Long term follow up of rheumatic fever and predictors of severe rheumatic valvar disease in Brazilian children and adolescents

Abstract

Objectives: To investigate the progress of rheumatic fever (RF) and the predictors of severe chronic valvar disease.

Design: Patients prospectively followed up since their first attack of acute RF (ARF).

Setting: Universidade Federal de Minas Gerais, Brazil.

Patients: 258 children and adolescents who met the revised Jones criteria for RF. The follow up period ranged from 2-15 years.

Main outcome measures: The presence and severity of mitral or aortic valvar disease were determined by both clinical and Doppler echocardiographic examinations. The variables associated with severe chronic valvar disease were initially identified by the Kaplan-Meier method and, later, by multivariate analysis.

Results: Doppler echocardiography of 258 patients studied showed that 186 (72.1%) developed chronic valvar disease and 41 (15.9%) progressed to severe chronic mitral or aortic lesions. Of 146 patients who developed carditis, 49 (33.6%) had a normal clinical examination in the chronic phase but only nine (6.2%) had normal Doppler echocardiographic findings--that is, 40 (27.4%) patients progressed to chronic subclinical valvar disease. Moderate or severe carditis, recurrences of ARF, and mother's low educational level were risk factors in predicting severe chronic valvar diseases.

Conclusion: The increased risk of progressing to severe chronic valvar disease was associated with moderate or severe carditis, recurrences of ARF, and mother's low educational level. Hence, in a country such as Brazil, the options available for disease control are mainly primary and secondary prophylaxis.

Figure 1

Actuarial survival curves with no severe chronic valvar diseases by (A) mother’s educational level, (B) severity of carditis, and (C) recurrent attacks of acute rheumatic fever (ARF).