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Screening-detected rheumatic heart disease can progress to severe disease
  1. Daniel Engelman1,2,3,
  2. Gavin R Wheaton4,
  3. Reapi L Mataika5,
  4. Joseph H Kado5,6,
  5. Samantha M Colquhoun1,2,
  6. Bo Remenyi7,
  7. Andrew C Steer1,2,3
  1. 1Department of Paediatrics, Centre for International Child Health, University of Melbourne, Melbourne, Victoria, Australia
  2. 2Group A Streptococcal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
  3. 3Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
  4. 4Department of Cardiology, Women's and Children's Hospital, Adelaide, South Australia, Australia
  5. 5Department of Paediatrics, Colonial War Memorial Hospital, Suva, Fiji
  6. 6College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
  7. 7Menzies School of Health Research, Darwin, Northern Territory, Australia
  1. Correspondence to Dr Daniel Engelman, Department of Paediatrics, Centre for International Child Health, University of Melbourne, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia; Daniel.Engelman{at}


Objectives Echocardiography is a sensitive test for rheumatic heart disease (RHD) screening; however the natural history of RHD detected on screening has not been established. We aimed to evaluate the progression of screening-detected RHD in Fiji.

Methods All young people previously diagnosed with RHD through screening, with echocardiograms available for review, were eligible. All baseline echocardiograms were reported again. Participants underwent follow-up echocardiography. A paediatric cardiologist determined the diagnosis using the World Heart Federation criteria and assessed the severity of regurgitation and stenosis.

Results Ninety-eight participants were recruited (mean age, 17 years; median duration of follow-up, 7.5 years). Two other children had died from severe RHD. Fourteen of 20 (70%) definite RHD cases persisted or progressed, including four (20%) requiring valve surgery. Four (20%) definite RHD cases improved to borderline RHD and two (10%) to normal. Four of 17 (24%) borderline cases progressed to definite RHD (moderate: 2; severe: 2) and two (12%) improved to normal. Four of the 55 cases reclassified as normal at baseline progressed to borderline RHD. Cases with a follow-up interval >5 years were more likely to improve (37% vs 6%, p=0.03).

Conclusions The natural history of screening-detected RHD is not benign. Most definite RHD cases persist and others may require surgery or succumb. Progression of borderline cases to severe RHD demonstrates the need for monitoring and individualised consideration of prophylaxis. Robust health system structures are needed for follow-up and delivery of secondary prophylaxis if RHD screening is to be scaled up.

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  • Contributors DE and ACS conceived the study and devised the protocol with input from GRW, JHK, BR, RLM and SMC. GRW and BR evaluated the echocardiograms. DE coordinated the data collection, performed the analysis and was the main author of the manuscript. All authors provided critical feedback on the manuscript, and read and approved the final version.

  • Funding This project was supported by Cure Kids New Zealand. DE, SMC and ACS are supported by Australian National Health and Medical Research Council research fellowships. DE and ACS are supported by the National Heart Foundation of Australia. DE is supported by the University of Melbourne Nossal Global Scholars program.

  • Competing interests None.

  • Ethics approval Fiji National Research Ethics Review Committee (2015.17) and the Human Research Ethics Committee of the Royal Children's Hospital, Australia (35059A).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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