Melomed Articles

14 February 2019 - Dr. Muhammad Chevaan Hendrickse

Matters of the Heart - What is rheumatic heart disease?

Heart awareness is one of the key steps in the detection, diagnosis and management of heart disease. September is Heart Awareness Month' and we put the spotlight on rheumatic fever and rheumatic heart disease.
What is rheumatic fever and rheumatic heart disease?

Rheumatic heart disease (RHD) is a chronic heart condition caused by rheumatic fever. Rheumatic fever is an autoimmune reaction to an untreated streptococcal infection, known a strep throat. The body will sometimes attack its own tissues (immunological attack) after it's been infected with the strep throat bacteria (Streptococcus). This reaction will cause widespread inflammation through the body, causing the symptoms of rheumatic fever: tiredness, joint pain, fever and a rash. The risk of developing rheumatic fever is also related to genetic susceptibility and to those who had prior infections. This, coupled with environmental susceptibility creates the milieu for the disease process to take effect. 

While the symptoms of rheumatic fever may disappear on their own, untreated rheumatic fever can cause rheumatic heart disease, where there is scarring of the heart valves causing severe heart valve damage. Heart valve damage may result in stroke, congestive heart failure and death.

Complications of rheumatic heart disease.
Carditis: Carditis means involvement of the heart muscle, valves and lining (the endocardial surface). The valves may be seen as an extension of the endocardial surface of the heart. One of the most common valves involved with rheumatic heart disease is called the mitral valve. The mitral valve forms the doorway' between the left upper chamber, named the left atrium, and the left ventricle, the main pumping chamber of the heart. The left ventricle pumps blood into the main blood vessel (aorta) and to the rest of the body. Another important valve often affected is the aortic valve, connecting the left pumping chamber (left ventricle) to the aorta and the rest of the body. 

Affected valves, may become severely inflamed and eventually scarred in a fairly characteristic manner, recognisable on cardiac ultrasound (echocardiography). In summary, roles may become tight/narrowed (valvular stenosis). Valves may also become incompetent, resulting in valve leakage (valvular regurgitation).

When valves are not working properly, blood may not travel in the correct direction, resulting in congestion  and cardiac chamber dilation. The heart may become enlarged, associated with symptoms of heart failure. Valvular heart disease, on the basis of rheumatic heart disease, typically becomes symptomatic, if significant in the late 20s and 30s (even sooner) and may require surgical correction. 

If heart damage from rheumatic fever is identified in childhood or young adulthood, antibiotics may be required to help prevent recurrence of rheumatic fever and avoid the development of infective bacterial endocarditis. Antibiotics (oral penicillin or erythromycin) can prevent streptococcal infection from developing into rheumatic fever as recurrent bouts of rheumatic fever may result in worsening carditis and worsening valvular heart disease.

A further complication of rheumatic fever and rheumatic heart disease is that of bacterial endocarditis. Endocarditis is a bacterial infection involving the heart lining and valves. It is a serious condition, requiring hospitalisation and intravenous antibiotics. The best form of management of endocarditis is that of prevention. Patients with severe rheumatic valvular disease, previous valve replacement and prior endocarditis are recommended to have prophylaxis prior to dental or certain surgical procedures. 

Prevention is better than cure! Prompt treatment of bacterial pharyngitis (strep throat) is advocated. Improving socioeconomic conditions is also an important cornerstone of primary prevention. A preventative strategy known as secondary prevention, is directed at the administration of penicillin.

With the onset of active carditis, a high dose of aspirin and possibly steroids is used. Steroids may be used in severe heart failure acutely. Heart failure therapy may entail the use of diuretics. 

In severe valvular disease associated with heart failure and severe symptoms, surgical valve replacement is the only option. Open surgical procedures involving mitral or aortic valve replacement is fairly common in general cardiology practice in Cape Town. Mechanical heart valves may be subdivided into metallic valves and tissue valves. When metallic valves are used, warfarin therapy is compulsory.

Although it is a reaction to a common infectious disease, RHD is a chronic condition that kills or debilitates young people in their most productive years, particularly in sub-Saharan Africa. Treatment of this disease is expensive and complicated. Community awareness is an important step in the treatment and prevention of rheumatic fever and RHD. Controlling a strep throat is effective and inexpensive and can prevent the development of rheumatic fever. In the spirit of heart month, let's overcome rheumatic heart disease.

Rheumatic Heart Disease (RHD) is permanent damage to the heart following rheumatic fever. 

Rheumatic Heart Disease can lead to heart failure and sometimes the need for cardiac surgery. A case of rheumatic fever can cause the heart to inflame and leave permanent damage to the heart, specifically the heart valves.


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