Auscultation versus echocardiography for assessment of patients with acute rheumatic fever and rheumatic heart disease

ABSTRACT

Rheumatic fever is a major health problem in many countries, and RHD, a sequelae of RF, is a very common cause of cardiovascular mortality and morbidity especially in developing countries as in Egypt. Due to many factors like tachycardia, an untrained ear and low intensity of the murmur, many murmurs in the cardiovascular system are missed clinically. It has been seen in many studies that the echo is much more sensitive in picking up the lesions which are easily missed on clinical examination. This study was designed to determine the effectiveness of auscultation in detecting valvular affection in cases with acute rheumatic fever [ARF] and in those with established RHD and to assess the usefulness of echocardiographic examination in such cases. The study included sixty patients with RHD [mean age 1 +/- 4.2 years] who came for follow up in the RF outpatient clinic of the Children hospital of Cairo University and 64 children with ARF [mean age 9.8 +/- 2.9 years] who were admitted to the inpatient wards of the same hospital. Each patient underwent detailed clinical evaluation and relevant investigations including echocardiography. The most common lesion was mitral regurgitation [MR] both by auscultation and by echo. Mixed lesions were seen more often than pure lesions. In the whole studied patients, MR had the highest sensitivity while tricuspid regurgitation [TR] had the highest specificity. TR showed the highest positive predictive value and MS showed the highest negative predictive value. Sensitivity of aortic regurgitation [AR] was very low. There was a statistically significant difference between echo diagnosis and clinical auscultation diagnosis of MR, TR and AR [p < 0.05 in MR, <0.001 in TR and AR]. Clinical auscultation skills were noticed to be suboptimal regarding AR and MS murmurs. Clinical auscultation alone can miss various lesions, especially when the lesions are mild or when multiple lesions are present, so it is recommended that echocardiography be done routinely for the diagnosis of cardiac lesions in patients of ARF and RHD