da Rocha Araújo Fátima Derlene, de Andrade Goulart Eugênio Marcos, Meira Zilda Maria Alves
Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
Pediatr Cardiol. 2013 Jun;34(5):1073-80. doi: 10.1007/s00246-012-0601-4. Epub 2012 Dec 13.
Secondary prophylaxis remains the safest way to prevent or minimize heart valve damage in patients with rheumatic fever. However, criteria to determine the duration of prophylaxis have not been well established. This study aimed to evaluate the clinical and Doppler echocardiographic profile of patients with rheumatic fever and a normal clinical examination at least 5 years after the first episode and to discuss the contribution of Doppler echocardiography in supporting the decision to discontinue secondary prophylaxis. An observational longitudinal study analyzing 183 patients with rheumatic fever and a normal clinical examination 5 years or more after the initial attack was conducted. The patients underwent Doppler echocardiography to study the severity of mitral or aortic valvular disease. Of the 183 patients, 77 (42 %) had clinical carditis. Subclinical chronic heart disease occurred for 79 % of the patients with previous clinical carditis and for 25 % of the patients without clinical carditis. Of the 35 patients with previous clinical carditis who were in the period of discontinued prophylaxis, residual valvular heart disease was observed in all, whereas of the 62 patients without clinical carditis, only 27 % showed residual valvular heart disease. Considering Doppler echocardiographic criteria, prophylaxis would be continued for 13 (34 %) of the patients with previous clinical carditis and for only 2 (3 %) of those without clinical carditis. Return of cardiac auscultation to normal is not always accompanied by return of Doppler echocardiographic findings to normal. Criteria regarding Doppler echocardiographic findings and valve morphology should be evaluated by the time secondary prophylaxis is discontinued. However, further studies are needed to demonstrate whether prolonged prophylaxis provides any benefit to patients with persistent echocardiographic findings.
二级预防仍然是预防或尽量减少风湿热患者心脏瓣膜损害的最安全方法。然而，确定预防持续时间的标准尚未完全确立。本研究旨在评估首次发作后至少5年临床检查正常的风湿热患者的临床和多普勒超声心动图特征，并探讨多普勒超声心动图在支持停止二级预防决策方面的作用。开展了一项观察性纵向研究，分析了183例首次发作后5年或更长时间临床检查正常的风湿热患者。这些患者接受了多普勒超声心动图检查，以研究二尖瓣或主动脉瓣疾病的严重程度。在183例患者中，77例（42%）有临床心脏炎。既往有临床心脏炎的患者中，79%发生亚临床慢性心脏病，无临床心脏炎的患者中这一比例为25%。在35例既往有临床心脏炎且处于停止预防阶段的患者中，全部观察到残余瓣膜性心脏病，而在62例无临床心脏炎的患者中，只有27%表现出残余瓣膜性心脏病。根据多普勒超声心动图标准，既往有临床心脏炎的患者中13例（34%）需要继续预防，无临床心脏炎的患者中只有2例（3%）需要继续预防。心脏听诊恢复正常并不总是伴随着多普勒超声心动图检查结果恢复正常。在停止二级预防时，应评估关于多普勒超声心动图检查结果和瓣膜形态的标准。然而，需要进一步研究来证明延长预防是否对超声心动图检查结果持续异常的患者有益。
