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Evaluation of a screening protocol using auscultation and portable echocardiography to detect asymptomatic rheumatic heart disease in Tongan schoolchildren


Background Rheumatic heart disease (RHD) is an important problem in developing countries; however, many cases are detected only when the disease has progressed to cardiac failure. Screening can detect cases earlier, but there are no screening guidelines.

Methods We performed a cross-sectional screening study in Tonga among 5,053 primary school children, in whom auscultation followed by echocardiography of those with heart murmurs were used to identify RHD. We also analyzed whether a three-stage screening protocol of auscultation performed by a medical student to detect any heart murmur, second-stage auscultation performed by a local pediatrician to differentiate pathological from innocent murmurs and echocardiography of those with pathological murmurs altered outcomes.

Results The prevalence of definite RHD was 33.2 per 1,000. The prevalence of RHD increased significantly with age, peaking at 42.6 per 1,000 in children aged 10–12 years. Most valve lesions (91 [54%] of 169) were mild. Auscultation to detect pathological murmurs was poorly sensitive (46.4%), and the finding of any murmur on auscultation did not affect the likelihood of detecting pathology on echocardiography. The finding of a pathological murmur did significantly increase the likelihood of detecting pathology on echocardiography, but still missed 54% of those with pathology (mainly RHD) detected on echocardiography.

Conclusions Screening is a useful method for detecting asymptomatic RHD in regions of high prevalence and we report a high echocardiographically confirmed prevalence. The most appropriate screening strategy remains to be confirmed, however, and implementation will depend on the availability of echocardiography and trained staff.

Key Points

  • The prevalence of echocardiographically confirmed rheumatic heart disease in Tonga is the highest described in the world

  • Auscultatory screening alone missed more than half of pathological valvular lesions compared with echocardiographic screening

  • This study indicates that screening of schoolaged children for rheumatic heart disease by echocardiography might be the most appropriate approach

  • Further work is needed to determine whether echocardiographic screening for rheumatic heart disease can be practical and cost effective in developing countries

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We thank the Tongan Ministries of Health and Education, the staff of all of the participating schools, and the staff of the hospitals on the islands of Tongatapu, 'Eua and Ha'apai for their support and assistance. W Uahwatanasakul performed second stage auscultation on a number of the children in this study. R Restall and P Kelly assisted in performing echocardiograms. We thank N Wilson for advice regarding echocardiographic methodology and validation. R Andrews provided assistance in data analysis. This study was funded partly by the Australian and New Zealand Children's Heart Research Centre.

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Correspondence to Jonathan R Carapetis.

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J Carapetis is a recipient of rheumatic heart disease-related research funding from the Australian National Health and Medical Research Council, the National Heart Foundation of Australia, NIH and numerous other Australian funding bodies, none of which has any vested interest in rheumatic heart disease-related topics. He has undertaken paid rheumatic fever-related consultancy work for the WHO and acted as an unpaid advisor for the NIH. The other authors declared no competing interests.

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Carapetis, J., Hardy, M., Fakakovikaetau, T. et al. Evaluation of a screening protocol using auscultation and portable echocardiography to detect asymptomatic rheumatic heart disease in Tongan schoolchildren. Nat Rev Cardiol 5, 411–417 (2008).

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