Cardiology in the Young
cambridge.org/cty
Original Article
Cite this article: Atalay S, Tutar E, Uçar T,
Topçu S, Köse SK, and Doğan MT (2019)
Echocardiographic screening for rheumatic
heart disease in Turkish schoolchildren.
Cardiology in the Young, page 1 of 6.
doi: 10.1017/S1047951119002075
Received: 1 February 2019
Revised: 22 July 2019
Accepted: 31 July 2019
Key words:
Echocardiography; paediatrics; rheumatic
heart disease; screening
Author for Correspondence: Seda Topçu, MD,
Associate Professor, Division of Social
Pediatrics, Department of Pediatrics, Ankara
University School of Medicine, 1549. Cadde,
Hardem Apartmanı, B Blok, Daire 12. Çiğdem-
Çankaya, Ankara, Turkey. Tel.: +90 505 706 46
32; Fax: +90 312 306 59 17;
E-mail: mdsedatopcu@gmail.com
© Cambridge University Press 2019.
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Echocardiographic screening for rheumatic
heart disease in Turkish schoolchildren
Semra Atalay1, Ercan Tutar1, Tayfun Uçar1, Seda Topçu2 , Serdal K. Köse1 and
Melih T. Doğan1
1
Division of Pediatrics Cardiology, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
and 2Division of Social Pediatrics, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
Abstract
Background: The aim of this study is to investigate the prevalence of subclinical rheumatic heart
disease in schoolchildren aged 5–18 by using portable echocardiography in Ankara, Turkey.
Methods: The portable echocardiography screening was performed by a paediatric cardiologist
for all of the cases. The mean age of 2550 healthy students was 11.09 ± 2.91 years (1339 females,
1211 males) in three private and three public schools. Echocardiographic studies were assessed
according to 2012 World Heart Federation criteria for rheumatic heart disease. Results: After
reviewing the echocardiographic images, 73 students were reevaluated by an advanced
echocardiography device in the university hospital. Evidence of definite subclinical rheumatic
heart disease was found in 39 students (15/1000) and borderline rheumatic heart disease in
20 students (8/1000). No children had any clinical symptoms. The mean age of children diag-
nosed with rheumatic heart disease and borderline rheumatic heart disease is 12.4 and 11.4 years,
respectively. The risk of rheumatic heart disease was found to be increased sevenfold in girls
between 14 and 18 years. We surprisingly observed that the prevalence of definite rheumatic
heart disease in private schools located in high-income areas of Ankara was higher than that in
public schools. Conclusions: This is the first and largest single-centred echocardiographic
screening study for subclinical rheumatic heart disease in Turkish schoolchildren. The
frequency of rheumatic heart disease has been found to be 15/1000. This finding is similar
to those of recent echocardiographic screening studies performed in middle and high-risk
populations. We conclude that to decrease the burden of rheumatic heart disease,
echocardiographic screening studies are necessary, and long-term follow-up of children with
echocardiographically diagnosed subclinical rheumatic heart disease is needed.
In developing countries, rheumatic heart disease remains a significant cause of cardiovascular
morbidity and mortality.1,2 Global burden of such disease is too high according to estimates
performed in 2010. These estimates calculated the number of individuals living with rheumatic
heart disease as at least 34.2 million in worldwide.3,4 Several studies have displayed a very high
prevalence of rheumatic heart disease when asymptomatic children are screened by portable
echocardiography in endemic countries.5–8 These studies demonstrated the superiority of
echocardiography over auscultation in detecting the early stages of rheumatic structural and
functional changes of the mitral and aortic valves.6,9
As echocardiographic screening studies were performed using different criteria, the
prevalence of subclinical rheumatic heart disease varies in developing countries.6–9
Therefore, the publication of the World Heart Federation criteria for the echocardiographic
diagnosis of rheumatic heart disease in 2012 has provided standardisation and improved
specificity.10
There are only a few population surveys available in Turkey for the prevalence of rheumatic
heart disease.11,12 These studies based on only auscultation have indicated the prevalence rates of
rheumatic heart disease in schoolchildren as being within the range of 9.4 per 1000 to 3.7 per
1000.11,12 Until now, there has not been a study reporting the frequency of rheumatic heart
disease using portable echocardiography in asymptomatic schoolchildren in Turkey.
The main objective of this study has been to obtain the echocardiographic prevalence of
rheumatic heart disease in a large group of asymptomatic schoolchildren in Ankara using
World Heart Federation criteria.10
Methods
Study population
This epidemiological survey was performed on three private schools and three public schools in
the capital city of Turkey from May 2017 to April 2018. After obtaining institutional ethical
approval, consent was taken from school principals. Consent forms were sent to parents of
 2 S. Atalay et al.
4517 schoolchildren from six schools. About 2550 asymptomatic
schoolchildren were included within this study whose parents
provided written signed consent forms. Moreover, questionnaires
were completed by parents with respect to age, gender, family and
personal history of acute rheumatic fever and/or rheumatic
heart disease of each child. The screening team consisted of
three paediatric cardiologists with extensive experience in diag-
nosing rheumatic heart disease, two paediatricians, and one
intern doctor.
Physical examination
At each screening visit, we obtained demographic information and
recorded height, weight, and cardiac examination findings. We
recorded blood pressure and heart rate. In case of a suspected
murmur, it was described as innocent or pathologic at the discretion
of the paediatric cardiologist.
Echocardiographic examination
An echocardiogram was performed by one of the three experienced
paediatric cardiologists using portable screening echocardiography
(General Electric Vivid Q). Gain settings were optimised by sonog-
raphers. Standard views included parasternal long axis, parasternal
short axis, and apical four and five-chamber views (2D and
Doppler), using a 4 MHz transducer. Valve morphology and valve
regurgitation were evaluated meticulously by 2D imaging. Valve
thickness was evaluated only if the images were acquired at optimal
gain setting without harmonics. Anterior mitral valve thickness
was measured during diastole at full excursion. The average time
to complete the echocardiographic examination was 5–10 minutes.
All of the echocardiograms were recorded to the hard disc of the
echocardiography device for further review. Echocardiograms
defined as abnormal were reevaluated by at least two of the paedi-
atric cardiologists involved in the study at the end of the screening
week. Children confirmed as having echocardiographic abnormal-
ities were invited to the university hospital. Then, a detailed
echocardiographic examination was performed using an advanced
echocardiography device (Philips İE 33) by two paediatric
cardiologists. Any discrepancies were discussed, and if there was
any controversy, the third paediatric cardiologist reviewed the
echocardiograms and the final decision was taken by consensus.
An abnormal echocardiogram was defined according to the
2012 World Heart Federation criteria.10
Echocardiographic criteria for individuals aged ≤20 years
Definite rheumatic heart disease (either A, B, C, or D):
A) Pathological mitral regurgitation and at least two morphological
features of rheumatic heart disease of the mitral valve
B) Mitral stenosis mean gradient ≥4 mmHg*
C) Pathological aortic regurgitation; and at least two mor-
phological features of rheumatic heart disease of the aortic
valve‡
D) Borderline disease of both the aortic valve and mitral valve§
*Congenital MV anomalies must be excluded. Furthermore, inflow obstruction due to
nonrheumatic mitral annular calcification must be excluded in adults.
‡
Bicuspid AV, dilated aortic root, and hypertension must be excluded.
§
Combined AR and MR in high prevalence regions and in the absence of congenital
heart disease is regarded as rheumatic.
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Borderline rheumatic heart disease (either A, B, or C):
A) At least two morphological features of rheumatic heart disease
of the mitral valve without pathological mitral regurgitation
or mitral stenosis
B) Pathological mitral regurgitation
C) Pathological aortic regurgitation
Normal echocardiographic findings (all of A, B, C, and D):
A) Mitral regurgitation that does not meet all four Doppler echo-
cardiographic criteria (physiological mitral regurgitation)
B) Aortic regurgitation that does not meet all four Doppler echo-
cardiographic criteria (physiological aortic regurgitation)
C) An isolated morphological feature of rheumatic heart disease
of the mitral valve (e.g. valvular thickening) without any asso-
ciated pathological stenosis or regurgitation
D) Morphological feature of rheumatic heart disease of the aortic
valve (e.g. valvular thickening) without any associated patho-
logical stenosis or regurgitation
Echocardiographic criteria for individuals aged >20 years
Definite rheumatic heart disease (either A, B, C, or D):
A) Pathological mitral regurgitation and at least two morphologi-
cal features of rheumatic heart disease of the mitral valve
B) Mitral stenosis mean gradient ≥4 mmHg*
C) Pathological aortic regurgitation and at least two morphologi-
cal features of rheumatic heart disease of the aortic valve, only
in individuals aged <35 years‡
D) Pathological aortic regurgitation and at least two morphologi-
cal features of rheumatic heart disease of the mitral valve
Statistical analysis was carried out using the SPSS software (ver.
17; SPSS Inc., Chicago, Illinois, United States of America).
Student’s t-test was used for parametric variables between groups,
and a χ2 test for non-parametric variables. Descriptive statistics for
continuous variables were shown as mean-standard deviation, and
categorical variables were given as case numbers and percentiles.
Categorical variables were compared using the χ2 or Fisher’s exact
test where appropriate. Bivariate logistic regression was used to
control for confounding factors, including age, sex, and socio-
economically level of groups when comparing the proportion of
children with rheumatic heart disease in each group. P values
<0.05 were considered to be significant.
Results
About 2550 healthy students were screened by portable echocardi-
ography in total. The percentage of informed consent forms signed
was higher in public schools compared to that in private schools
(70.9 versus 49.1%) (p < 0.001). The characteristics of patients
are summarised in Table 1. The mean age of 2550 children was
11.09 ± 2.91 years (range 5–18 years) with a slightly predominance
of girls. Mean weight was 43.57 ± 15.91 kg, and mean height was
148.56 ± 17.25 cm. In cardiac examination, mean heart rate of all
students was 93.49 ± 13.72, and mean blood pressure was (systolic/
diastolic) 104.56 ± 11.68/67.24 ± 9.18 mmHg.
About 1473 students (58.0%) were attending private schools
and 1077 students (42.0%) public schools. There was no difference
as to the age and sex of the students between private and public
schools (Table 2). Only two students with rheumatic heart disease
 Cardiology in the Young 3

Table 1. Sociodemographic characteristics of students. Table 3. Bivariate logistic regression analysed.

Middle–high OR 95% CI p
socio-economic Low socio-economic
private school public school Total Sex 1.83 0.918–3.576 0.077
n = 1473 (58%) n = 1077 (42%) n = 2550 (100%) Age
Sex 5–9 – – –
Girls 790 (53.6) 549 (51) 1339 (52.5) 10–13 2.308 0.918–5.806 0.075
Boys 683 (46.4) 528 (49) 1211 (47.5) 14–18 3.263 1.247–8.543 0.016
Age (years) Middle-high (private school) 1.656 0.835–3.283 0.149
5–9 455 (30.9) 364 (33.8) 819 (32.1)
10–13 827 (56.1) 308 (28.6) 1135 (44.5)
14–18 191 (13.0) 405 (37.6) 596 (23.4) and high risk groups (odds ratio 1.66) (95% confidence intervals,
0.835–3.283, p = 0.149) (Table 3). Twelve female and eight male
students were diagnosed among 20 children diagnosed with
Table 2. Characteristics of patients with definite RHD/borderline RHD. borderline rheumatic heart disease.
Of the 39 children who met criteria for definite rheumatic heart
Definite RHD Borderline RHD disease, 30 (76.92%) had isolated mild mitral regurgitation. One
(n = 399) (n = 20) p
child had previously been diagnosed with mitral stenosis. Six chil-
Total prevalence 15/1000 8/1000 dren had isolated mild aortic regurgitation, and two children had
Prevalence for socio-economic state 0.335 both aortic regurgitation and mitral regurgitation. None of the
children had a history of acute rheumatic fever. Mild isolated
Middle-high (private school) 18/1000 7/1000
mitral regurgitation was found in all children with borderline
Low (public school) 11/1000 8/1000 rheumatic heart disease (Table 4).
Sex 0.160 Although at least two morphological changes were present in
the mitral valve, the regurgitant jet length was less than 2 cm in
Girls (n) 26 12
15 children with borderline rheumatic heart disease. Although
Boys (n) 13 8 the criteria for pathological mitral regurgitation were met,
Mean age (years) 12.5 11.4 0.176 morphological changes were not observed in the mitral valve of five
(min-max) (6.59–17.4) (7.5–17)
children with borderline rheumatic heart disease.
At the end of the screening study, structural abnormalities other
min-max = minimum-maximum; RHD = rheumatic heart disease than rheumatic heart disease were identified in 49 children. Most
were minor anomalies, with the most common being mitral valve
prolapse and bicuspid aortic valve. Additionally, there were two
had a heart murmur suggesting valvular regurgitation at cardiac
children with a small atrial septal defect, six with a patent foramen
auscultation.
ovale, and four with aortic root dilatation. Partial anomalous
Sixty-three children with abnormal screening echocardiograms
pulmonary venous connection was detected in one patient, and
were invited to the university hospital for detailed echocardio-
she underwent surgical correction. Physiologic mitral regurgita-
graphic study. Three were re-classified with physiologic mitral
tion was present in 155 children (6%).
regurgitation and one mitral valve prolapse after echocardiographic
Penicillin injections were given to all definite rheumatic heart
examination. Children were classified as having definite or border-
disease cases every 21 days. We did not recommend secondary pro-
line rheumatic heart disease according to the 2012 World Heart
phylaxis for the children with borderline rheumatic heart disease.
Federation criteria.10 Thirty-nine definite and 20 borderline cases
Parents of children with borderline rheumatic heart disease were
having subclinical rheumatic heart disease in total were detected
advised to report sore throat, fever, joint swelling, or pain to the
by echocardiography. The prevalence of definite rheumatic heart
paediatric cardiology department. We also planned follow-up
disease was found to be 15.0 per 1000 children, and it was 8.0 per
echocardiographic examinations every 6 months.
1000 children for borderline rheumatic heart disease (Table 2).
The mean age of children diagnosed with definite rheumatic heart
disease and borderline rheumatic heart disease is 12.5 years (mini-
Discussion
mum: 6.50, maximum: 17.42) and 11.4 years (minimum: 7.5, maxi-
mum: 17.03), respectively. There was no statistically significant School surveys are the most common method of assessing
difference between the two groups (p < 0.05). The prevalence of def- the prevalence of rheumatic heart disease at the community
inite rheumatic heart disease in private schoolchildren was 18/1000 level.13–15 This is the first and largest echocardiographic screening
and was 11/1000 in public schoolchildren (p > 0.33) (Table 2). study for subclinical rheumatic heart disease in Turkish schoolchil-
The prevalence of definite rheumatic heart disease increased dren. There is a limited number of studies displaying the preva-
with age, 23 per 1000 among children aged between 14 and 18 lence of rheumatic heart disease in Turkey, and the diagnosis of
(odds ratio 3.263) (95% confidence intervals, 1.247–8.543, rheumatic heart disease was previously confirmed by only auscul-
p = 0.016) with a prevalence of 17 per 1000 children aged 10–13 tation. As obtained by Imamoğlu et al, the prevalence of rheumatic
years and 7 per 1000 children aged 5–9 years. The frequency of heart disease was found to be 9.4/1000 among 3039 schoolchildren
definite rheumatic heart disease increased with female gender in 1976; however, Imamoğlu et al specified that the prevalence of
(odds ratio 1.83) (95% confidence intervals, 0.918–3.576, p = 0.07) such disease was decreased to 5.6/1000 after 10 years.11 In another

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 4 S. Atalay et al.
Table 4. Rheumatic heart disease cases by 2012 WHF category.
RHD category WHF definition
Definite RHD
Definite RHD-1 Pathologic MR þ abnormal MV
Definite RHD-2 Mitral stenosis
Definite RHD-3 Pathologic AR þ abnormal AV
Definite RHD-4 Borderline disease of MV and AV
Borderline RHD
Borderline RHD-1 2 or more MV morphologic abnormalities
Borderline RHD-2 Pathologic MR
Borderline RHD-3 Pathologic AR
AR = aortic regurgitation; AV = aortic valve; MR = mitral regurgitation; MV = mitral valve;
RHD = rheumatic heart disease; WHF = World Heart Federation
study conducted by Olguntürk et al the prevalence was found to be
3.7/1000 in schoolchildren in 1999.12
This study demonstrated a high prevalence of subclinical rheu-
matic heart disease in Ankara. Evidence of definite subclinical
rheumatic heart disease was found in 39 students (15.0 per 1000
children), while 20 students were diagnosed with borderline rheu-
matic heart disease (8.0 per 1000 children). The prevalence rates of
rheumatic heart disease diagnosed with echocardiography give
estimates which are much higher than previously reported data
based on only auscultation in Ankara. Similar studies also noted
that echocardiographic screening reveals approximately 10 times
higher prevalence of rheumatic heart disease, as compared to clini-
cal evaluation.5,6,16 Rothenbühler et al reported that the prevalence
of rheumatic heart disease was 2.9 per 1000 people by auscultation
as compared to 12.9 per 1000 by echocardiography.17
The first study to use Doppler echocardiography was conducted
in rural schools of Kenya in 1996.18 The highest prevalence rates
have been documented in Southeast Asia, Africa, Australia,
India, Fiji, and New Zealand.10 Since different criteria were used
to define echocardiographic rheumatic heart disease, differences
were seen regarding rheumatic heart disease prevalence.5,15,19–22
Earlier studies used the World Health Organization definition of
pathologic mitral regurgitation (jet length ≥ 1 cm compared with
≥2 cm in the World Heart Federation criteria) as a marker for
rheumatic heart disease.22 Most of the echocardiographic screen-
ing studies used either World Health Organization or modified
World Health Organization criteria to diagnose rheumatic heart
disease.16,19,22–26
Previous studies based on World Health Organization, World
Health Organization/National Institute Health 2005, or modified
World Health Organization criteria showed high rates (ranging
from 14.8 per 1000 to 56.5 per 1000) of subclinical rheumatic
heart disease in endemic areas.5,7,16,18,27,28 The World Health
Organization criteria were exclusively Doppler based and
inadequate to diagnose subclinical cases, thus prompting the
development of new morphology-based modified criteria.26
The modified World Health Organization criteria also may
overestimate the prevalence of rheumatic heart disease in
some cases by classifying physiological mitral regurgitation
as pathological.19
Recently, World Heart Federation proposed new echocardiog-
raphy criteria to diagnose subclinical rheumatic heart disease.10
The 2012 World Heart Federation criteria are currently considered
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gold standard as they involve both morphologic and Doppler fea-
tures and are more specific in differentiating pathologic lesions
n (%)
from physiologic.10 Very few studies have been reported using
39 (100) these criteria.29,20,30,31 The largest population study (16,294 school-
30 (82) children) in India documented that the prevalence of definite rheu-
matic heart disease was 7.7/1000, and borderline rheumatic heart
1 (2.5)
disease was 5.7/1000 using World Heart Federation criteria.29
6 (15.3) Another study documented that the prevalence of definite rheu-
2 (5.1) matic heart disease was 0.5 per 1000 and borderline rheumatic
heart disease was 4.0 per 1000 in 12,048 schoolchildren in
20 (100)
Brazil.30 The prevalence of definite or borderline rheumatic heart
15 (75) disease in 1058 schoolchildren was found to be 12.9 per 1000 in
5 (25) American Samoa.20 Similar to our findings, Davis et al had found
that the prevalence of definite rheumatic heart disease was 18.3 per
– (0)
1000 in Timor-Leste.31 The prevalence of rheumatic heart disease
was higher than we expected to be seen in Ankara. This study was
performed by paediatric cardiologists with experience in the diag-
nosis of rheumatic heart disease. We do not think over-diagnosis is
responsible for this high prevalence because the diagnosis of rheu-
matic heart disease in all cases was reached by the consensus of at
least two experienced paediatric cardiologists.
Among demographic and socio-economic factors, age and sex
seem to be independently associated with the prevalence of rheumatic
heart disease. In the present study, subclinical rheumatic heart disease
was associated with advancing age and female sex, as in other
studies.19,29,30,31 We found that the prevalence of definite rheumatic
heart disease increased with age: 23 per 1000 in 14–18-year-old
children (odds ratio 3.263) (95% confidence intervals 1.247–
8.543, p = 0.016) with a prevalence of 17 per 1000 children aged
10–13 years and 7 per 1000 children aged 5–9 years. The risk of
rheumatic heart disease was found to be increased 7.7-fold in girls
and children aged between 14 and 18 years. There were no signifi-
cant differences in the proportion of age groups or gender among
patients with definite and borderline rheumatic heart disease.
Nascimento et al had found that the prevalence of rheumatic heart
disease was higher among girls who were older than 12 years old.30
Roberts et al also reported the prevalence of both definite and
borderline rheumatic heart disease increased with age.32 However,
they did not observe significant differences in the proportion of girls
among cases of definite or borderline rheumatic heart disease.
In the present study the number of definite cases is almost two
times more than that of borderline cases. Although most of
reported studies show borderline cases to be more frequent than
definite ones, some studies found definite rheumatic heart disease
dominance, as in the case of the present study.27,28,30,33–35
Rheumatic heart disease has been consistently associated with
poor socio-economic conditions, lower income, and rural
areas.20,21,35,36 In the present study, the prevalence of definite
rheumatic heart disease in children in private schools situated in
high-income areas of Ankara is higher than expected. These findings
contrast with the findings of previously published studies. 13,33 As it
is known, group A beta-hemolytic streptococci infection is more
common among people living in crowded areas.13,21 In Turkey,
private schools provide full-time education and public-schools
provide part-time education. We suggest that children in private
schools are together for a longer period of time, unlike public
schools. Besides, they often go to school by school bus instead of
walking, as in the case of public schoolchildren. Furthermore,
children tend to be in more crowded areas, such as sports halls,
pools, and dining halls, in private schools, and this may also be a
factor increasing the spread of group A beta-hemolytic streptococci
infection. Also, the parents whose children are in private schools
 Cardiology in the Young
have more concerns about using antibiotics, and we suggest that this
may be another factor for the higher prevalence of rheumatic heart
disease in private schools. Nascimento et al found that the preva-
lence rates of rheumatic heart disease were also more than expected
in private schools located in high-income areas in Brazil. 30
The involvement of valve disease is detailed in Table 4. In the
present study, the mitral valve was the most commonly involved in
children with both definite rheumatic heart disease and borderline
rheumatic heart disease, as in other similar studies.9,20,36,37 Aortic
valve and mitral valve morphologic changes should be evaluated
carefully by echocardiography. Minor congenital mitral valve
anomalies and mitral valve prolapse should be differentiated from
rheumatic mitral morphologic changes.8 Aortic regurgitation may
be associated with a bicuspid aortic valve or a dilated abnormal
aortic root or sinus.8,19 These anomalies are easily excluded by
detailed echocardiography. In the present study, physiologic mitral
regurgitation was differentiated from borderline rheumatic heart
disease according to the 2012 World Heart Federation criteria
and was found to be present in 155 children (6%).10 Previous
reports found that the rates of physiologic mitral regurgitation
in normal children to be between 2.5 and 45%. 8,37,38
The clinical significance of borderline rheumatic heart disease
and the need for secondary prophylaxis remains unknown.13 Some
studies reported that with borderline rheumatic heart disease a
benign prognosis was expected.7,14 Nevertheless, recent studies
have found that the valvular lesions of children with borderline
rheumatic heart disease may progress and definite rheumatic heart
disease may develop.34,35,39 Remond et al. reported that among 55
Aborigines with borderline disease, 13 of them (23%) progressed to
definite rheumatic heart disease after an interval of 2.5–5 years.40
Kotit et al evaluated the way subclinical findings detected by
echocardiography progressed during the subsequent 4–5 years.34
Follow-up progression was documented in 14 of 72 children
(19.4%) and regression in 30 children (41.7%). Ten of the border-
line cases had regressed, 10 remained unchanged, and 6 had
developed definite rheumatic heart disease. They also emphasised
that functional defects of the valve tended to have higher rates of
regression than structural changes of the valve.34 It has also been
reported by Bahaya et al that if the mitral regurgitation coexists
with valve deformities, mitral valve disease is more likely to
persist.16 According to the findings of Kotit, children with border-
line rheumatic heart disease should be frequently evaluated by
echocardiography.34 Moreover, we previously reported the
progression of valvular regurgitation in 6 children (30%) among
20 children who were diagnosed with subclinical rheumatic heart
disease, after a follow-up of 43.4 ± 25 months.41 Therefore, we
suggest long-term penicillin prophylaxis in children with subclinical
rheumatic heart disease. It is known that secondary prophylaxis
improves the prognosis of this disease and prevents recurrence.13,37,42,43
Limitations
This study has some limitations. It was performed in the capital
city of Turkey, so it does not represent the true prevalence in
the entire country and cannot determine the definitive prevalence
of rheumatic heart disease in Turkey. Another limitation of the
current study is the unequal distribution of signed parental consent
forms in private school and public schools (70 versus 49%). This
figure may create a selection bias. Studies that will investigate the
frequency of rheumatic heart disease with echocardiography in
different regions of Turkey will contribute to better clarification
of rheumatic heart disease prevalence.
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5
Conclusions
Rheumatic fever is still an important health problem with signifi-
cant morbidity and mortality, in particular in developing countries
such as Turkey. Portable echocardiography is an important screen-
ing test for the early diagnosis of rheumatic heart disease. This
study demonstrates a high prevalence of subclinical rheumatic
heart disease by echocardiography in schoolchildren in Ankara.
The prevalence of group A beta-hemolytic streptococci infection
among Turkish children presenting with acute pharyngotonsillitis
is frequent. Prevention and early treatment of streptococcal infec-
tions with appropriate antibiotics should be the most important
step for acute rheumatic fever eradication in Turkey. Moreover,
further multi-centre screening of subclinical rheumatic heart
disease in schoolchildren by portable echocardiography should
be performed in different regions of Turkey. The high prevalence
rates of rheumatic heart disease in the capital city of Turkey suggest
that the prevalence rates might be higher in the rural areas.
Acknowledgements. None.
Financial Support. This research received grant from Scientific Research
Projects Committee of Ankara University.
Conflicts of Interest. None.
Ethical Standards. The authors assert that all procedures contributing to this
work comply with the ethical standards of the relevant national guidelines on
human experimentation (Turkish Medicines and Medical Devices Agency) and
with the Helsinki Declaration of 1975, as revised in 2008, and has been approved
by Ankara University Institutional Review Board and the Ethics Committee.
Before resuming the research project written consent was obtained from parents
of each participant child.
Statement of Human and Animal Rights: In case of experimenting on
human, the authors have certified that the process of the research is in
accordance with ethical standards of Helsinki declaration, domestic and foreign
committees that preside over human experiment. In case of experimenting on
animals, the authors have certified that the authors had followed the domestic
and foreign guideline related to experiment of animals in a laboratory.
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