To the Editor.
—The American Heart Association's "Guidelines for the Diagnosis of Rheumatic Fever: Jones Criteria, 1992 Update"1 was most noteworthy for including "Exceptions in the Jones Criteria," which had been long overdue. This scholarly document, however, fell short of offering a complete 1990s update. In particular, the discussion on the role of echocardiography was inadequate. Echocardiography is the only new diagnostic tool for rheumatic fever to be introduced in the past two decades. Because echocardiography currently is a vital and integral part of cardiac evaluation, a 1992 update of its role in the diagnosis of acute rheumatic fever should have had a broader discussion, and more specific guidelines should have been offered.Three reports2-4 address the problem of silent mitral regurgitation associated with rheumatic fever. A study reported in 1987 from our institution with a large echocardiographic service (9000 studies per year) demonstrated pathological mitral regurgitation that