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Echo Screening for Rheumatic Heart Disease.

Encountering for the first time a child suffering from rheumatic heart disease (RHD) is often a life-altering event for those who seek to improve cardiovascular care in low-income countries around the world. How can a disease that is so rarely seen in the United States still affect 33 million people and cause 319 000 annual deaths globally?1 Isn’t there something we can do? There is. And in May of 2018 a growing awareness about what can be done led to a landmark resolution on RHD control and prevention at the World Health Assembly.2 The resolution lays out a number of concrete things for member states to do such as identifying highrisk sub-populations, effectively treating strep pharyngitis to prevent rheumatic fever, and implementing effective monitoring and treatment programs for those with established RHD. Seeking another way to do something, various groups—including our own RHD Action Uganda coalition—have been screening children for RHD using echocardiography for over a decade.3–7 The World Heart Federation (WHF) criteria,8 established in 2012, have been largely effective at standardizing methods. Using these criteria, echo screening for RHD is more sensitive than auscultation and can serve 2 main purposes: (1) to estimate the potential burden of disease in populations and (2) to actively find cases of mild RHD that might be treated early to prevent clinical complications. Although the goal of improving epidemiological estimates of the disease has proven useful for advocacy, whether the strategy of active case finding using echo improves outcomes or is cost-effective is not at all clear. Some shortterm longitudinal studies using the WHF criteria have been published4,9,10; however, the natural history of latent disease and clinical predictors of outcomes are incompletely understood, particularly for those with borderline disease. We also know that giving a child a diagnosis of latent RHD decreases his or her quality of life,11 which may alter the risk-benefit ratio of large screening programs. For these reasons, the late Bongani Mayosi—a tireless advocate for investment in RHD—and Liesl Zuhlke cautioned us against using echo screening outside of research until more studies of its impact on disease progression could be done.12 The landmark study by Nunes et al13 published in this issue of Circulation: Cardiovascular Imaging moves the field forward in some important ways. Using large screening studies from Brazil and Uganda, they have identified the key components of the WHF criteria that have the strongest predictive value for definite RHD. It has long been suspected that certain components of the WHF criteria such as spectral Doppler do not add substantially to a screening study and are not practical for frontline health workers to employ. Thus, simplified criteria without spectral Doppler have been developed for hand-held ultrasound.14 Nunes et al13 have now gone further to show that only 5 simple components of the WHF criteria (anterior mitral valve thick© 2019 American Heart Association, Inc. Circulation: Cardiovascular Imaging