Rheumatic Heart Disease in Europe: Insights from a Pilot Screening Study and a Scoping Review

Background: Rheumatic heart disease (RHD) remains a preventable cause of cardiovascular morbidity/mortality, disproportionately affecting socioeconomically disadvantaged populations. While largely controlled in high-income countries, RHD persists in low- and middle-income countries and may remain underrecognized among migrants from endemic regions in Europe, where systematic surveillance data are lacking. This study aimed to explore the implementation and diagnostic yield of echocardiographic screening in a migrant population and to contextualize these findings through a scoping review of European RHD research.

Methods: We conducted a single-center pilot study in Munich, Germany, screening 150 recently-arrived migrants (aged 5–26 years) from RHD-endemic regions using 2023 World Heart Federation (WHF) echocardiographic criteria. Medical history was documented. Furthermore, we conducted a scoping literature review of European studies reporting RHD published since 2000, in accordance with Cochrane and PRISMA guidelines (PROSPERO ID: CRD42024538000).

Results: Among screened participants (mean age 20.0 ± 5.9 years), ten (6.8%) showed abnormalities warranting confirmatory echocardiography according to the WHF protocol for RHD diagnosis, with mitral regurgitation being the most frequent finding. No participant had a prior diagnosis of RHD. Screening was integrated into routine health examinations without any obvious disruption of routine workflows. The scoping review identified 86 publications, predominantly from Turkey and Italy, highlighting fragmented research, methodological heterogeneity, limited prevalence data, and a focus on surgical management rather than early detection. No multicenter screening studies in asymptomatic at-risk populations were identified, limiting a more accurate assessment of disease burden.

Conclusions: This study suggests that systematic echocardiographic screening for RHD in high-risk migrant populations in Europe may facilitate the identification of individuals with echocardiographic abnormalities requiring confirmatory evaluation. Combined with the fragmented European literature, these findings underscore the need for harmonized surveillance, larger multicenter studies, and careful evaluation of targeted screening approaches into migrant health programs to inform future epidemiologic and implementation research.

Lay Summary

What question did this study address, and why does it matter?

This study asked whether echocardiographic screening for rheumatic heart disease (RHD) can be implemented in migrant health assessments in Europe, and whether such screening could contribute to a better understanding of RHD in a potentially high-risk population. In addition, we sought to explore whether existing research suggests that RHD may be under-recognized in selected high-risk populations in Europe, particularly in the context of migration from endemic regions. To address this, we reviewed the current European literature to assess the extent of research activity and available evidence on RHD.

Where was the study done, and what were the main results?

The study was conducted in Munich, Germany, where 150 recently-arrived migrants aged 5–26 years underwent echocardiographic screening as part of a pilot program. Approximately 7% of participants showed cardiac abnormalities that may require further evaluation, although these findings do not represent confirmed diagnoses. In addition, a scoping review of 86 publications from across Europe was performed to contextualize the pilot findings within the broader European RHD literature. The literature was highly fragmented, with most studies originating from a small number of countries. Many focused on hospital-based management rather than early detection, and only a few addressed screening in at-risk populations such as migrants.

What do these findings mean in practice?

Given that early identification of RHD could help prevent long-term cardiac complications, echocardiographic screening may be a relevant component of routine migrant health assessments to identify individuals requiring further diagnostic evaluation. RHD may still be present in select high-risk groups in Europe, but appears to be insufficiently systematically monitored. Since current European evidence remains limited and fragmented, we recommend that larger studies be conducted to determine whether targeted screening should be implemented more widely.