Francis Joshua R, Fairhurst Helen, Yan Jennifer, Fernandes Monteiro Anferida, Lee Anne-Marie, Maurays Joaquina, Kaethner Alex, Whalley Gillian A, Hardefeldt Hilary, Williamson Jacqui, Marangou James, Reeves Benjamin, Wheaton Gavin, Robertson Terry, Horton Ari, Cush James, Wade Vicki, Monteiro Andre, Draper Anthony D K, Morris Peter S, Ralph Anna P, Remenyi Bo
Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia; Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia.
Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
J Am Soc Echocardiogr. 2023 Jul;36(7):733-745. doi: 10.1016/j.echo.2023.02.007. Epub 2023 Feb 18.
Early detection of rheumatic heart disease (RHD) through echocardiographic screening can facilitate early access to effective treatment, which reduces the risk for progression. Accurate, feasible approaches to echocardiographic screening that can be incorporated into routine health services are needed. The authors hypothesized that offsite expert review could improve the diagnostic accuracy of nonexpert-obtained echocardiographic images.
This prospective cross-sectional study was performed to evaluate the diagnostic accuracy of health worker-conducted single parasternal long-axis view with a sweep of the heart using hand-carried ultrasound for the detection of RHD in high-risk populations in Timor-Leste and Australia. In the primary analysis, the presence of any mitral or aortic regurgitation met the criteria for a positive screening result. Sensitivity and specificity were calculated for a screen-and-refer approach based on nonexpert practitioner assessment (approach 1) and for an approach using offsite expert review of nonexpert practitioner-obtained images to decide onward referral (approach 2). Each participant had a reference test performed by an expert echocardiographer on the same day as the index test. Diagnosis of RHD was determined by a panel of three experts, using 2012 World Heart Federation criteria.
The prevalence of borderline or definite RHD among 3,329 participants was 4.0% (95% CI, 3.4%-4.7%). The sensitivity of approach 1 for borderline or definite RHD was 86.5% (95% CI, 79.5%-91.8%), and the specificity was 61.4% (95% CI, 59.7%-63.1%). Approach 2 achieved similar sensitivity (88.4%; 95% CI, 81.5%-93.3%) and improved specificity (77.1%; 95% CI, 75.6%-78.6%).
Nonexpert practitioner-obtained single parasternal long-axis view with a sweep of the heart images, reviewed by an offsite expert, can detect borderline and definite RHD on screening with reasonable sensitivity and specificity. Brief training of nonexpert practitioners with ongoing support could be used as an effective strategy for scaling up echocardiographic screening for RHD in high-risk settings.
通过超声心动图筛查早期发现风湿性心脏病（RHD）有助于尽早获得有效治疗，从而降低疾病进展风险。因此需要准确、可行的超声心动图筛查方法，并将其纳入常规医疗服务中。作者推测，远程专家评审可以提高非专业人员获取的超声心动图图像的诊断准确性。
本前瞻性横断面研究旨在评估卫生工作者使用便携式超声在东帝汶和澳大利亚的高危人群中进行心脏扫查的单胸骨旁长轴视图对RHD的诊断准确性。在初步分析中，任何二尖瓣或主动脉瓣反流的存在均符合阳性筛查结果的标准。计算基于非专业从业者评估的筛查和转诊方法（方法1）以及使用远程专家对非专业从业者获取的图像进行评审以决定进一步转诊的方法（方法2）的敏感性和特异性。每位参与者在索引检查当天由专业超声心动图医生进行参考检查。RHD的诊断由三位专家组成的小组根据2012年世界心脏联合会标准确定。
3329名参与者中，临界或确诊RHD的患病率为4.0%（95%CI，3.4%-4.7%）。方法1对临界或确诊RHD的敏感性为86.5%（95%CI，79.5%-91.8%），特异性为61.4%（95%CI，59.7%-63.1%）。方法2的敏感性相似（88.4%；95%CI，81.5%-93.3%），特异性提高（77.1%；95%CI，75.6%-78.6%）。
由远程专家评审非专业从业者获取的心脏扫查单胸骨旁长轴视图图像，在筛查时能够以合理的敏感性和特异性检测临界和确诊的RHD。对非专业从业者进行简短培训并持续提供支持，可作为在高危环境中扩大RHD超声心动图筛查的有效策略。
