Dear Sir,

We have read with interest the articles published in the Journal concerning rheumatic fever (Mota C. Rheumatic fever in the 21st century. Cardiol Young 2003; 13: 491–494 and Ozkutlu S, Hallioglu O, Ayabakan C. Evaluation of subclinical valvar disease in patients in rheumatic fever. Cardiol Young 2003; 13: 495–499). We agree that rheumatic fever is far from being eradicated, even in the well-developed western countries, and that the epidemiologic features have changed, no longer being related to unfavourable socio-economic conditions, and with a more frequent carditis that may be difficult to detect. In the same period as the one analysed by Ozkutlu et al., specifically for the winter season over 1999 and 2000, we observed a remarkable increase in the incidence of new patients with rheumatic fever presenting to our Institution in Northern Italy, noting 17 cases instead of the usual 4–5 cases seen each year over the previous decade. Half of them were diagnosed late due to diagnostic difficulties encountered by family doctors. These patients had more severe lesions than the group diagnosed at earlier stages. In contrast to what is stated by Otzkutlu et al., however, our cases with mild mitral valvitis presented murmurs that could be mistaken for “innocent” murmurs, but were properly defined when auscultated by an experienced cardiologist. Our criterion for significant mitral regurgitation as judged using colour Doppler was a jet reaching one-third of the height of the left atrium, while Ozkutlu et al. considered as a cut-off of a jet extending 1 cm from the mitral valvar annulus, this criterion being less restrictive. It would be interesting to know the grades of mitral or aortic lesions in cases of patients deemed to have “innocent” murmurs in the experience of the Turkish group. We agree that Doppler echocardiography is fundamental for the recognition of mild lesions, but we feel that the family doctors should be aware of the fact that rheumatic fever still poses a significant problem, and that an early diagnosis allows a better prognosis. Our data also indicate an improvement in valvar lesions at follow-up in this new cohort of patients with rheumatic fever.¹