What is the role of echocardiography in the workup of acute rheumatic fever (ARF)?

Updated: Dec 10, 2020
  • Author: Robert J Meador, Jr, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

Echocardiography is the gold standard for diagnosis of rheumatic heart disease (RHD). [19] Current American Heart Association criteria recommendations regarding echocardiography are as follows [25] :

  • Echocardiography with Doppler should be performed in all cases of confirmed and suspected ARF (class I)
  • It is reasonable to consider performing serial echocardiography/Doppler studies in any patient with diagnosed or suspected ARF, even if documented carditis is not present on diagnosis (class IIa)
  • Echocardiography/Doppler testing should be performed to assess whether carditis is present in the absence of auscultatory findings, particularly in moderate- to high-risk populations and when ARF is considered likely (class I)
  • Echocardiography/Doppler findings not consistent with carditis should exclude that diagnosis in patients with a heart murmur otherwise thought to indicate rheumatic carditis (class I)

The World Health Organization has recommended that children in endemic areas undergo echocardiographic screening for RHD, to identify candidates for secondary prophylaxis to prevent ARF recurrences. In 2012, the World Heart Federation published criteria for echocardiographic diagnosis of RHD. However, discriminating mild RHD from normal variants can be very difficult, and false-positive tests expose the patient to inappropriate and lengthy treatment. [19]

Doppler findings in rheumatic valvulitis

To diagnose pathological mitral regurgitation by Doppler, all four of the following criteria must be met:

  • Seen in at least two views
  • Jet length ≥2 cm in at least one view
  • Peak velocity >3 m/sec
  • Pan-systolic jet in at least one envelope

To diagnose pathological aortic regurgitation by Doppler, all four of the following criteria must be met:

  • Seen in at least two views
  • Jet length ≥1 cm in at least one view
  • Peak velocity >3 m/sec
  • Pan-diastolic jet in at least one envelope

Echocardiographic findings in rheumatic valvulitis

Acute mitral valve changes include the following:

  • Annular dilation
  • Chordal elongation
  • Chordal rupture resulting in flail leaflet with severe mitral regurgitation
  • Anterior (less commonly, posterior) leaflet tip prolapse
  • Beading/nodularity of leaflet tips

Chronic mitral valve changes that are not seen in acute carditis include the following:

  • Leaflet thickening
  • Chordal thickening and fusion
  • Restricted leaflet motion
  • Calcification

Aortic valve changes in either acute or chronic carditis include the following:

  • Irregular or focal leaflet thickening
  • Coaptation defect
  • Restricted leaflet motion
  • Leaflet prolapse

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