2015 Jones criteria for the diagnosis of rheumatic fever

In this ppt, I am going to discuss 2015 Jones criteria for the diagnosis of rheumatic fever and various modification made into it and basis for those modifications

1. 2015 Jones criteria for Diagnosis of Rheumatic fever Presenter Dr Praveen Gupta Moderator DR Santhosh satheesh Department of cardiology JIPMER Pondicherry India 13.02.2018 1

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3. Diagnosis of rheumatic fever Development of the first clinical criteria for the diagnosis of ARF known as the ‘Jones Criteria ’ Allowed RF to be diagnosed uniformly in multicenter studies of RF 3 Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11.

4. Jones criteria for the diagnosis of rheumatic fever Two major, or one major and two minor manifestations evidence of rheumatic activity Previous history of definite RF or RHD was considered a major criterion, diagnosis of a recurrence of RF did not require strict application of these guidelines, and minor manifestations were considered sufficient for the diagnosis . Preceding streptococcal infection has been emphasized for diagnosis of RF Insidious and chronic carditis, chorea, were exempted to demonstrate streptococcal etiology Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 4

5. Revising the standard Decline in ARF in the USA motivated four revisions to Dr Jones’ criteria High specificity at the cost of lowered sensitivity C hanges were appropriate for high-income, Low-prevalence countries , 1992 revision of the Jones criteria lacked sufficient sensitivity in high prevalence regions Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 5

6. Jones criteria for the diagnosis of rheumatic fever Australia and New Zealand , publish ARF diagnostic guidelines, diverged from Jones criteria WHO released its own version Other countries followed suit, and the Jones criteria risked becoming a relic of history Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 6

7. 7 World Health Organization. Rheumatic Fever and Rheumatic Heart Disease: Report of a WHO Expert Consultation, Geneva, 29 October-1 November, 2001. World Health Organization; 2004 Feb 4.

8. 8 World Health Organization. Rheumatic Fever and Rheumatic Heart Disease: Report of a WHO Expert Consultation, Geneva, 29 October-1 November, 2001. World Health Organization; 2004 Feb 4.

9. 2015 Jones criteria I n 2012, AHA took on another revision Include prominent authors working in high prevalence regions Guidelines , in 2015, acknowledge the importance of including pretest probability in weighing sensitivity versus specificity, and S eparate guidelines for low-risk and moderate-to high- risk populations Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 9

10. 2015 Jones criteria This revision also embraces echocardiography , recommending its use in all populations, when available, for the diagnosis of rheumatic carditis 2015 revision will ensure the Jones criteria are re-established as the international gold standard for ARF diagnosis Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 10

11. 2015 JONES CRITERIA AHA criteria categories manifestations of ARF into major and minor criteria First episode of ARF is diagnosed when there is recent streptococcal infection in addition to either two major or one major and two minor criteria Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 11

12. Three main changes in Jones diagnostic criteria Risk stratification E chocardiographic detection of subclinical carditis J oint manifestations 12 Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11.

13. Separation into low-risk and moderate/high-risk populations The burden of ARF is distributed unequally around the globe High-income countries have seen a near eradication of disease Low-income/low-resource countries, or poorer populations within wealthy countries, have seen very little change in ARF incidence C ommon in endemic regions to see hyperendemic disease patterns Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 13

14. Separation into low-risk and moderate/high-risk populations Data from high-prevalence settings such as Australia that the Clinical manifestations of ARF, in particular joint presentations and peak fever, may be substantially less dramatic, and thus less clinically obvious, compared with those seen in low-risk settings. Australian guidelines were the first to consider high-risk and low-risk populations separately, emphasising high sensitivity among those at greatest risk and high specificity for those at lower risk. The 2015 Jones criteria revision has embraced this risk-stratified approach. Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 14

15. Separation into low-risk and moderate/high-risk populations T he 2015 revision defines low risk (ARF incidence <2 per 100 000 school-aged children per year or an all-age prevalence of RHD of ≤1 per 1000 population per year), Children not clearly from a low-risk ARF population should be considered at moderate-to-high risk Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 15

16. Addition of subclinical carditis as a major manifestation Clinical carditis been defined as an audible murmur consistent with AR/MR In 2000, interest was growing in the importance of subclinical carditis, or clinically silent valvular involvement only detectable through echocardiography, as an indicator of ARF Substantial prevalence and significance of subclinical carditis among patients with ARF Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 16

17. Addition of subclinical carditis as a major manifestation These findings led to the inclusion of echocardiography for the evaluation of patients with suspected or confirmed ARF and the addition of subclinical carditis as a major manifestation for all populations in the 2008 New Zealand guidelines and high-risk populations in the 2012 Australian guidelines. Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 17

18. Addition of subclinical carditis as a major manifestation 2015 Jones revision made similar recommendations: either clinical or subclinical carditis qualifies as a major manifestation in low-risk and high-risk populations The criteria recommend that, when possible, all patients with confirmed or suspected ARF undergo echocardiography to evaluate for carditis, with those who are negative on first evaluation undergoing repeated study to assess for evolving cardiac diseases Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 18

19. Addition of subclinical carditis as a major manifestation Diagnosis of subclinical carditis is made based on specific recommendations for pathological Mitral Regurgitation/ Aortic Regurgitation (MR/AR) Normal echocardiogram can rule out a diagnosis of carditis made through clinical auscultation (improving specificity ) Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 19

20. Joint manifestations As arthritis/arthralgia can be seen in a wide spectrum of diseases , I nclusion of different forms of joint involvement in Jones criteria, subject of debate Many patients self-medicate which effectively treat the arthritis/ arthralgia Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 20

21. Joint manifestations Classic migratory polyarthritis is not the only form of joint involvement in ARF In high-risk populations , it results in missed cases of ARF In high-risk populations aseptic monoarthritis is an important manifestation of ARF Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 21

22. Joint manifestations Monoarthritis in 16– 18% of children with ARF 27 out of 75 children with monoarthritis who would have met criteria for ARF had monoarthritis been included as a major criterion 55% went on to develop either ARF or RHD Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 22

23. Joint manifestations 2015 Jones criteria revision includes polyarthritis, monoarthritis and polyarthralgia as major criteria and monoarthralgia as a minor criterion in moderate-risk and high-risk populations. No change has been made to the diagnosis of joint involvement in low-risk populations D ifferential diagnoses for joint involvement have first been excluded Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 23

24. Minor criteria To improve the sensitivity of ARF diagnosis in moderate to high-prevalence population Fever cut-off was lowered to 38.0 ° C , ESR >30 mm/h in moderate-risk to high-risk populations ( >60 mm/h in low-risk) Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 24

25. ARF recurrences Patients with history of ARF at high risk for recurrences 2015 revision provide direct guidance, requiring that two major, one major and two minor, or three minor criteria be met in a patient with a reliable past history of ARF/RHD and documentation of a recent streptococcal infection Excluding more likely diagnoses, when only minor manifestations are present Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 25

26. Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 26

27. Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 27

28. Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 28

29. Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 29

30. Potential impact on revised jones criteria 2015 2015 Jones criteria would translate into national governments raising the priority level of ARF/RHD within their health agendas and establishing national programmes for ARF/ RHD prevention. Help answer , Where are all the children with ARF? Single criteria, ensuring uniform system for diagnosis and data collection across research sites Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 30

31. Increased research potential Will remain imperfect because diagnosis still relies on a clinical diagnostic algorithm . Always be potential for imperfect specificity and overinclusive diagnoses, as well as imperfect sensitivity and missed cases of ARF Have the potential to increase case detection, with more internationally accepted guidelines Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 31

32. Take home message 2015 revision has re-established the Jones criteria for ARF diagnosis in all settings The guidelines stay true to the approach of Dr Jones by High specificity for ARF in low-risk populations S ensitive guidelines for use in moderate/high-risk settings Beaton A, Carapetis J. The 2015 revision of the Jones criteria for the diagnosis of acute rheumatic fever: implications for practice in low-income and middle-income countries. Heart Asia. 2015 Jul 1;7(2):7-11. 32

33. Thank you 33