Objectives: Acute rheumatic fever and its sequel, rheumatic heart disease, is a major problem in children, adolescents and young adults. Despite the widespread application of the Jones criterions, carditis is either underdiagnosed or overdiagnosed. Echocardiography is rarely used optimally for precise diagnosis. The objective of our study, therefore, was to define the potential role of echocardiography in detecting carditis in the setting of acute rheumatic fever. Materials and methods: We performed echocardiography in 452 consecutive patients with acute rheumatic fever, clinically diagnosed by the strict Jones criterions, using the patients as part of a multi-centric and double blinded prospective study. Results: Of our 452 patients, 230 were males, and 222 were females. The youngest was aged 1 year 11 months, while the oldest was a 51-year-old female. Out of the 452 cases of acute rheumatic fever, 239 patients (52.8%) had arthritis. Out of 164 cases of clinically diagnosed carditis, only 141 cases had echocardiographic evidence of carditis (85.97%). The remaining 23 patients (14%) had functional murmurs, tachycardia, or anaemia. Of the patients, 2 also had congenitally malformed hearts. Of 40 patients with rheumatic chorea, 28 (70%) had echocardiographic evidence of carditis or valvitis. Polyarthralgia was seen in 213 cases (47.12%), from which only 38 patients (17.8%) had carditis clinically, albeit that 88 patients (41.3%) showed echocardiographic evidence of subclinical carditis or valvitis. Conclusion: Echocardiography, when carried out in patients with acute rheumatic fever diagnosed strictly according to the Jones criterion, can avoid both overdiagnosis and underdiagnosis of carditis. A high incidence of carditis, or subclinical carditis, is detected by echocardiography when performed in patients with rheumatic chorea or arthralgia.

In order prospectively to investigate the frequency and evolution of subclinical valvitis, we selected 40 consecutive patients suffering their initial attack of rheumatic fever, seen in our clinic from 1992 to 1994, and followed-up until 2001, with a mean period of follow-up of 8.1 years, and a standard deviation of 0.6 year. We also assembled a matched control group of 37 healthy children and adolescents. We discovered a murmur of mitral regurgitation in 28 (70.0%) of the patients. In 3 (7.5%) of these patients, there was also a murmur of aortic regurgitation. In the group of 28 symptomatic patients, Doppler echocardiography showed mitral regurgitation in all, and aortic regurgitation in 17. In the group of 12 patients without clinical evidence of cardiac involvement, Doppler echocardiography identified mitral regurgitation in 2, isolated in one and associated with aortic regurgitation in the other. Thus, the frequency of subclinical valvitis was 16.7%. In patients with subclinical valvitis only the aortic regurgitation regressed during the period of follow-up. In the group of 28 symptomatic patients, mitral regurgitation disappeared in 6 (21.4%), aortic regurgitation in 7 of the 17 having this feature (41.2%), while 2 patients (7.1%) developed mitral stenosis. The sensitivity and specificity of cardiac auscultation were, respectively, 93.3%, with 95% confidence intervals between 72.3% and 97.4%, and 100%, with 95% confidence intervals between 65.5% and 100%, for the diagnosis of mitral regurgitation, and 16.7%, with 95% confidence intervals between 4.4% and 42.3%, and 100%, with 95% confidence intervals between 81.5% and 100%, for that of aortic regurgitation. We conclude that the Doppler echocardiogram is an important means of diagnosing and assessing the evolution of subclinical rheumatic valvar lesions, which are not always transient. We suggest that Doppler echocardiography should be performed in all patients with acute rheumatic fever. Subclinical valvitis should be considered as mild carditis, provided that strict criterions are observed in the differential diagnosis from physiological regurgitation, and Doppler echocardiographic findings are analyzed in the context of the other manifestations of the disease.