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Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: a systematic review and meta-analysis of diagnostic accuracy.

ABSTRACT: OBJECTIVE:To summarise the accuracy of handheld echocardiography (HAND) which, if shown to be sufficiently similar to that of standard echocardiography (STAND), could usher in a new age of rheumatic heart disease (RHD) screening in endemic areas. DESIGN:Systematic review and meta-analysis. DATA SOURCES:PubMed, Scopus, EBSCOHost and ISI Web of Science were initially searched on 27 September 2017 and again on 3 March 2020 for studies published from 2012 onwards. ELIGIBILITY CRITERIA:Studies assessing the accuracy of HAND compared with STAND when performed by an experienced cardiologist in conjunction with the 2012 World Heart Federation criteria among populations of children and adolescents living in endemic areas were included. DATA EXTRACTION AND SYNTHESIS:Two reviewers independently extracted data and assessed the methodological quality of included studies against review-specific Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 criteria. A meta-analysis using the hierarchical summary receiver operating characteristic model was conducted to produce summary results of sensitivity and specificity. Forest plots and scatter plots in receiver operating characteristic space in combination with subgroup analyses were used to investigate heterogeneity. Publication bias was not investigated. RESULTS:Six studies (N=4208) were included in the analysis. For any RHD detection, the pooled results from six studies were as follows: sensitivity: 81.56% (95% CI 76.52% to 86.61%) and specificity: 89.75% (84.48% to 95.01%). Meta-analytical results from five of the six included studies were as follows: sensitivity: 91.06% (80.46% to 100%) and specificity: 91.96% (85.57% to 98.36%) for the detection of definite RHD only and sensitivity: 62.01% (31.80% to 92.22%) and specificity: 82.33% (65.15% to 99.52%) for the detection of borderline RHD only. CONCLUSIONS:HAND displayed good accuracy for detecting definite RHD only and modest accuracy for detecting any RHD but demonstrated poor accuracy for the detection of borderline RHD alone. Findings from this review provide some evidence for the potential of HAND to increase access to echocardiographic screening for RHD in resource-limited and remote settings; however, further research into feasibility and cost-effectiveness of wide-scale screening is still needed. PROSPERO REGISTRATION NUMBER:CRD42016051261.

SUBMITTER: Telford LH

PROVIDER: S-EPMC7597508 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: a systematic review and meta-analysis of diagnostic accuracy.

Telford Lisa Helen LH Abdullahi Leila Hussein LH Ochodo Eleanor Atieno EA Zuhlke Liesl Joanna LJ Engel Mark Emmanuel ME

BMJ open 20201029 10

<h4>Objective</h4>To summarise the accuracy of handheld echocardiography (HAND) which, if shown to be sufficiently similar to that of standard echocardiography (STAND), could usher in a new age of rheumatic heart disease (RHD) screening in endemic areas.<h4>Design</h4>Systematic review and meta-analysis.<h4>Data sources</h4>PubMed, Scopus, EBSCOHost and ISI Web of Science were initially searched on 27 September 2017 and again on 3 March 2020 for studies published from 2012 onwards.<h4>Eligibilit ...[more]

PMID: 33122317

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Project description:INTRODUCTION:Rheumatic heart disease (RHD) is a preventable and treatable chronic condition which persists in many developing countries largely affecting impoverished populations. Handheld echocardiography presents an opportunity to address the need for more cost-effective methods of diagnosing RHD in developing countries, where the disease continues to carry high rates of morbidity and mortality. Preliminary studies have demonstrated moderate sensitivity as well as high specificity and diagnostic odds for detecting RHD in asymptomatic patients. We describe a protocol for a systematic review on the diagnostic performance of handheld echocardiography compared to standard echocardiography using the 2012 World Heart Federation criteria for diagnosing subclinical RHD. METHODS AND ANALYSIS:Electronic databases including PubMed, Scopus, Web of Science and EBSCOhost as well as reference lists and citations of relevant articles will be searched from 2012 to date using a predefined strategy incorporating a combination of Medical Subject Heading terms and keywords. The methodological validity and quality of studies deemed eligible for inclusion will be assessed against review specific Quality Assessment of Diagnostic Accuracy Studies 2 criteria and information on metrics of diagnostic accuracy and demographics extracted. Forest plots of sensitivity and specificity as well as scatter plots in receiver operating characteristic (ROC) space will be used to investigate heterogeneity. If possible, a meta-analysis will be conducted to produce summary results of sensitivity and specificity using the Hierarchical Summary ROC method. In addition, a sensitivity analysis will be conducted to investigate the effect of studies with a high risk of bias. ETHICS AND DISSEMINATION:Ethics approval is not required for this systematic review of previously published literature. The planned review will provide a summary of the diagnostic accuracy of handheld echocardiography. Results may feed into evidence-based guidelines and should the findings of this review warrant a change in clinical practice, a summary report will be disseminated among leading clinicians and healthcare professionals in the field. PROSPERO REGISTRATION NUMBER:CRD42016051261.

Project description:INTRODUCTION:Rheumatic heart disease (RHD) causes significant morbidity and mortality in young people from disadvantaged populations. Early detection through echocardiography screening can facilitate early access to treatment. Large-scale implementation of screening could be feasible with the combination of inexpensive standalone ultrasound transducers and upskilling non-expert practitioners to perform abbreviated echocardiography. METHODS AND ANALYSIS:A prospective cross-sectional study will evaluate an abbreviated echocardiography screening protocol for the detection of latent (asymptomatic) RHD in high-risk populations. The study will evaluate the diagnostic accuracy of health worker conducted single parasternal long axis view with a sweep using handheld devices (SPLASH) (Philips Lumify S4-1 phased array transducer). Each participant will have at least one reference test performed on the same day by an expert echocardiographer. Diagnosis of RHD will be determined by a panel of three experts, using 2012 World Heart Federation criteria. Sensitivity and specificity of the index test will be calculated with 95% CIs, to determine diagnostic accuracy of a screen-and-refer approach to echocardiography screening for RHD. Remote review of SPLASH images obtained by health workers will facilitate evaluation of the sensitivity and specificity of an alternative approach, using external review of health worker obtained SPLASH images to decide onward referral. ETHICS AND DISSEMINATION:Ethics approval was obtained from the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research, for the project to be carried out in Timor-Leste (HREC 2019-3399), and in Australia, following review by the Aboriginal Ethics subcommittee (HREC 2019-334). Ethical and technical approval was granted in Timor-Leste, by the Institute National of Health Research Ethics and Technical Committee (1073-MS-INS/GDE/VII/2019). Study results will be disseminated in the communities involved in the study, and through peer-reviewed publications and conference abstracts. TRIAL REGISTRATION NUMBER:The Australia New Zealand Clinical Trials Registry (ACTRN12620000122954).

Project description:IntroductionRheumatic heart diseases (RHDs) contribute significant morbidity and mortality globally. To reduce the burden of RHD, timely initiation of secondary prophylaxis is important. The objectives of this study are to determine the frequency of subclinical RHD and to train a deep learning (DL) algorithm using waveform data from the digital auscultatory stethoscope (DAS) in predicting subclinical RHD.Methods and analysisWe aim to recruit 1700 children from a group of schools serving the underprivileged over a 12-month period in Karachi (Pakistan). All consenting students within the age of 5-15 years with no underlying congenital heart disease will be eligible for the study. We will gather information regarding sociodemographics, anthropometric data, history of symptoms or diagnosis of rheumatic fever, phonocardiogram (PCG) and electrocardiography (ECG) data obtained from DAS. Handheld echocardiogram will be performed on each study participant to assess the presence of a mitral regurgitation (MR) jet (>1.5 cm), or the presence of aortic regurgitation (AR) in any view. If any of these findings are present, a confirmatory standard echocardiogram using the World Heart Federation (WHF) will be performed to confirm the diagnosis of subclinical RHD. The auscultatory data from digital stethoscope will be used to train the deep neural network for the automatic identification of patients with subclinical RHD. The proposed neural network will be trained in a supervised manner using labels from standard echocardiogram of the participants. Once trained, the neural network will be able to automatically classify the DAS data in one of the three major categories-patient with definite RHD, patient with borderline RHD and normal subject. The significance of the results will be confirmed by standard statistical methods for hypothesis testing.Ethics and disseminationEthics approval has been taken from the Aga Khan University, Pakistan. Findings will be disseminated through scientific publications and to collaborators.Article focusThis study focuses on determining the frequency of subclinical RHD in school-going children in Karachi, Pakistan and developing a DL algorithm to screen for this condition using a digital stethoscope.

Project description:BackgroundSputum smear microscopy is the most widely available diagnostic test for pulmonary tuberculosis in countries with a high burden of the disease. Improving its accuracy is crucial to achievement of case-detection targets established by the Millennium Development Goals. Unfortunately, many patients are unable to submit all of the specimens needed for examination or to return for treatment because standard sputum collection and reporting requires several clinic visits. To inform policy recommendations by a WHO-convened Expert Group, we aimed to assess the accuracy of sputum smear examination with strategies for obtaining sputum on 1 day compared with strategies for obtaining sputum over 2 days.MethodsWe did a systematic review and meta-analysis of research articles comparing the accuracy of front-loaded or same-day microscopy and standard sputum smear microscopy for diagnosis of culture-confirmed pulmonary tuberculosis. We searched Medline, Embase, Biosis, and Web of Science for articles published between Jan 1, 2005, and Feb 14, 2012. Two investigators identified eligible articles and extracted data for individual study sites. We generated pooled summary estimates (95% CIs) for sensitivity and specificity by use of random-effects meta-analysis when four or more studies were available.FindingsWe identified eight relevant studies from five articles enrolling 7771 patients with suspected tuberculosis in low-income countries. Compared with the standard approach of examination of two smears with Ziehl-Neelsen light microscopy over 2 days, examination of two smears taken on the same day had much the same sensitivity (64% [95% CI 60 to 69] for standard microscopy vs 63% [58 to 68] for same-day microscopy) and specificity (98% [97 to 99] vs 98% [97 to 99]). We noted similar results for studies employing light-emitting diode fluorescence microscopy and for studies examining three smears, whether they were compared with two-smear strategies or with one another.InterpretationSame-day sputum smear microscopy is as accurate as standard smear microscopy. Data from tuberculosis programmes are needed to document the changes required in the health system to successfully implement the strategy and understand its effects.FundingWHO and US National Institutes of Health.

Project description:AimsThe World Heart Federation (WHF) criteria identify a large borderline rheumatic heart disease (RHD) category that has hampered the implementation of population-based screening. Inter-scallop separations (ISS) of the posterior mitral valve leaflet, a recently described normal variant of the mitral valve, appears to be an important cause of mild mitral regurgitation (MR) leading to misclassification of cases as WHF 'borderline RHD'. This study aims to report the findings of the Echo in Africa project, a large-scale RHD screening project in South Africa and determine what proportion of borderline cases would be re-classified as normal if there were a systematic identification of ISS-related MR.Methods and resultsA prospective cross-sectional study of underserved secondary schools in the Western Cape was conducted. Participants underwent a screening study with a handheld (HH) ultrasound device. Children with an abnormal HH study were re-evaluated with a portable laptop echocardiography machine. A mechanistic evaluation was applied in cases with isolated WHF 'pathological' MR (WHF 'borderline RHD'). A total of 5255 participants (mean age 15± years) were screened. A total of 3439 (65.8%) were female. Forty-nine cases of WHF 'definite RHD' [9.1 cases/1000 (95% confidence interval, CI, 6.8-12.1 cases/1000)] and 104 cases of WHF 'borderline RHD' [19.5 cases/1000 (95% CI, 16.0-23.7 cases/1000)] were identified. Inter-scallop separations-related MR was the underlying mechanism of MR in 48/68 cases classified as WHF 'borderline RHD' with isolated WHF 'pathological' MR (70.5%).ConclusionIn a real-world, large-scale screening project, the adoption of a mechanistic evaluation based on the systematic identification of ISS-related MR markedly reduced the number of WHF 'screen-positive' cases misclassified as WHF 'borderline RHD'. Implementing strategies that reduce this misclassification could reduce the cost- and labour burden on large-scale RHD screening programmes.

Dataset Information

Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: a systematic review and meta-analysis of diagnostic accuracy.

Publications

Standard echocardiography versus handheld echocardiography for the detection of subclinical rheumatic heart disease: a systematic review and meta-analysis of diagnostic accuracy.

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