Echocardiography screening to detect rheumatic heart disease: A cohort study of schoolchildren in French Pacific Islands

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Highlights

  • Subclinical rheumatic heart disease often persists in children.

  • Valve disease remains often mild under secondary prophylaxis in young patients.

  • Serial screening in children at risk of rheumatic heart disease may be of interest.

Abstract

Objective

The objective of this study is to assess the outcomes of rheumatic heart disease (RHD) diagnosed by means of echocardiography-based screening.

Methods

A cohort of children with and with no RHD was driven from a systematic echocardiography-based nationwide surveillance among 4th grade (age 9–10 years) schoolchildren in South-Pacific New Caledonia (2008–2011). The specific follow-up programme used clinical and standardised echocardiography (2012 World Heart Federation criteria) predefined endpoints.

Results

Out of the 17,633 children screened, 157 were detected with findings of RHD. Among them, 114 consented children (76.5%) were enrolled (RHD-group), and were compared to 227 randomly selected healthy classmates (non-RHD group). After a median follow-up period of 2.58 years [1.31–3.63], incidence of acute rheumatic fever was similar in RHD and non-RHD groups (p = 0.23): 10.28/1000/year and 3.31/1000/year, respectively. By echocardiography, 90 children in the RHD group (78.9%) still presented with RHD at follow-up, compared to 31 (13.7%) in the non-RHD group (p < 0.0001). Only 12 children (10.5%) experienced progression of RHD over time, mild single valve disease lesions remaining unchanged in the majority of cases (61 out of 73, 83.6%). Overcrowded living conditions were independently associated with persistent RHD on echocardiography (OR 8.27 95% CI (1.67–41.08), p < 0.01). Benzathine penicillin G was given in 88.6% of children in the RHD-group.

Conclusions

Children screened positive for RHD by echocardiography have mostly mild but irreversible heart valve disease under secondary prophylaxis. Our findings also suggest that a single screening point in childhood may prove insufficient in high-risk populations.

Introduction

Rheumatic heart disease (RHD) is the result of valvular damage caused by an exaggerated immune response to group A streptococcal infections, usually during childhood and adolescence [1]. Although RHD, a disease of poverty, has almost disappeared from wealthy countries [2], its burden remains a major challenge in the developing world and among aboriginal populations in Pacific countries with approximately 345,000 deaths per year worldwide [3], [4], [5].

Rheumatic heart disease is still prevalent among Oceanic populations (Melanesians and Polynesians) in New Caledonia, a French overseas territory of 250,000 inhabitants. Unlike other countries, comprehensive programmes to tackle the burden of disease have proven inefficient so far in the region [6], [7], [8]. The World Health Organization has recommended active surveillance in order to initiate secondary prophylaxis early and prevent complications of the disease [9]. Echocardiography-based screening may present an attractive solution, ultrasounds being more sensitive to detect very mild valve lesions [10]. In this setting, the New Caledonians launched an echocardiography-based screening programme aiming at all primary schools (targeting 4th grade) from February 2008.

However, the natural history of echocardiography-detected RHD has never been established and the need for secondary prophylaxis still remains debated [11], [12]. There are therefore several unanswered questions in the field, as the outcomes of children screened for RHD, the need for secondary prophylaxis, and the target age-range. We address here the outcomes and modalities of screening through a cohort study of children with and without RHD who took part in the first large RHD echocardiography-based surveillance programme.

Section snippets

Study design and settings

In New Caledonia, active surveillance for RHD by means of ultrasounds was decided as a public health programme in 2007, and conduced in 17,633 schoolchildren in 4th grade (i.e., aged 9–10 years) between February 2008 and November 2011. All children diagnosed with RHD were offered free of charge secondary prophylaxis, yearly echocardiograms, and entered a national register. The aim of the study was to assess the outcomes of children detected by echocardiography as having RHD (RHD group), compared

Characteristics according to the initial diagnosis

One hundred and fourteen children with RHD diagnosed by echocardiography and 227 previously healthy children participated in the study (Fig. 1). Subjects' characteristics, according to groups, are depicted in Table 2. The mean age (SD) at the time of screening was 9.9 ± 0.7 in the RHD group, and 10.0 ± 0.7 in the normal baseline echocardiography group (non-RHD group), with a sex ratio (M/F) of 0.9 in the RHD group and of 1.0 in the non-RHD group. Among the 114 children with a positive screening for

Discussion

We assess here the largest cohort of children diagnosed with RHD by means of school-based echocardiography screening and compare them to matched schoolchildren with normal baseline echocardiography. We demonstrate that the majority of valve lesions, albeit mild, persist under secondary prophylaxis. Overcrowded living conditions were associated with the persistence of the disease. Oceanic children with normal baseline echocardiograms when aged 9–10 years yield considerable risk of developing ARF

Conclusion

Rheumatic heart disease diagnosed by echocardiography-based screening is often mild but nevertheless an irreversible condition in schoolchildren under secondary prophylaxis. Overcrowding appears to be the strongest predictor of the persistence of the disease. Serial assessment throughout childhood may be of interest. Further studies are warranted to assess the need for secondary prophylaxis in subclinical RHD.

Conflict of interest

The authors report no relationships that could be construed as a conflict of interest.

Acknowledgements

We are very grateful to Dr. Sylvie Laumond and Dr. Jean Paul Grangeon for their assistance regarding the National Mortality Database, and to Dr. Bertrand Huon and Dr. Pierre-Henri Ledos for their work in the surveillance programme.

Funding: Dr. Mirabel received funding from the Fondation pour la Recherche Médicale (Grant #2356) and the Fondation Lefoulon Delalande (Grant #15_2014).

References (32)

  • J.G. Lawrence et al.

    Acute rheumatic fever and rheumatic heart disease: incidence and progression in the Northern Territory of Australia, 1997 to 2010

    Circulation

    (2013)
  • WHO

    Rheumatic Fever and Rheumatic Heart Disease — Report of a WHO Expert Consultation

    (2001)
  • E. Marijon et al.

    Prevalence of rheumatic heart disease detected by echocardiographic screening

    N. Engl. J. Med.

    (2007)
  • K. Roberts et al.

    Screening for rheumatic heart disease: current approaches and controversies

    Nat. Rev. Cardiol.

    (2013)
  • R.O. Bonow et al.

    ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons

    Circulation

    (2006)
  • B. Remenyi et al.

    World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease — an evidence-based guideline

    Nat. Rev. Cardiol.

    (2012)
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