Evaluation of a screening protocol using auscultation and portable echocardiography to detect asymptomatic rheumatic heart disease in Tongan schoolchildren

Nat Clin Pract Cardiovasc Med. 2008 Jul;5(7):411-7. doi: 10.1038/ncpcardio1185. Epub 2008 Apr 8.


Background: Rheumatic heart disease (RHD) is an important problem in developing countries; however, many cases are detected only when the disease has progressed to cardiac failure. Screening can detect cases earlier, but there are no screening guidelines.

Methods: We performed a cross-sectional screening study in Tonga among 5,053 primary school children, in whom auscultation followed by echocardiography of those with heart murmurs were used to identify RHD. We also analyzed whether a three-stage screening protocol of auscultation performed by a medical student to detect any heart murmur, second-stage auscultation performed by a local pediatrician to differentiate pathological from innocent murmurs and echocardiography of those with pathological murmurs altered outcomes.

Results: The prevalence of definite RHD was 33.2 per 1,000. The prevalence of RHD increased significantly with age, peaking at 42.6 per 1,000 in children aged 10-12 years. Most valve lesions (91 [54%] of 169) were mild. Auscultation to detect pathological murmurs was poorly sensitive (46.4%), and the finding of any murmur on auscultation did not affect the likelihood of detecting pathology on echocardiography. The finding of a pathological murmur did significantly increase the likelihood of detecting pathology on echocardiography, but still missed 54% of those with pathology (mainly RHD) detected on echocardiography.

Conclusions: Screening is a useful method for detecting asymptomatic RHD in regions of high prevalence and we report a high echocardiographically confirmed prevalence. The most appropriate screening strategy remains to be confirmed, however, and implementation will depend on the availability of echocardiography and trained staff.

Publication types

  • Comparative Study
  • Evaluation Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Child
  • Cross-Sectional Studies
  • Diagnosis, Differential
  • Echocardiography*
  • Female
  • Heart Auscultation*
  • Heart Murmurs / diagnosis*
  • Humans
  • Male
  • Mass Screening / methods*
  • Predictive Value of Tests
  • Prevalence
  • Rheumatic Heart Disease / diagnosis*
  • Rheumatic Heart Disease / diagnostic imaging
  • Rheumatic Heart Disease / epidemiology
  • Sensitivity and Specificity
  • Stethoscopes
  • Tonga / epidemiology