Echocardiographic Detection of Latent Rheumatic Heart Disease
A Pandora’s Box?
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Thomas Sydenham, an English physician, is credited with the first description of acute rheumatic fever in 1685.1 In the >300 years that have followed, notable landmarks include description of valve thickening at autopsy by Matthew Baillie in 1797, invention of the stethoscope and diagnosis of mitral valve murmurs by Rene Laennec in 1818, identification of streptococcus as a cause of pharyngitis by Theodore Billroth in 1874, recognition of the Aschoff nodule as pathognomonic of rheumatic carditis by Ludwig Aschoff in 1883, and formulation of a set of clinical criteria for the diagnosis of acute rheumatic fever by T. Duckett Jones in 1944.2 Arguably, in modern history, the unique capability of echocardiography to allow detailed insights into cardiac structure and function must rank as a milestone for cardiology in general and rheumatic heart disease (RHD) in particular. In recognition of the utility of echocardiography, in 2015, the American Heart Association included Doppler echocardiography as a major criterion in the revised Jones criteria for the diagnosis of acute rheumatic fever.3
Prevalence of RHD is a litmus test of a society’s state of health. The persistence of RHD in disparate regions of the world bears testimony to both economic deprivation in low-income economies and unequal access to health care in middle- and high-income regions. Before the advent of echocardiography, RHD prevalence was estimated by clinical examination of cohorts at high risk—usually children of school-going age. In 1996, Anabwani and Bonhoeffer4 were the first to sound the alarm that the prevalence of RHD using echocardiographic screening was much higher than by clinical screening alone. Several studies thereafter, using conventional or portable handheld ultrasound devices and a variety of different criteria, confirmed that the prevalence of RHD detected by echocardiographic screening was up to 10-fold higher compared …