Screening
Screening, also known as active case-finding, of asymptomatic populations in high-risk regions has the potential to identify patients with mild rheumatic heart disease (RHD) who may receive the greatest benefit from secondary prophylaxis.[86] Auscultation-based standard screening protocols were first developed by the World Health Organization and focused on screening of school-aged children.[87] In these early screening programmes, follow-up echocardiography was recommended for suspected cases with pathological murmurs. However, a landmark 2007 study conducted in Cambodia and Mozambique demonstrated that echocardiography was more sensitive and more specific than cardiac auscultation, and detected RHD 10 times more than auscultation alone. The authors concluded that echocardiography should be the initial procedure.[88] Multiple studies since then have implemented echocardiographic screening.[89] Standardised guidelines for the diagnosis of RHD on echocardiogram were developed by an expert panel and published in 2012.[58] Data on outcomes of children with echocardiographically detected RHD show differential medium-term outcomes, from regression of lesions (improvement) to progression (worsening); the GOAL study demonstrated that secondary prophylaxis given for 24 months was associated with less progression of valve lesions.[90] The study also noted no association between the prophylaxis group and no prophylaxis group in improvement of lesions, and so the role of widespread echocardiographic screening in public health surveillance is unclear and an integrated approach into the healthcare system is preferred.[91]
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