Baker Heart and Diabetes Institute, Melbourne, Australia.
Department of Cardiology, The Alfred Hospital, Melbourne, Australia.
PLoS One. 2020 Jun 4;15(6):e0234196. doi: 10.1371/journal.pone.0234196. eCollection 2020.
The World Health Organisation previously recommended routine screening in school-aged children in countries with a high prevalence of rheumatic heart disease (RHD); however, it is unclear if screening-detected (latent) valve disease will inevitably evolve to a pathological lesion. Understanding the natural history of latent RHD is essential prior to recommendation of screening in endemic areas. Studies documenting the progression of latent RHD have had contrasting conclusions about the pathogenicity of latent valvular lesions. This review provides estimates of rates of progression of latent RHD.
In this systematic review and meta-analysis, we searched EMBASE, MEDLINE, Global Index Medicus, Africa Wide, Cochrane Database of Systematic Reviews and Global Health Database for studies published before April 30, 2019. Study data were extracted from all studies which reported follow-up data on progression of latent valve lesions. Studies with control cohorts were used to calculate comparative prevalence ratios. This study is registered with PROSPERO, number CRD42019119427. We identified 12 studies reporting follow-up data on latent RHD for 950 people in 9 countries. The estimated pooled prevalence rate for progression per year of latent RHD was 5%/year (95% CI 2-8). Eight studies reported on the progression of borderline latent RHD with an estimated pooled prevalence of 2%/year (95% CI 0-4). Three studies included control groups. There was a significant increase in the risk of progression of valvular disease in the latent group compared with controls (RR = 3.57 (95%CI = 1.65-7.70, P = 0.001). The overall risk of bias was low. Given most studies included penicillin administration we were unable to document the natural history of latent RHD. Furthermore, we were unable to perform a sensitivity analysis to determine the effect of administering penicillin prophylaxis on progression of valve disease given prescription of penicillin was not standardised.
Latent RHD has a slow rate of progression but it is significantly higher compared to controls, with definite latent RHD having a higher rate of progression compared with borderline latent disease. There are a massive number of individuals at risk for RHD in the developing world as well as logistical challenges of screening and delivering penicillin prophylaxis. The low rate of progression from untargeted screening may be an important consideration in resource-constrained environments.
世界卫生组织曾建议在风湿性心脏病（RHD）高发国家对学龄儿童进行常规筛查；然而，筛查发现的（潜伏性）瓣膜疾病是否必然会发展为病理性病变尚不清楚。在推荐在流行地区进行筛查之前，了解潜伏性 RHD 的自然史至关重要。记录潜伏性 RHD 进展的研究对于潜伏性瓣膜病变的致病性得出了相互矛盾的结论。本综述提供了潜伏性 RHD 进展率的估计值。
在这项系统评价和荟萃分析中，我们在 EMBASE、MEDLINE、全球索引医学、非洲广泛、Cochrane 系统评价数据库和全球健康数据库中搜索了截至 2019 年 4 月 30 日发表的研究。从所有报告潜伏性瓣膜病变进展随访数据的研究中提取研究数据。使用对照队列的研究来计算比较患病率比。这项研究在 PROSPERO 注册，编号 CRD42019119427。我们确定了 12 项研究，这些研究报告了 9 个国家的 950 人潜伏性 RHD 的随访数据。每年潜伏性 RHD 进展的估计合并患病率为 5%/年（95%CI 2-8）。有 8 项研究报告了边缘潜伏性 RHD 的进展，估计合并患病率为 2%/年（95%CI 0-4）。有 3 项研究纳入了对照组。与对照组相比，潜伏组瓣膜疾病进展的风险显著增加（RR=3.57（95%CI=1.65-7.70，P=0.001）。总体偏倚风险较低。由于大多数研究都包括青霉素治疗，我们无法记录潜伏性 RHD 的自然史。此外，我们无法进行敏感性分析来确定青霉素预防接种对瓣膜疾病进展的影响，因为青霉素的处方并未标准化。
潜伏性 RHD 的进展速度较慢，但与对照组相比明显更高，且明确的潜伏性 RHD 比边缘性潜伏性疾病的进展速度更高。在发展中国家，有大量的人面临 RHD 的风险，而且筛查和提供青霉素预防接种存在后勤方面的挑战。在资源有限的环境中，从非目标筛查中进展的低速度可能是一个重要的考虑因素。
