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Transthoracic echocardiography is the gold standard for early detection of RHD. Yet, no single echocardiographic finding or combination of findings unequivocally confirms RHD, especially in subclinical stages. As a result, multiple diagnostic guidelines have been proposed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To characterise the echocardiographic RHD findings and criteria included in five of those guidelines; to assess how these diagnostic criteria differ when applied to a concrete population, namely a cohort of high-school students in Sierra Leone; and, as a secondary objective, to provide an initial estimate of the burden of RHD in this country.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Our study has two parts. First, we performed a qualitative comparison of five major echocardiographic guidelines, mapping every diagnostic criterion into four roles (required, sufficient, combined, or not considered) for each guideline. Second, we conducted a school-based screening in Sierra Leone. A cohort of 604 asymptomatic female students (aged 10\u201322 years) underwent a two-phase echocardiographic protocol. We quantified regurgitant jet characteristics and morphological signs according to the criteria of the compared guidelines.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Guideline discrepancies were substantial, particularly in jet length thresholds and the diagnostic role of morphological features. These differences shifted individual classifications across categories. In our cohort, 13 students (2.2%) had findings beyond normal under at least one guideline, and positive cases ranged from 0.99% to 2.15% depending on the guideline. Using the World Heart Federation (WHF) 2023 criteria, 1.16% (95% CI: 0.47\u20132.37) were classified as positive.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Variability in echocardiographic criteria influences RHD classification and prevalence estimation. Our empirical study shows that the use of rigid echocardiographic cut-offs may lead to discarding some cases suspicious of RHD, especially in the WHF 2023 screening guideline, because one unfulfilled criterion automatically leads to a negative diagnosis, regardless of the number and relevance of positive findings. We argue that a probabilistic causal model that ponders the numerical measurements and considers correlations among findings would be more appropriate for screening and diagnosis.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12872-026-05758-0","type":"journal-article","created":{"date-parts":[[2026,3,19]],"date-time":"2026-03-19T04:46:06Z","timestamp":1773895566000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Comparison of different criteria for rheumatic heart disease screening: an empirical study in Sierra Leone"],"prefix":"10.1186","volume":"26","author":[{"given":"Bel\u00e9n","family":"Fern\u00e1ndez-de-Toro","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luc\u00eda","family":"Cobarro","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jorge","family":"P\u00e9rez-Mart\u00edn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francisco Javier","family":"D\u00edez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,3,19]]},"reference":[{"issue":"25","key":"5758_CR1","doi-asserted-by":"publisher","first-page":"2982","DOI":"10.1016\/j.jacc.2020.11.010","volume":"76","author":"GA Roth","year":"2020","unstructured":"Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, et al. 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Each participant was assigned a randomised identification number that was used to record pseudonymised echocardiographic videos. The study protocol was approved by the Ethics Committee of the UNED on October 31st, 2023. A waiver of parental consent was granted by this committee, given that echocardiography is a non-invasive and innocuous procedure with no associated risk. It is generally accepted that children aged 10 years and above are competent to provide consent for interventions with high benefit and low risk [20]. In our study, those who wished to be examined came to the examination room where two female cardiologists were doing the echocardiograms. No one supervised which students went to the room and which did not, so participation was entirely voluntary.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"364"}}