Abstract
Dear Editor,
We write to provide an update regarding the diagnosis and treatment of rheumatic heart disease. Echocardiographic screening revealed a significant global burden of undetected rheumatic heart disease (RHD) over a decade ago [1]. The medical community's reaction to the World Heart Federation's (WHF) 2012 publication of a set of criteria for the echocardiographic diagnosis of RHD was astounding. But in 2023, these standards were carefully revised, transforming RHD screening from a research and epidemiology tool to a useful public health strategy. By embracing the success of task-shifting RHD screening to a variety of nontraditional clinicians, the amended criteria eventually expand reach into low-resource regions of the world. Furthermore, the WHF's 2023 guidelines removed the terms "definite RHD" and "borderline RHD," which had caused confusion regarding the diagnosis of RHD since 2012 [2]. Instead, they were more consistent with an A-D classification based on progression risk and offer recommendations for treating RHD in its early stages.
The development of integrated models for RHD screening has also advanced during the last four years. The goal of Uganda's ADUNU initiative, or "heart in the local language Lango," is to include it in the country's public healthcare system [3]. This was created in collaboration with the Uganda Ministry of Health and was intended to be carried out by the regional district health offices under the direction of their tertiary cardiac center. ADUNU employs a variety of screening techniques that have proven effective in the past, such as screening at medical institutions and schools, and incorporating them into community outreach and health activities. Additionally, ADUNU incorporates the ACT RHD Registry Tool, a dynamic, registry-based care platform created with a grant from the American Heart Association and currently Uganda's RHD clinical registry. ACT aims to bring RHD care closer to communities by shifting from a centralized, passive care delivery model to a decentralized, active, and scalable one. This includes elements that guarantee a sufficient supply of drugs at institutions, enhance prophylactic adherence and retention in care, and use quality dashboards and the RHD Care Cascade to implement continuous quality improvement. Finally, efforts are underway to support RHD screening using artificial intelligence [4]. For inexperienced scanners, navigational assistance can provide real-time guidance for probe insertion and image acquisition. These studies are ongoing and being evaluated to improve access to RHD screening and diagnosis globally.
The GOAL trial, published in 2022, found that echocardiographic screening and initiation of secondary prophylaxis resulted in substantially less disease progression among children with mild RHD, with a number needed to treat of only 13 to prevent one child from progressing [5]. These results have immediately informed public health recommendations for the treatment of RHD in the 2023 WHF guidelines. To improve treatment approaches, particularly the duration of prophylaxis, more work is needed. There are still unanswered questions, such as the duration of prophylactic treatment for children whose echocardiograms return to normal following an initial diagnosis. High rates of regression, both on and off prophylaxis, have been shown in the trial. Good adherence to penicillin for secondary prophylaxis decreased the risk of rheumatic fever or RHD development by up to 71% compared with poor adherence, according to a 2024 comprehensive review and meta-analysis [6]. Another worldwide issue where research is making some progress is achieving high adherence to secondary prophylaxis. With new initiatives emerging to offer culturally relevant and efficient support, ongoing community engagement, and patient-centered approaches to understanding hurdles, these efforts have been expanding. The development of new penicillin prophylactic formulations is now

Key words: Rheumatic heart disease; Penicillin; Rheumatic fever; Streptococcus pyogenes; Echocardiogram