Diagnosis of active rheumatic carditis. The echoes of change.

Acute rheumatic fever (RF) continues to be a major health problem at the dawn of the new millennium in many parts of the world.1–3 Rheumatic heart disease (RHD), the sequel of RF, is a very common cause of cardiovascular mortality and morbidity,1–5 accounts for 35% to 40% of cardiovascular disease-related hospital admissions, and is the predominant indication for cardiac surgery in developing countries.1,6 Although traditionally considered to be a disease associated with poverty and overcrowding, RF continues to persist, even among the prosperous middle-class population in developed countries.7–9 Although RF is a systemic disease with multiorgan involvement, none of its manifestations, except for carditis, lead to permanent damage. Clinical cardiac involvement has been reported in nearly one-third to almost all patients with RF in various series and in up to 50% of patients in prospective studies.10 Detection of active rheumatic carditis is of great prognostic and therapeutic importance and is currently based on the Jones criteria. Not infrequently, the diagnosis of carditis by the Jones criteria becomes difficult, especially when carditis is the isolated manifestation of the disease or when the rheumatic activity occurs on preexisting RHD.11–13 It is important to develop a diagnostic strategy that will improve our ability to diagnose rheumatic carditis and allow us to apply existing criteria more efficiently.13,14 The advent of modern, highly sensitive cardiac imaging modalities, predominantly echocardiography/Doppler ultrasound (echo-Doppler), has raised the question whether the Jones criteria should be modified to incorporate these techniques.