildren as seen in this study. As the authors conclude, these data represent a 3-fold increase in the number of potentially treatable children. But in the absence of a valid warranted treatment, such screening potentially generates spurious disease. The enigma of RHD continues to invite further studies.
Marijon E, Celemajer DS, Tafflet M, El-Haou S, Jani D, Ferreira B, Mocumbi A, Paquet C, Sidi D, Xavier J. Rheumatic heart disease screening by echocardiography: the inadequacy of World Health Organization criteria for optimizing the diagnosis of subclinical disease. Circulation. 2009; 120: 663–668.
Bland EF, Jones D. Rheumatic fever and rheumatic heart disease: a 20 year report on 1000 patients followed up since childhood. Circulation. 1951; 4: 836–843.