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Echocardiography is a sensitive test for detecting subclinical rheumatic heart disease (RHD) in asymptomatic individuals. However, it also detects a large number of minor abnormalities which may overlap with the normal range of variability in valve morphology and function in the population. These abnormalities do not fulfil criteria for the diagnosis of RHD and have been variously termed ‘possible’ or ‘borderline’ by different guidelines.1 ,2 The utility of routine screening echocardiography in endemic populations hinges on two critical parameters: (1) the rate of disease progression and (2) the impact of secondary antibiotic prophylaxis in stemming this progression. Data on disease progression from the earliest echocardiographic screening studies are now becoming available. But, these studies are generally limited by the small number of cases, short follow-up times, substantial attrition rates, and in the studies which preceded the World Heart Federation (WHF) recommendations, inconsistent diagnostic criteria.1 ,3–8
In this issue, Engelman and colleagues present findings from a retrospective study on disease progression in a screening-detected population in Fiji. The authors used the WHF criteria for diagnosis and report outcomes at a median of 7.5 years, which is the longest duration of follow-up reported till date. Four of seventeen people with borderline RHD progressed to definite RHD, and four of twenty with definite RHD went on to require valve replacement. Based on these data, the authors conclude that screening-detected valve disease is not benign. Is this assertion valid? Is it generalisable to other populations with subclinical RHD? Are these findings consistent with prior data? This study presents us with an opportunity to review and reassess the measurement and …
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