Two‐year evolution of latent rheumatic heart disease in Malawi

Abstract

Background In asymptomatic children, screening echocardiography has been used to attempt to diagnose rheumatic heart disease (RHD) at an early stage (latent RHD). World Heart Federation guidelines have standardized categorization of “definite,” “borderline,” or no RHD by echo findings. The progression of RHD diagnosed through echo screening is not known. In 2014, we screened 1450 schoolchildren in Malawi. Objective Our objective was to evaluate 2‐year RHD evolution among those diagnosed through screening. Methods Two‐year follow‐up echocardiograms of those diagnosed with latent RHD were read by a primary, secondary, then third reader if there was disagreement. Progression or regression of both definite and borderline groups were tabulated. Penicillin adherence, age, gender, number in home, and household income were compared between those with definite RHD who regressed to borderline and those that stayed definite. We utilized the local system used to track HIV defaulters in order to bring participants back into care. Comparisons were made using Fisher’s exact and Wilcoxon rank‐sum tests. Results Of the 39 with borderline RHD, 1 was lost to follow‐up (2.6%), 1 progressed to definite (2.6%), 19 remained borderline (48.7%), 17 (43.6%) regressed to normal, and 1 was reclassified as mitral valve prolapse (2.6%). Of the 11 with definite RHD, 6 (54.5%) remained definite, 4 regressed to borderline (36.4%), and 1 regressed to normal (9.1%). Two of 11 with definite RHD had penicillin adherence above 80% for the 2‐year follow‐up period. There were no differences in adherence, gender, age, household income, or number in household between those with definite RHD that regressed to borderline and those who did not (P > .19). Conclusions Borderlines had a very low progression rate to definite RHD. A strength of our study was a high retention rate (98%). Longer follow‐up is needed to determine expected disease evolution.

Echocardiographic screening to determine progression of latent rheumatic heart disease in endemic areas: A systematic review and meta-analysis

“…The progression of latent RHD was reported in 9 studies and was 11% (95% CI 6-16) in total, 6% (95% CI 1-11%) using non-WHF criteria and 15% (11)(12)(13)(14)(15)(16)(17)(18)(19)(20) using the 2012 WHF criteria ( Fig 2) for the entire cohort over the duration of the study (follow up range 5.7-90 months). The heterogeneity of reported prevalence was high between all studies (I 2 = 84.5%, P<0.001).…”

“…We performed a sensitivity analysis on progression of valvular disease in borderline cases by removing 4 studies which did not report on the progression of borderline RHD. Three studies were not included in the analysis of the primary endpoint because they did not report on the progression of definite cases or only followed up borderline cases [11], [14], [12] All three were included in the sensitivity analysis for progression of borderline cases.…”

“…(17%), one due to lack of standardised echocardiographic criteria [13] and one due to short follow up time. [21] Furthermore, there were four studies [21] [13] [12] [10] which did not report whether echocardiography reporters were blinded to the diagnosis in the original studies which has the potential to introduce significant bias.…”

“…Furthermore, the sequelae of screening are far from inconsequential with the current Australian guidelines recommending administration of intramuscular penicillin every 28 days for 5 years following diagnosis of RHD or until age 21-40 years, depending on the severity of the lesion. [8] Studies reporting follow-up data in patients with latent RHD have had conflicting results [9] with some reporting predominantly stability and improvement [10][11][12][13] and others showing heterogenous outcomes with significant progression, development of Definite RHD, ARF and even death [14][15][16][17][18]. While the optimal approach of ascertaining the balance between benefits and harms of penicillin administration in latent RHD is a randomised controlled trial, there have been none so far.…”

“…[20] Our search was conducted approximately 1.5 years later and includes additional cohorts. [12,21,22] We also present an annualised rate of progression of latent and borderline RHD and comparison with controls. The primary outcome of this study was to determine the pooled prevalence of progression of latent RHD.…”