Circulation. 2020 Nov 17;142(20):e337-e357. doi: 10.1161/CIR.0000000000000921. Epub 2020 Oct 19.
The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.
风湿性心脏病的全球负担仍然很大，尽管它主要局限于贫困和边缘化人群。在大多数流行地区，受影响的患者表现为心力衰竭。本报告将探讨当前的最新建议，并确定全球在诊断和治疗方面的差距，为减少疾病负担提供信息。基于世界心脏联合会超声心动图标准的超声心动图筛查有望更早地发现患者，此时预防措施更有可能有效；然而，在这转化为公共政策之前，还有几个重要的问题需要回答。基于人群的登记册可以有效地在现有资源内实现最佳护理和二级青霉素预防。苄星青霉素注射仍然是二级预防的基石。青霉素采购方面的挑战以及对晚期疾病患者不良反应的担忧仍然是重要问题。心力衰竭管理、预防、心内膜炎的早期诊断和治疗、心房颤动的口服抗凝以及人工瓣膜是重要的治疗辅助手段。在妊娠前、妊娠期间和妊娠后管理未经手术和已手术的风湿性心脏病患者的健康是一项重大挑战，需要多学科团队的努力。孤立性二尖瓣狭窄的患者通常受益于经皮二尖瓣球囊成形术。及时的心脏瓣膜手术可以减轻向心力衰竭、残疾和死亡的进展。瓣膜修复优于风湿性二尖瓣反流的瓣膜置换，但在流行地区的绝大多数患者中无法实现。这一系列工作为风湿性心脏病的宣传倡导提供了一个基础文件。最终，扩大治疗选择、研究和倡导，建立在现有知识和科学基础上，为解决风湿性心脏病负担提供了最佳机会。
