Echocardiographic diagnosis of subclincal carditis in acute rheumatic fever

doi:10.1016/0167-5273(95)02325-Q

International Journal of Cardiology

Volume 50, Issue 1, 2 June 1995, Pages 1-6

https://doi.org/10.1016/0167-5273(95)02325-Q Get rights and content

Abstract

The diagnosis of carditis in acute rheumatic fever traditionally depends on characteristic auscultatory findings. The advent of pulsed and colour Doppler echocardiography provides a method of detecting minor degrees of pathological regurgitation without characteristic clinical signs. Using strict criteria, pathological left heart regurgitation can be differentiated from physiological regurgitation: colour Doppler must show a substantial colour jet in two planes extending well beyond the valve leaflets; pulsed Doppler must confirm a high velocity signal, holosystolic for mitral regurgitation, or holodiastolic for aortic regurgitation. Several centres have observed subclinical carditis in children with acute rheumatic fever. We are confident that we are not overdiagnosing valvulitis, having tested this in a blinded fashion. Subclinical valvulitis should be accepted as evidence of carditis, a major diagnostic criterion for acute rheumatic fever.

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The World Heart Federation criteria raise the threshold of diagnosis for mild rheumatic heart disease: Three reviewers are better than one
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The World Heart Federation (WHF) criteria, published in 2012, provided an evidence-based guideline for the minimal diagnosis of echocardiographically-detected RHD.
Primary aim of the study was to determine whether use of the WHF criteria altered the threshold for the diagnosis of echocardiographically-detected RHD compared with the previous WHO/NIH criteria. A secondary aim was to explore the utility of a three reviewer reporting system compared to a single or two reviewer reporting structure.
144 de-identified echocardiograms (RHD, congenital valvar abnormality, physiological valvar regurgitation) were independently reported using the WHF criteria by two reviewers blinded to the previous WHO/NIH diagnosis. If there was discordance between the two reviewers, a third cardiologist independently performed a tie-breaker review.
There was a 21% reduction of cases classified as RHD using the WHF criteria compared to the modified WHO/NIH criteria (68 cases compared to 86, p = 0.04). There was a 60% consensus across the different diagnostic categories with 2 reviewers, 89% majority agreement with 3 reviewers. 11% required an open label discussion. There was moderate agreement between 2 reviewers for any RHD, kappa 0.57 (CI 0.44–0.70), with no significant difference in agreement between the different categories.
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Rheumatic fever (RF) is the prototype of postinfectious autoimmune diseases. Similarities of structure and/or spatial conformation between Streptococcus pyogenes and human tissue proteins lead to autoimmune reactions due to molecular mimicry. The activation of T and B lymphocytes involves several genetically controlled molecules that act in both the innate and adaptive immune response. In this chapter, we describe the strains of bacteria that are more commonly involved in the development of RF worldwide as well as the genetic predisposition of diverse ethnic groups. The disease manifests in susceptible children and teenagers, usually starting as polyarthritis or Sydenham's chorea. This condition generally occurs several months after streptococcal infection. Erythema marginatum and subcutaneous nodules are rare cutaneous manifestation, and carditis is the most serious sequelae and can lead to severe valve damage and rheumatic heart disease (RHD). The immune mechanisms that lead to the diverse manifestations mentioned above are discussed. The diagnosis and treatment, particularly the revision of Jones Criteria in the era of Doppler echocardiography, as well as the perspective of vaccine development, are also presented.
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Citation Excerpt :
We have to be aware of carditis until the sixth week of acute phase. Some authors have drawn attention to the existence of subclinical carditis, that is, to the rheumatic carditis detected just by Doppler echocardiography [38–40]. Murmurs present during the acute phase do not indicate a permanent valvular defect, and in the majority of cases (60%), they are transient.
Rheumatic fever (RF) and rheumatic heart disease remain important causes of morbidity and mortality mainly in developing countries. The important role played by T-cell lymphocytes and by particular M types of group A streptococci has been the focus of some studies. Arthritis continues to be its most frequent and intriguing manifestation due to its variability of presentations. Although not formally recognized, the subclinical carditis may constitute 15–20% of all cases of RF, which could lead carditis to the most frequent manifestation of RF. Sydenham's chorea is frequently associated with clinical and subclinical carditis. The diagnosis of RF continues to be a challenge even for the specialists. The adequate treatment of streptococcal infections should be a target for political effort in order to prevent this devastating disease.
Valvular Regurgitation Using Portable Echocardiography in a Healthy Student Population: Implications for Rheumatic Heart Disease Screening
2015, Journal of the American Society of Echocardiography
Citation Excerpt :
The present study, using portable echocardiographic platforms, shows prevalence figures within the range of previous studies using large-platform echocardiographic technology. Great care must be taken when interpreting echocardiograms to separate physiologic from pathologic MR, but this cutoff is still arbitrary.14 A body of literature about this has arisen in descriptions of carditis in ARF.14,18
There is increasing use of portable echocardiography as a screening test for rheumatic heart disease (RHD). The prevalence of valvular regurgitation in healthy populations as determined using portable echocardiography has not been well defined. Minimal echocardiographic criteria for RHD have recently been clarified, but the overlap of normal and abnormal valvular regurgitation warrants further study. The aim of this study was to determine the spectrum of echocardiographic findings using portable echocardiography in children from a population with low prevalence of RHD.
Screening echocardiography was conducted in 396 healthy students aged 10 to 12 years using portable echocardiographic equipment. Echocardiograms were assessed according to 2012 World Heart Federation criteria for RHD. The prevalence of physiologic valvular regurgitation was compared with that found in previous studies of children using large-platform machines.
Physiologic mitral regurgitation (MR) was present in 14.9% of subjects (95% CI, 11.7%–18.7%) and pathologic MR in 1.3% (95% CI, 0.6%–2.9%). Two percent (95% CI, 1.0%–3.9%) had physiologic aortic regurgitation, and none had pathologic aortic valve regurgitation. Physiologic tricuspid regurgitation was present in 72.7% of subjects (95% CI, 68.1%–76.9%) and physiologic pulmonary regurgitation in 89.6% (95% CI, 85.7%–91.8%). After cardiology review, no cases of definite RHD were found, but 0.5% of patients (95% CI, 0.1%–1.8%) had pathologic MR meeting World Heart Federation criteria for borderline RHD. Two percent (95% CI, 1.4%–4.6%) of the cohort had minor forms of congenital heart disease.
The spectrum of physiologic cardiac valvular regurgitation in healthy children as determined using portable echocardiography is described and is within the range of previous studies using large-platform echocardiographic equipment. The finding of two children with pathologic-grade MR, likely representing the upper limit of physiologic regurgitation, has implications for echocardiographic screening for RHD in high-prevalence regions.
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^☆: Presented in part at the 42nd Annual Scientific Meeting of the Cardiac Society of Australia and New Zealand, Adelaide, South Australia, 7–10 August 1994.

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EditorialEchocardiographic diagnosis of subclincal carditis in acute rheumatic fever☆

Abstract

Am J Cardiol

Int J Cardiol

Am J Cardiol

J Pediatr

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Int J Cardiol

Clinical evaluation versus Doppler echocardiography in the quantitative assessment of valvular heart disease

Circulation

Editorial
Echocardiographic diagnosis of subclincal carditis in acute rheumatic fever☆