Diagnosing rheumatic heart disease: where are we now and what are the challenges?

ABSTRACT

Introduction

Rheumatic heart disease (RHD), a sequela of acute rheumatic fever (ARF), affects 40.5 million people worldwide. The burden of disease disproportionately falls on low- and middle-income countries (LMIC) and sub-populations within high-income countries (HIC). Advances have been made in earlier detection of RHD, though several barriers to ideal management persist.

Areas Covered

This article reviews the current burden of RHD, highlighting the disparate impact of disease. It also reviews the clinical and echocardiographic presentation of RHD, as some may present in late stages of disease with associated complications. Finally, we review the advances which have been made in echocardiographic screening to detect latent RHD, highlighting the challenges which remain regarding secondary prophylaxis management and uncertainty of best practices for treatment of latent RHD.

Expert opinion

Advances in technology and validation of portable echocardiography have made screening and identifying latent RHD feasible in the most burdened regions. However, uncertainty remains around best management of those with latent RHD and best methods to ensure ideal secondary prophylaxis for RHD. Research regarding latent RHD management, as well as continued work on innovative solutions (such as group A streptococcal vaccine), are promising as efforts to improve outcomes of this preventable disease persist.

KEYWORDS:

• Echocardiography
• prevention
• rheumatic heart disease
• rheumatic fever
• screening

Article highlights

• RHD remains a disease of disparity, with most disease burden seen in LMICs and subpopulations of HICs.

• Advances in technology combined with upskilling of non-experts have made echocardiographic screening for latent RHD feasible in endemic regions.

• Understanding outcomes for those with latent RHD, as well as the impact of secondary prophylaxis on latent disease, remains unclear; though ongoing research may soon provide insight into best management strategies.

• Echocardiography remains an important tool not only for diagnosis of valvular involvement of RHD, but also for guiding timing for and type of intervention needed.

• While benzathine penicillin G (BPG) is recognized as the gold standard for management of RHD, multiple barriers at the individual and systemic level remain and obstruct attaining ideal compliance with BPG management.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.