Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: A systematic review

Master Thesis


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University of Cape Town

Rheumatic heart disease (RHD) is a permanent heart valve condition resulting from an abnormal immune reaction to group A streptococcal (GAS) infection typically occurring in childhood. If left untreated, disease progression can result in irreversible heart valve damage, cardiac failure, stroke and premature death. Significantly, RHD is a preventable and treatable chronic condition which mostly effects disadvantaged populations across the world. Moreover, the continued persistence of RHD contributes to considerable amounts of preventable morbidity and mortality, predominantly among adolescents and young adults. The accurate detection of subclinical RHD in children and adolescents, however, remains hampered by the cost of diagnostic machinery and scarcity of trained personnel. Alternative RHD screening tests, which are both accurate and affordable, are therefore needed in many endemic areas. Recently, handheld echocardiography has become widely available with a variety of clinical uses. If shown to be sufficiently accurate, use of these handheld devices could potentially expand access to echocardiographic screening in RHD endemic areas. The research undertaken for this MPH dissertation compares the accuracy of handheld echocardiography for the detection of rheumatic heart disease to the reference standard using systematic review methods. The dissertation is structured into three parts. PART A is a research protocol which describes the background and process of the proposed review. This section details the quantitative methods to be used in the systematic review and meta-analysis of studies which assess the diagnostic accuracy of handheld echocardiography for rheumatic heart disease detection in children and adolescents. The proposed systematic review methods are based on those of the Cochrane Collaboration. PART B is an extended literature review which expands on some of the topics raised in the background section of the protocol. A more in depth insight into the context surrounding the proposed research is offered and its importance highlighted. By reviewing the current body of evidence, this literature review aimed to both describe and contextualise the global burden of rheumatic heart disease whilst providing a rationale for further research into better screening modalities. Similarly, it also sought to describe the importance of understanding rheumatic heart disease epidemiology so that future research and screening programmes may be targeted accordingly. PART C is a full systematic review of diagnostic test accuracy studies presented as a journal ‘ready’ manuscript in a format suitable for submission to PLoS ONE. The background to the systematic review is briefly summarised after which the results are then presented and discussed. The main findings, from seven included studies, provide some evidence for the potential of handheld echocardiography to increase access to echocardiographic screening for rheumatic heart disease. Lastly and in conclusion, implications arising from the findings of the review are posited and suggestions for future research offered.