Letter by DeGroff 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:
In reading a recent article by Marijon et al,1 I would not help but think that the authors are using circular reasoning in diagnosing subclinical rheumatic heart disease. The authors compare their criteria only to the criteria used by the World Health Organization. They show that their criteria lead to a significant increase in the number of children diagnosed with subclinical rheumatic heart disease. But the real question is, are their criteria sound? Having looked at thousands of echocardiograms on normal children (in the United States) over the years, I am quite suspect about the usefulness of the criteria and the high risk of false positives that using such criteria would cause. Any echocardiographer worth his or her weight will tell you that there is a wide variety of normality in any population in terms of heart valve leaflet morphology. Perhaps even more worrisome, with the improved echocardiographic technology the industry has seen recently, echocardiographers can attest to the increased frequencies of finding trivial valvular regurgitation in our general pediatric population. Contrary to what the authors imply, newer enhanced echocardiography machines will find more positives (false and otherwise), not less. Will all such patients have subclinical rheumatic heart disease? I think not. The authors need to discuss the implications of false positives from their combined criteria, especially in light of the lack of a gold standard test for subclinical rheumatic heart disease.
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.