Clinical Investigation
Valvular Heart Disease
Simplified Rheumatic Heart Disease Screening Criteria for Handheld Echocardiography

https://doi.org/10.1016/j.echo.2015.01.001Get rights and content

Highlights

  • Standard echocardiography-based screening for RHD may be cost prohibitive.

  • Handheld echocardiography has good sensitivity and specificity for RHD.

  • Optimal screening criteria are MR jet length ≥ 1.5 cm or any AI.

  • Handheld echocardiography could greatly decrease the need for standard echocardiography-based screening

Background

Using 2012 World Heart Federation criteria, standard portable echocardiography (STAND) reveals a high burden of rheumatic heart disease (RHD) in resource-poor settings, but widespread screening is limited by cost and physician availability. Handheld echocardiography (HAND) may decrease costs, but World Heart Federation criteria are complicated for rapid field screening, particularly for nonphysician screeners. The aim of this study was to determine the best simplified screening strategy for RHD detection using HAND.

Methods

In this prospective study, STAND (GE Vivid q or i or Philips CX-50) was performed in five schools in Gulu, Uganda; a random subset plus all children with detectable mitral regurgitation or aortic insufficiency also underwent HAND (GE Vscan). Borderline or definite RHD cases were defined by 2012 World Heart Federation criteria on STAND images, by two experienced readers. HAND studies were reviewed by cardiologists blinded to STAND results. Single and combined HAND parameters were evaluated to determine the simplified screening strategy that maximized sensitivity and specificity for case detection.

Results

In 1,439 children (mean age, 10.8 ± 2.6 years; 47% male) with HAND and STAND studies, morphologic criteria and the presence of any mitral regurgitation by HAND had poor specificity. The presence of aortic insufficiency was specific but not sensitive. Combined criteria of mitral regurgitation jet length ≥ 1.5 cm or any aortic insufficiency best balanced sensitivity (73.3%) and specificity (82.4%), with excellent sensitivity for definite RHD (97.9%). With a prevalence of 4% and subsequent STAND screening of positive HAND studies, this would reduce STAND studies by 80% from a STAND-based screening strategy.

Conclusions

In resource-limited settings, HAND with simplified criteria can detect RHD with good sensitivity and specificity and decrease the need for standard echocardiography. Further study is needed to validate screening by local practitioners and long-term outcomes.

Section snippets

Study Population

This prospective study included five primary schools in Gulu, Uganda. All students 5 to 17 years of age were eligible for inclusion. Parents of minors provided written informed consent; adolescents >15 years of age provided informed consent, as is customary in Uganda. This study was approved by the institutional review boards at the University of Michigan, Children's National Medical Center, and Makerere University.

All enrolled children underwent STAND. A random subset of 10% of all subjects

Results

Of 4,773 subjects screened with STAND, 140 (2.9%) had borderline RHD by 2012 WHF criteria, and 52 (1.1%) had definite RHD, for a total prevalence of 4.0%. HAND was performed in 1,439 children (mean age, 10.8 ± 2.6 years; 47% male). Within this cohort, 133 (9.2%) had borderline RHD, 47 (3.3%) had definite RHD, and six (0.4%) had other diagnoses. The subset of children randomly assigned to HAND had a similar prevalence of disease to the overall cohort, with borderline RHD in 11 of 447 (2.5%) and

Discussion

We have shown that HAND, using screening criteria of MR jet length ≥ 1.5 cm or any AI, can detect any (borderline or definite) RHD with good sensitivity and specificity, with excellent sensitivity for definite RHD. To our knowledge, this is the first study to evaluate screening criteria for RHD using HAND in a large endemic population.

HAND is an attractive approach to screening for RHD because of the highest prevalence of RHD in resource-limited populations. HAND machines are less expensive,

Conclusions

HAND offers promise in extending the reach of screening for RHD in resource-limited populations. Simplified criteria of MR jet length ≥ 1.5 cm or any AI can detect RHD with good sensitivity and specificity and greatly reduce the need for standard echocardiography. Further studies are needed to evaluate differences in outcomes with early detection, as well as the accuracy of handheld echocardiographic screening in the hands of nonphysicians, particularly local caregivers such as nurses.

Acknowledgments

The authors thank Alison Reese, Ashley Shrestha-Astudillo, Peter Dean, Lasya Gaur, and Jacqueline Weinberg for assistance in performing echocardiograms; the Rotary Club of Gulu for organizational and logistical support throughout this project; as well as the children and families who consented for participation.

References (14)

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This project was supported by Award Nos. UL1TR000075 and KL2TR000076 from the NIH National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Advancing Translational Sciences or the National Institutes of Health. This study was also funded in part by grants from General Electric, the World Heart Federation, and the CHAMPS for Mott fund.

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