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Open Access Study protocol

Rheumatic Fever Follow-Up Study (RhFFUS) protocol: a cohort study investigating the significance of minor echocardiographic abnormalities in Aboriginal Australian and Torres Strait Islander children

Marc Gerard Wootton Rémond1*, David Atkinson23, Andrew White4, Yvonne Hodder1, Alex DH Brown57, Jonathan R Carapetis6 and Graeme Paul Maguire17

Author Affiliations

1 School of Medicine and Dentistry, Faculty of Medicine, Health and Molecular Sciences, James Cook University, Cairns, QLD, Australia

2 Rural Clinical School of Western Australia, The University of Western Australia, Broome, WA, Australia

3 Kimberley Aboriginal Medical Services Council, Broome, WA, Australia

4 School of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia

5 South Australian Health and Medical Research Institute, Adelaide, SA, Australia

6 Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, WA, Australia

7 Baker IDI, Alice Springs, Northern Territory, Australia

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BMC Cardiovascular Disorders 2012, 12:111  doi:10.1186/1471-2261-12-111

Published: 27 November 2012

Abstract

Background

In Australia, rheumatic heart disease (RHD) is almost exclusively restricted to Aboriginal Australian and Torres Strait Islander people with children being at highest risk. International criteria for echocardiographic diagnosis of RHD have been developed but the significance of minor heart valve abnormalities which do not reach these criteria remains unclear. The Rheumatic Fever Follow-Up Study (RhFFUS) aims to clarify this question in children and adolescents at high risk of RHD.

Methods/design

RhFFUS is a cohort study of Aboriginal and/or Torres Strait Islander children and adolescents aged 8–17 years residing in 32 remote Australian communities. Cases are people with non-specific heart valve abnormalities detected on prior screening echocardiography. Controls (two per case) are age, gender, community and ethnicity-matched to cases and had a prior normal screening echocardiogram. Participants will have echocardiography about 3 years after initial screening echocardiogram and enhanced surveillance for any history suggestive of acute rheumatic fever (ARF). It will then be determined if cases are at higher risk of (1) ARF or (2) developing progressive echocardiography-detected valve changes consistent with RHD.

The occurrence and timing of episodes of ARF will be assessed retrospectively for 5 years from the time of the RhFFUS echocardiogram. Episodes of ARF will be identified through regional surveillance and notification databases, carer/subject interviews, primary healthcare history reviews, and hospital separation diagnoses.

Progression of valvular abnormalities will be assessed prospectively using transthoracic echocardiography and standardized operating and reporting procedures. Progression of valve lesions will be determined by specialist cardiologist readers who will assess the initial screening and subsequent RhFFUS screening echocardiogram for each participant. The readers will be blinded to the initial assessment and temporal order of the two echocardiograms.

Discussion

RhFFUS will determine if subtle changes on echocardiography represent the earliest changes of RHD or mere variations of normal heart anatomy. In turn it will inform criteria to be used in determining whether secondary antibiotic prophylaxis should be utilized in individuals with no clear history of ARF and minor abnormalities on echocardiography. RhFFUS will also inform the ongoing debate regarding the potential role of screening echocardiography for the detection of RHD in this setting.

Keywords:
Rheumatic heart disease; Acute rheumatic fever; Screening; Aboriginal; Torres Strait Islander; Indigenous; Diagnosis; Prevention; Australia; Echocardiography