Prevalence of Rheumatic Heart Disease Detected by Echocardiographic Screening
Eloi Marijon, M.D., Phalla Ou, M.D., David S. Celermajer, Ph.D., F.R.A.C.P., Beatriz Ferreira, M.D., Ph.D., Ana Olga Mocumbi, M.D., Dinesh Jani, M.D., Christophe Paquet, M.D., M.P.H., Sophie Jacob, Ph.D., Daniel Sidi, M.D., Ph.D., and Xavier Jouven, M.D., Ph.D.
N Engl J Med 2007; 357:470-476August 2,2007
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In poor and developing nations, rheumatic heart disease remains a major cause of morbidity and premature death and imposes a substantial burden on health care systems with limited budgets.1,2 Nevertheless, primary and secondary prevention efforts may be highly effective.1,3 Secondary prevention relies on accurate case detectionfor the appropriate use of prophylactic antibiotics and regular medical surveillance. Exact prevalence data are also highly desirable to facilitate health care planning.
Almost all population-based epidemiologic surveys have relied on careful clinical examination of school-age children, with confirmation of clinically suspected cases by echocardiography. Such surveys show current prevalence ratesof rheumatic heart disease of approximately 1 to 5 cases per 1000 among school-age children in developing countries, with the highest rates in sub-Saharan Africa.2
Cardiac ultrasonography is known to be more sensitive than auscultation for the detection of pathologic valve disease,4 and the recent availability of high-quality portable ultrasound equipment makes it possible to screen largenumbers of children at schools in developing nations. Furthermore, the 2004 World Health Organization Expert Consultation Report states that echocardiographically diagnosed, clinically silent rheumatic valve involvement should be managed as rheumatic heart disease until proved otherwise.3 We therefore hypothesized that comprehensive screening, including echocardiography in all children, might reveal ahigher prevalence of cases than clinical examination with echocardiographic confirmation of clinically suspected cases only.
We performed two large, population-based studies of school-age children, one in Southeast Asia (Cambodia) and one in sub-Saharan Africa (Mozambique), to assess the feasibility of echocardiographic screening and to ascertain whether this method would yield a more realisticestimate of the prevalence of rheumatic heart disease than that obtained by screening with the use of predominantly clinical criteria.
Setting and Survey Methods
Our study was conducted in Cambodia and Mozambique, because these countries are representative of two regions of the developing world where previous surveys have documented an apparently high prevalence of rheumatic heartdisease in school-age children2 and because local investigators and authorities were willing and able to participate in the studies. The two studies were carried out after prospective planning by a central group of investigators, which included establishing protocols for prospectively defined clinical and echocardiographic criteria for the diagnosis of rheumatic valvular abnormalities.
The first studywas carried out in Cambodia in 2001 and 2002 after approval by the Ministry of Health. The investigators approached the directors of randomly selected schools in the capital of Phnom Penh, and all agreed to participate. All children in each school were invited to participate; those children whose parents or guardians gave oral informed consent were brought to the Phnom Penh Heart Center, wherethey underwent comprehensive clinical and echocardiographic examination (with a Philips Sonos 4500 4–7 MHz transducer) for signs of rheumatic heart disease. Images were recorded on super-VHS videotape for later review by an independent physician who was experienced in diagnosing rheumatic heart disease and was not aware of the clinical findings. The results of this study appeared to confirm our...
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