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CARDIOLOGY CHAPTER OF INDIAN ACADEMY OF PEDIATRICS
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Discussion from National IAP Consensus meeting on pediatric
acute rheumatic fever and Rheumatic Heart
disease2007Indian Academy of Pediatrics
(Vision2007)
Nodal Committee
Chairperson
Dr. R. K. Agarwal
Consultant Pediatrician. Udaipur
President elect central IAP 2008
Convener
Dr. Smita Mishra
Consultant Pediatric Cardiologist,
Max Heart & vascular Institute, New Delhi.
Co-Chairperson
Dr. Zulfikar Ahamed
HOD, Govt Medical College,Trivandrum
Chairperson Cardiology Chapter, Central IAP
Co-convener
Dr. Rani Gera
Consultant Dept of Pediatrics LNJP hospital
Secretary, Cardiology Chapter Central IAP
Advisory Committee
Dr. R.K. Agarwal,
Dr. Rani Gera
Dr J Singh,
Dr Y K Mishra
, Dr M Sharma,
Dr Simi Manocha,
Dr A Gupta
Special Contribution:
Dr Ashok Seth
Chairman, Max Heart & Vascular Institute
Saket New Delhi
Dr Anil Bhan
Director Cardio vascular Surgery
MHVI Saket New Delhi
Dr Pradipta Acharya,
Clinical Associate, MHVI Saket New Delhi
Conceptualization
Dr Naveen Thackar,
President IAP (year2007)
Dr. Deepak Ugra
Secretary IAP (Year 2007)
Dr H. P. Singh,
Professor of Pediatrics,
SS Medical college Rewa(MP)
Organization
Dr Ajay Gambhir
Vice President IAP(Year 2007)
Dr Anupam Sachdev
Consultant Pediatric Gastroenterologist,
Sir Ganga ram Hospital New Delhi
Mr Verma IMA
Content Author & correspondence : Dr Smita Mishra
Pediatric Cardiologist, MHVI Saket New Delhi
Contact : Dr Ashok Mittal Coordinator, Cardiology chapter IAP Andhra Pradesh
(dr_ashok_mittal@yahoo.co.in)
Discussion National IAP Consensus meeting on pediatric acute rheumatic fever and Rheumatic Heart disease2007
Content:
Chapter I (Introduction & Management of streptococcal Pharyngitis)
1. Introduction
2. Management of streptococcal pharyngitis
Prevention
Diagnosis
Investigation
Treatment
Chapter II (Diagnosis, treatment of ARF and associated manifestation)
.Management of Acute Rheumatic fever
1. Diagnosis
i. Description of major criteria
ii. Clinical features of carditis
iii .Defining the Recurrence of carditis
iv. Echocardiography
v Valve involvement in carditis
vi. Terminology
vii. Association of carditis
viii. Polyarthritis
ix. Chorea
x. Subcutaneous nodule
xi. Erythema Marginatum
xii. Minor criteria
xiii. Supportive evidence of preceding str infection
2..ARF: Goal of treatment:
a-Eradication of Group A Streptococcal Infection.
b- Symptom Relief & Anti-inflammatory treatment
General measures
7-9
7
7
7
8
8
9
9-19
9-19
9
10-13
10
11-12
11
11
12
12
12
12,13
13
13
13,14
14
1414
15
15,16
Anti-inflammatory treatment
i. Aspirin
16
ii. Steroids
17
Treatment of Heart Failure
17,18
Treatment of Chorea
18
Treatment of Atrial Fibrillation
18
Chapter III LONG TERM MANAGEMENT OF ACUTE RHEUMATIC FEVER & RHEUMATIC HEART DISEASE
1. Prevention of recurrences
19-23
Secondary prophylaxis
19,20
BPG sensitivity test/Pen administration
.Management of anaphylaxis
2. Prevention & Management of Infective Endocarditis
3. Anticoagulation for Prosthetic valve
Embolization in RHD
4. Intervention in valvular heart disease
a. Percutaneous valvuloplasties
b. Surgery
Chapter IV Guidelines for community out reach
Appendix:
.Acronyms & Abbriviation
Table1:Rheumatic Fever/Rheumatic Heart Disease status in India
Table 2. Definitions ARF/RHD
Table 3.. Investigations
Table 4. Clinical features of CHF
Table 5.Auscultation and other finding of valve disease
Table 6. NYHA classification
Table 7. Echo evaluation of regurgitant lesion
Table8 The prevalence of physiological valvular regurgitation in normal people:
Table 9. Warfarin Doses adjustment
Flow Chart: Management of ARF
Table 10. Vit K content of vegetables
Table11: Drugs affecting INR
Table 12. Clinical evaluation of prosthetic valve
Table 13. Thrombolytic Therapy for prosthetic valve
Table 14. X- ray evaluation of prosthetic valve
Table 15. Post intervention follow-up
Table16. SBE prophylaxis recommendations
Table17. SBE prophylaxis Recommendation for
Dental procedure
20-21
22,23,
24-27
27-28
28 -29
29-33
29-32
32-33
33-34
35
36
37
37
37
38
38
39
39
39
40
41
42
43
43
44
44
45
46
47
47
47
48
49-53
54
55-57
57-61
Chapter I
1. Introduction
2. Management of streptococcal Pharyngitis
1 Introduction 1-7 & 20
Acute rheumatic fever is a non suppurative complication of Group A beta hemolyticus gram positive
streptococcal (GABHS) sore throat. It affects joints, skin, subcutaneous tissue, brain and heart1,.Only
cardiac complications are significant, chronic and life threatening and require proper interventions. 2
Cardiac damage usually results from recurrent episodes of acute rheumatic fever. Early diagnosis and
secondary prophylaxis to prevent recurrent attacks, is the best possible way to avoid long term
cardiac sequelae.
Historically, Chorea, a neurological complication was probably first to get attention in 15 th -16th
century5, full spectrum of disease was recognized subsequently in early part of 19th century6. This
growing understanding resulted in evolution of clinical and laboratory based criteria for diagnosis , by
Dr T D Jone in 19447. These criteria underwent many revisions and modifications. Most latest revision
was done in1992 and later was accepted by WHO with some modification20..
Acute Rheumatic Fever and Rheumatic Heart Disease remains a cause of concern in rural and low
socioeconomic parts of India. This disease actually has its roots in child hood (5-15 yrs)2.
Prevalence in Indian population varies from 0.5 /1000 to 11/1000 in various studies. In developed
countries it is around 5 /100,000. Pediatric age group is the vulnerable population for residual cardiac
defects. Therefore, Indian academy of Pediatrics took the initiative and convened a national
consultative meeting at Delhi on 20th May 2007.
2. Streptococcal Pharyngitis: Prevention. Diagnosis and Treatment 12,13
Prevention:
There is no chance of getting a cost effective vaccine in near future.*14 Hence suggested preventive
measures are:
Use of handkerchief while coughing
Nonstreptococcal
Pharyngitis**
Age
Mode of onset
Initial symptoms
Fever
Characteristics of sore throat
5- 15 yrs
All
Sudden
More gradually
Sore throat with pain on swallowing
Mild sore throat
High - 38C
Not so high
Redness, tenderness of anterior Redness of the pharynx
cervical lymph nodes, hyperemia of Cough
the pharynx, petechiae on the palate, Hoarseness of voice
scabby erosions on the edge of Watery nasal secretions
nostrils. Clinical picture of scarlet Conjunctivitis
fever.
Throat cultures: Obtain specimen by vigorous swabbing of both tonsils and posterior pharynx.
Streptozyme tests for detection of GAS antigen: Not available easily.
**Non streptococcal Pharyngitis :Viral pharyngitis, adenovirus, enterovirus, herpes virus
influenza virus, other bacteria, Streptococci group C and group G, Neisseria gonorrhoeae
Mycoplasma pneumoniae, Chlamydia pneumoniae, Arcanobacterium haemolyticum
McIsaac Score: fever>=38c (+1),No cough (+1), Tonsillar exudates(+1),Tender ant cervical lymph node(+1)
Age<15(+1)Score >4highly predictive.
Current recommendations are based on discussions on safety, cost effectiveness, acceptability and
availability of drugs. Penicillins as a group show excellent eradication rate. Single dose of Benzathine
penicillin12,13 can eradicate the streptococci effectively with a very low cost and can be used for
supervised injections, at community level and strongly recommended for regular use as a first line of
drug. Adequate blood levels persist at least for 3 weeks with 1.2 MU & 2 weeks with 0.6 MU. Though
pain at injection site may often persist for 1-2 days, other adverse effects are far less common and
fear for them seems unjustified..(Anaphylaxis: see section on secondary prophylaxis)
However, lately, availability of injections has been a problem. Oral penicillin is cost effective and
needs a 10 days course. Penicillin V 12,13, unlike pen G is an acid resistant drug and yields greater
blood levels. Compliance with Azithromycin15 is expected to better due to single daily dose and five
shorter duration.. It is the third choice. Although superiority over BPG has been established.. Till now
resistance has not been reported. First and second generation Cephalosporins have shown good
sensitivity12,13. The older brands are available in market at reasonable price.
Antimicrobials preferably not to be used for GABHS pharyngitis
Tetracycline
High prevalence of resistant strain.
Sulfonamide
and
sulfamethoxazole
Chloramphenicol
10
Chapter II
1.Diagnosis
2.treatment of acute rheumatic fever and associated manifestation
1. Diagnosis of Rheumatic Fever: 16,17&23
Diagnosis: WHO adoption of (2004) revised Jones criteria 1992.9
Clinical & Lab criteria
Anti streptolysin O
anti-deoxyribonuclease B:
History of (within previous 45 days)
Streptococcal sore Throat
Scarlet fever
Positive Sore throat culture
Positive Rapid streptococcal antigen detection test
11
??Myocarditis19,20
(Literature suggests the so called
features of myocarditis are secondary
to valve regurgitation and not a true
myocarditis)
Unexplained Cardiomegaly.
Tachycardia
Congestive Heart Failure (CHF)
Soft S1/ S3 Gallop
Pericarditis
Pain
Rub
Effusion
12
9.
10.
11.
Role of Echocardiography : ECHO is not required to establish a diagnosis of ARF but in absence of
overt clinical signs, it helps to recognize undetected carditis (sub-clinical carditis)
It helps in differentiating the acute carditis from Endocarditis
Unlike ESR or CRP it is not a major or minor criteria but plays very significant role in establishing the
diagnosis of carditis, a major Jones criteria.
Terminology :
a. Recurrence: A new episode of RF following another GABHS infection; occurring > 8 wks
following stopping treatment.
b. Rebound: Manifestations of RF occurring within 4-6 wks of stopping treatment or while
tapering drugs.
c. Relapse: Worsening of RF while under treatment and often with Carditis (4%)
d. Sub clinical carditis: When clinical examination is normal but Echo cardiogram (ECHO) is
abnormal. (Around 30 percent of patients having chorea present as sub clinical carditis.)
e. Indolent Carditis: It is a common entity in our country. Patient presents with persistent
features of CHF, Murmur and Cardiomegaly. There are no or very few features of carditis
Association of severe Carditis with joint involvement
Arthritis
Arthralgia
No joint involvement
10%
33%
50%
60-75%
- 60 - 75 %
- > 95 %
13
Clinical presentation: Usually big joints are affected most (Knee> Ankle> Wrist> elbow >
Hip>shoulders rarely neck).Joints are warm, swollen, red and painful. Synovial fluid is sterile but has
inflammatory cells. Pain is out of proportion.
Character: Fleeting or Migratory. Inflammation in first joint starts to recede before involvement of
next joint.
Course : Occurs in first 2-4 weeks .Spontaneous resolution without residual defects. Magical
response to Aspirin.
Variant: Additive Arthritis (Involvement of many joint at a time).
Monoarthritis (? Early use of non-steroidal anti-inflammatory drugs). Must be differentiated
from post streptococcal reactive arthritis and monoarticular rheumatoid arthritis. In high endemic
areas possibility of rheumatic arthritis must be kept and close observation is indicated. Secondary
prophylaxis for a year can be considered during follow-up.
Polyarthralgia : Included in minor criteria.
Co-existence with other major criteria: : 50-75% may have associated carditis .10% cases have
moderate to severe carditis. Can co-exist with other major manifestations except Chorea which
presents late.
Jaccouds arthritis is a progressive deforming arthro-pathy of the hands and feet in young adults
following recurrent rheumatic fever/Systemic Lupus erythematosus.
Post streptococcal reactive Arthritis : This non-migratory arthritis occurs after a relatively short
latent period of a week following the episode streptococcal sore throat and lacks in dramatic response
to anti-inflammatory treatment. Mostly it is difficult to differentiate it from
True rheumatic arthritis. It may be wise to give secondary prophylaxis in presence of other Jones
criteria and evidence of recent streptococcal infection.
SYDENHAMS CHOREA 5,16,23-24,26 (Chorea derived from Greek word Khoreia means dance)
Onset: Chorea is a delayed manifestation (1-7 months) It has an insidious onset.
Clinical Presentation : Clinically it presents with irritability , emotional lability, uncoordinated
movements, muscular weakness and choreiform movement.. Many clinical signs can be seen or
elicited like, milkman grip, pronator sign, and Spoon disfiguration of wrist.
It can last for few days to several years.
Course : can persists for months to years. Recurrences are common.
Coexistence with other Major manifestations: association with Carditis is high. Arthritis almost
never co-exists.
Variants: Hemi chorea and chorea gravidorum can be manifestation of acute ARF.
PANDAS: Pediatric Autoimmune Neuro-psychiatric Disorders Associated with Streptococcal
Infections: it is believed that something very similar to rheumatic Chorea occurs. Till now diagnosis is
taken as hypothetical and no recommendations are made on it.
14
15
Minor
Clinical Presentation
Coexistent Major
Course
Manifestation
criteria
1. Fever
pattern
Chorea
2.Arthralgia
3. ECG
Prolonged PR interval.
Cause:? due to effect of RF on
conduction system
. PR Interval (Normal Value)
ESR
4.
LAB
CRP
Leuko
cytosis
PR prolongation is seen in
absence of Carditis.
.
ASO
ASO + Anti DNAs
POLYARTHRITIS
80%
95%
CARDITIS
80%
95%
CHOREA
30%
80%
The blood titers of antistreptolysin-O raised against extra cellular antigens of streptococci appear in
10 15 days and reach a peak in 34 weeks after the acute infection, and usually are maintained for
23 months before declining. 20% case may remain positive till 6 months.
In absence of any major Jones criteria, isolated antibody titer rise of any level just suggest a past or
present streptococcal infection and not the acute rheumatic activity. Hence unlike ESR and CRP it is
not a minor criteria. There is no need to treat high ASO titers with secondary prophylaxis (Benzathine
16
penicillin). To show the rising titer, in selected patients ( having high suspicion of ARF but normal
ASO titer) one can repeat it after 1 week . Routinely it is not recommended.
ASO titer must be done in a standardized lab and values must be used according to that lab standard.
The Streptozyme test :Is a screening test for antibodies to the streptococcal antigens NADase,
DNase, streptokinase, streptolysin O, and hyaluronidase. Although it detects several antibodies in a
single assay and is expected to be more sensitive. However, it does not determines specific
antibodies. It is less sensitive in children than adults. In fact, borderline antibody elevations which
could be significant in children, may not be detected at all. Hence it is not recommended as a routine
test.
ACUTE RHEUMATIC FEVER: GOAL OF TREATMENT 16,17&23
A. Relevant Lab Tests:
Throat Culture/ Rapid Streptococcal Antigen detection tests.
ASO, ESR, CRP, Hemoglobin (Hb), CBC, Platelet count
Kidney Function test, Liver Function test
CXR, ECG,
Echocardiography.- see above.
?? Blood c/s & Coagulation profile in selected group of patients
Appropriate serological/ blood investigation according to clinical scenario.
B. Treatment of acute rheumatic fever and associated manifestation
I.
Eradication of Group A Streptococcal Infection.
II. Treatment of acute Rheumatic episodes
I. Eradication of Group A Streptococcal Infection.
(Treatment recommendations are same as for the streptococcal sore throat.)
II. Treatment of acute Rheumatic episodes:
17
i.
ii.
iii.
iv.
v.
vi.
assess the
3. Diet:: One should ensure adequate nutrition to growing child. Preventive measures like salt
restriction should be logically used. Enforcement of too rigid diet restrictions may lead to further
nutritional compromise.
4. Constitutional symptoms: Fever, mayalgia, loss of appetite and anemia improve with
management of RF and do not need specific measures.
5. Hospitalization:
i. If Diagnosis is not clear.
ii. To start secondary prophylaxis in group of patients carrying the high risk for allergic reactions like
history of atopic dermatitis, Asthma, reaction to any other substance.
Iii Acute Rheumatic fever with severe carditis, uncontrolled CHF, chorea and some times with severe
arthritis
iv. Patient is not doing well on appropriate treatment.
v. Patient having prolonged or unexplained fever.
vi. Illiterate patients /Patients with anxious parents: To make patient comfortable and to provide
adequate supervision and counseling to the family.
Aspirin*
To
achieve
serum
level
30mg/100dl.#
10-20mg/kg/day
intolerance detected)
No response to Aspirin Then rule out other conditions like Chronic
in 4 days
18
Moderate to
Steroids ***
severe Carditis
Non responders
Methyl Prednisolone23
(Intravenous)
*This group of experts strongly believed that Aspirin can be given in doses of 50 to 60 mg//kg /day for
full 12 weeks with good response, better gastric tolerance and less chances of toxicity. Although this
observation has never been mentioned in literature. With this observation treating pediatrician/
cardiologist can use his or her own discretion. Aspirin dose can be upgraded in absence of predicted
response.
One must ask for black stools and other features of gastric intolerance. Medicine must not be taken
empty stomach. Antacids must be supplemented.
If possible children should get vaccinated for Influenza and chickenpox.
Monitoring for Rheumatic Activity:
Monitor ESR and CRP to monitor anti-inflammatory Response after 7 days , 15th day and 30th day
sand 3 months (rebound/relapse).
Monitoring for Drug Side Effects : Watch for complaints of epigastric pain, black stools or frank
blood in stool & steroid effects like Cushingoid facies. Patients on steroid have propensity to catch
infections or reactivation of dormant co-morbid condition like tuberculosis. Sever infection may go unnoticed. Parents must be counseled for these effects.
Prolonged steroid therapy has less chances of aspirin induced GI bleeding but may have growth
related issues. There is no additional advantage in terms of residual cardiac effects
Sedative
like
diazepam is useful.
Valproate: 15 mg/kg/day
19
Resistant Chorea:
Plasmapheresis
Pimozide
If features of rheumatic activity (ESR, CRP, ASO) are present treat with Anti-inflammatory drugs as
given above.
Treatment should be continued 2-4 weeks after clinical improvement.
Diuretics
ACE inhibitors
Captopril: 0.25 mg/kg: Test dose. Build up doses from 1.5mg/day to 3 mg/kg/day in three
divided doses.
Sodium Nitroprusside
(Uncontrolled CHF)
Inotropes
Surgery
20
level of vagal and sympathetic tone, the presence or absence of accessory conduction pathways, and
the action of drugs.
Treatment of Atrial Fibrillation
Associated with chronic Valvular heart disease. Clinical presentation :Irregularly Irregular pulse.
ECG: Fibrillatory wave .
Rate Control:
Rhythm control
Electrical:
Cardio-version.*
Pharmacological
Amiodarone. Flecainide
Anticoagulant
Warfarin to achieve INR of 2-3. Avoid Vitamin K containing food like green
leafy vegetables.
Surgery
* Rule out left atrial clot and start anticoagulant before cardioversion
3. Chronic Valvular Heart Disease
Management 64-89 RHD primarily targets mitral and aortic valve and rarely tricuspid valve . Chronic
regurgitant lesions are better tolerated and can be medically managed for longer duration. Basically
management requires:
1.Good adherence to Benzathine penicillin prophylaxis preventing the second attack of ARF.
2.Diuretics (Thiazide or loop diuretic + /- K+ sparing diuretic like aldactone)
3.Vasodilators: Angiotensin converting enzymes inhibitors like Captopril.
4.Digoxin, most commonly indicated in presence of Atrial fibrillation &CHF
5.Management of associated arrhythmias. Commonest arrhythmia is Atrial fibrillation (see above)
6.Anticoagulation
Acute lesions or obstructive lesion may need immediate intervention.
Patients with surgical and cath intervention has to be followed up at long term basis for various issues
like secondary prophylaxis , anticoagulation, cardiac function and associated valvular lesion.
Valvuloplasties:
Most encouraging results are seem in patients with mitral stenosis only.
Mitral Stenosis:
Clinical features (ref:Table3)
21
Indications of BMV :
BMV required after basal assessment
CONTRAINDICATION
-LA clot (contraindication to BMV)
-Subvalvar apparatus: Unsuitable
Calcified valve
-Associated lesions of other
22
Successful BMV:
-MVA-> 1.5 cm2
-Increase in MVA->50 %
-< grade 2 MR
-Qp/Qs-<1.5
commissurotomy
-Balloon increases mitral valve
flexibility by fracturing calcified
deposits in MV leaflets
valves
-Commissural severe fibrosis
-MR grade III or more
Mitral Regurgitation
Indication:
Uncontrolled CHF
-LVEF FALLING<55%
-.Fractional shortening falling < 30%
-.LVEDd: > 7.5 cm
-.LVEDs: > 5cm or 2.6cm/m2
--LVESV: >60ml/m2
-.Radius: wall thickness ratio at end systole multiplied by
systolic pressure: 195mmHg
-.PA pressure> 50mmHg
Treatment Modalities
MV repair: Early intervention
MV replacement : One must wait
23
Aortic Valve
Isolated Aortic stenosis is less common than combined lesion.
If AS is isolated, think of pathology like Bicuspid AV.
Rheumatic AS : Result of balloon valvuloplasties are bad and valve replacement is choice. Ross
procedure is not a good choice in these cases & must be avoided.
Indication if intervention in Aortic valve disease
Aortic Stenosis
Aortic Regurgitation
Symptomatic patient
EF falling <40%
Mean gradient >40mmHg
LVES:<25 %
Aortic valve area <1.0cm2
LVEDd: 7 mm or 3.8cm/m2
Calcified valve
LVEDs: >5cm or >2.6cm/m2
AR is associated
Radius/ wall thickness ratio at end diastole
Presence Of Vegetations
multiplied by systolic BP >600mmHg
Ross J Jr: J Am Coll Cardiol 5: 811,1985
Treatment:
Repair / replacement
In patient showing symptom/systemic congestion, RV dysfunction
e. Treatment of Rheumatic Fever- Specific Points
Diagnosis must be established before initiation of treatment.
When CHF is intractable Invariably due to severe MR or AR. Valve replacement may be the only
chance of survival.
Aspirin and steroids suppress acute phase reactants, but do not modify the course of illness.
(Table :see Appendix)
24
Chapter III
LONG TERM MANAGEMENT OF ACUTE RHEUMATIC FEVER & RHEUMATIC HEART
DISEASE
1-Prevention of Recurrences: Secondary Prophylaxis (Section III)
2- Endocarditis Prophylaxis (SectionIV)
3. Management of Thrombo-embolism in RHD- Anticoagulation (Section V)
4. Intervention in valvular heart disease (Section VI)
1.Prevention of Recurrences
a. Secondary Prophylaxis 44-50
b.. Management of Anaphylaxis 51-52
a. SECONDARY PROPHYLAXIS 16,17.23
Definition : Secondary Prophylaxis (World Health Organization 2001)
Secondary prevention of rheumatic fever is defined as the continuous administration of
Specific antibiotics to patients with a previous attack of rheumatic fever, or well-documented
Rheumatic heart disease. The purpose is to prevent colonization or infection of the upper
Respiratory tract with group A beta-hemolytic streptococci and the development of recurrent
attack of rheumatic fever.
SIGNIFICANCE
Prevents recurrence of GAS infection, which can lead to recurrent ARF.
Reduces severity of RHD (can result in cure of RHD after many years).
Helps prevent death from severe RHD.
{RHD control programme (NHFA)}
Indications
ARF confirmed by the Jones Criteria
RHD confirmed on echocardiogram
Chorea
Points to be remembered:
a. Benzathine penicillin Remains the corner stone for Rheumatic Fever Prophylaxis.
b. ISOLATED ASO TITRE IS NOT A CRITERIA TO START SECONDARY PROPHYLAXIS.
25
c. Secondary prophylaxis is mandatory after cath or surgical intervention (2004 update of WHO
recommendation )
d. Patients with previous drug allergies must be treated more cautiously.
e. Benzathine penicillin should be continued during anticoagulant therapy. (except if INR is very
high.)
f. Allergic reactions to Benzathine penicillin are rare but may be fatal.(Alternative drug:
Erythromycin)
g. Anaphylaxis is a life threatening complication of BPG injection but it is not the only cause of
death. Death usually may occur after inadvertent IV injection leading to embolism and due to
vaso-vagal attack in patients with severely decompensated carditis. Occasional report of
Gangrene is most probably due to intra vascular injection)
Secondary prophylaxis in Pregnancy
Penicillin causes no risk to fetus during pregnancy.
Erythromycin can be continued during pregnancy to prevent ARF.
Doses of Benzathine Penicillin G
Injectable Benzathine Penicillin G most effective for secondary prophylaxis.
Deep intramuscularly
1.2 lakh for ALL people >=27 Kg every 21 days
6 lakh units for children< 27kg every 15 days.
Alternative Treatment
1. Penicillin V: is used in absence of Benzathine penicillin or if there is bleeding disorder.
Oral penicillin is not a very effective drug.
2. Erythromycin
Dose: ref table
Drugs preferably not to used for secondary prophylaxis
Benzyl penicillin IM/IV
Procaine Penicillin IM
Duration Secondary Prophylaxis
1.ARF (No carditis): Minimum of 5yrs after ARF or until 18 yrs age (whichever is longer)
2.Mild to Moderate Carditis (Healed Carditis): Minimum 10 years after last ARFor until age 25 years
(whichever is longer)
3.Severe RHD or following cardiac surgery:
Continue for life (WHO 2004 update) (Class 1 evidence).Second option is to stop it at the age of 40
years. (Class 2 evidedence)
26
benzylpenicilloate and benzylpenilloate. Unfortunately, This is difficult to comply in India where these
reagents are not available commercially .
Due to the fact that BPG is unsuitable for Intradermal injections sensitivity testing ,current IAP
recommendations are to use Benzyl penicillin for the skin testing. This method is not capable of
detecting all cases of possible penicillin allergy. Up to 4% of patients with a negative skin test to both
the major and minor determinants will develop non-life-threatening allergic reactions if they receive
penicillin again. A penicillin skin test predicts only the presence of IgE antibodies for the major or
minor penicillin determinants at the time of application and does not predict the future development of
IgE-mediated reactions during subsequent courses of penicillin. A penicillin skin test does not predict
non-IgE-mediated reactions caused by other immune mechanisms, such as cytotoxic antibodymediated reactions, antibody-antigen immune complex-mediated reactions, and delayed-type cellmediated reactions.
How to do senstivity test
Benzyl Pen 10,000 U/ml to be given for sensitivity test. Prick test must be used before intra dermal
test for the patients getting their first injection (A drop of Benzyl Penicillin 10,000/ml to be kept on
forearm volar surface- scratch with bifurcated needle).Then Intradermal test with both Benzyl pen
and control saline must be done (approximately 0.02ml at volar surface of fore arm or lat surface of
arm). A wheel 2 mm more than control or 4 mm more than initial edema must be taken as positive
test. Rest of injections must be preceded by Benzyl pen Intradermal test.: ( Test reading time:1530min)
(Control saline helps in recognizing the initial oedema due to intra dermal injection, if available, use of
histamine is helpful to recognize person incapable of producing skin response. )
The patient should not have taken antihistamines recently (e.g., chlorpheniramine maleate or
terfenadine during the preceding 24 hours, diphenhydramine hydrochloride (HCl) or hydroxyzine
during the preceding 4 days, or astemizole during the preceding 3 weeks).
Administration of benzathine penicillin
a. Site of injection
Deep intramuscular injection into upper and outer quadrant of buttock or anterolateral thigh (can be
converted in two injections at two different site)
b. Check medication and expiry date
c. Use 23 gauge needle if 12 lakhs is diluted in 6 ml water for injection.
c. Can be given through 20 G needle if 12lakhs is diluted in 3 ml of sterile water.
d. Benzathine penicillin is poor water-soluble drug. It should properly shaken after taking it in syringe.
Needle should be cleared and immediately prick must be done into deep muscular tissue. One must
withdraw the piston to detect any amount of blood. Once sure, push the drug without changing the
position of tip of needle to avoid any vascular access. Benzathine penicillin containing syringe is
prone for both- stuck needle and stuck syringe. One should not try to re-adjust needle position. Bring
it out and again check and prick.
e. Dispose used needles and syringes in puncture proof container.
Patient must be enquired about pain any nodule at the site of injection and h/o limping or weakness of
limb.
Secondary prophylaxis is a prolonged process. Every attempt should be made to take family in
confidence. Risk of anaphylaxis, injection related pain and risk of avoiding it must be explained in
27
detail. It might be a good idea to start secondary prophylaxis in second or third visit and to start in
presence of two doctors. It may be a good idea to get it endorsed by senior most Person from the
set-up and at least first injection to be given in a place, which is fully equipped with life saving drugs
and equipment.
Pain Reduction
a. Warm cold syringes to room temperature between hands
b. Apply gentle pressure for 10 seconds with finger or thumb before injection
c. Ensure skin swabbed with alcohol is dry before injection
d. Deliver the injection slowly over 2-3 minutes
e. Encourage movement before injection
Ceasing Secondary prophylaxis
Date for ceasing should be recorded
Assessment of patient should be recorded
Time since last ARF illness
Specialist review
Echocardiogram
b. Anaphylaxis:
a. Sudden and generalized reaction to the injection or ingestion of some antigen to a previously
hypersensitive individual.
b. Anaphylactic reaction: Occur at any age
c. Incidence: 0.004 to 0.04% in patients treated with penicillin- (Kucers & Bennett, 1987)
d. 0.001% of patients die due to anaphylaxis after use of penicillin ( 1/3 have previous history of
reaction to the drug)
e. Most commonly seen with Parenteral injection;
f. Rare with ingestion and after Intradermal skin test
Management of anaphylaxsis in the outpatient clinic
Clinical features:
The manifestations are many and variable.The most dramatic and constant feature of this process is
the rapidity of onset.
PREMONITORY SYMPTOM
Frequent.
commonest are not feeling well, itching
,around
the
eyes,
sneezing,
hoarseness of voice, anxiety and
lacrimation
28
Personnel: At least one nurse trained in cardiac resuscitation in addition to the physician.
Drugs: Adrenalin (1: 1000) loaded in 2 ml syringe
Adrenalin (1: 10,000) loaded in 10ml syringe
Venous access: Before the test dose is administered or be ready for IM injection. Given at
right time equally effective
Volume replacement : Normal saline,Haemaccel, Haestril-6%, 10% dextrose.
CONCLUSION 44-52
-Anaphylaxis is a rare but dreaded complication with Benzathine penicillin which is completely
reversible if managed with timely adrenaline , volume replacements and rarely with active
29
Moderate risk
Acquired valvular heart disease (RHD)
Residual lesion after valve repair
Others
30
Cardiac Symptom:
31
Native valve
IV Penicillin G 200,000 U/kg/d in 46doses
/Ceftriaxone
sodium100mg/kg/d
once daily +
gentamicin3mg/kg/d in 2-3 dose
x 4weeks
If
allergic
to
penicillin:
IV
Vancomycin40mg/kg/d in 2 doses +
gentamicin
B.Staphylococcal Infection Oxacillin/Nafcillin 200mg/kg/d IV in 4-6
doses
for 4-6 weeks
(+Gentamicin for first 3-5 days)
If allergic to penicillin: Vancomycin
in place of oxacillin/Nafcillin
Enterococcal Infection
Penicillin G + Gentamicin for 4 weeks
If
allergic
to
penicillin/penicillin
resistant:
Vancomycin+Gentamicin for 6 weeks
Prosthetic valve
IV Penicillin G/Ceftriaxone sodium +
gentamicin x6 weeks (same dosage)
If allergic to penicillin: IV Vancomycin +
gentamicin
Treatment of
Negative
Endocarditis
If
suspecting
infection:
Culture Vancomycin
+
gentamicin
+
Infective Ciprofloxacin
for
4-6
weeks
(Ciprofloxacin dose: 20-30mg/kg/d
IV/PO in 2 doses)
fungal AmphotericinB IV
PO
+ flucytosine AmphotericinB IV
+ flucytosine PO
Crystalline Penicillin is still a very effective antibiotic for streptococcal and enterococcal
endocarditis
For those allergic to penicillin/cephalosporines, vancomycin is the best alternative (if renal
parameters are normal)
Prosthetic valve endocarditis is difficult to treat, carries high mortality. Rifampin should be
added to antibiotic regimen and duration of treatment should be longer (8 weeks)
For culture negative endocarditis treatment should start with vancomycin plus gentamicin
Outpatient IV or oral antibiotic treatment for IE ?; till now no role.
32
d.
e.
f.
g.
h.
Heart block
Annular abscess/destructive lesions
Dehiscence of prosthetic valve
Recurrent embolisation
Large, mobile vegetations (> 10 mm in size)
33
1 day
3-4 day
Start Warfarin
INR 2.5, stop IV Heparin
34
If thrombus or vegetations are seen one must be aggressive in therapy. Prosthetic valve thrombus or
vegetation may need urgent surgery. CNS event may be life threatening hence hospitalization is
essential.
Chapter IV
Guidelines for community out reach
Guidelines for community out reach and collecting Epidemiological Information for Rheumatic
Fever and Rheumatic Heart Disease:
A number of studies have attempted to document RF incidence and RHD prevalence in India. School surveys are
traditionally considered useful for this purpose because the denominator is clear. However school surveys have serious
limitation due to possible non inclusion of susceptible population due to school drop outs or sick children not attending the
school and poor staying at home.
It is important to recognize, however, that data from these highly selected regions are not perhaps representative of the
country as a whole. The parts of the country with the highest prevalence today are also those regions with the poorest
health care infrastructure. Most comparative studies have reported a substantially higher prevalence in rural regions.
Because of serious limitations in the health care delivery systems, the magnitude of the problem remains unrecognized in
many poorly served regions. Very few systematic surveys are available from rural populations with a poor health care
infrastructure, urban slums and tribal colonies. Given the extraordinary variations in indices of human development across
the country and even within regions, it is difficult to make generalizations for the entire country
This observation was endorsed by all participant in meeting . Our group of experts have proposed verification of data from
the states having low per capita income.
Guidelines for Community out reach:
To take RHD prevention program to community levels: Use of existing Health care system.
Role of Government:
Role of Medical colleges/Civil hospitals and associated ancillary services
Role of IAP.:
Role of Paramedics:
Role of Government:
-Accept RHD prevention
programme
-Set-up goals & budget
allocation
-Sensitize health care
system
-Procure BPG & ensure turn
over
Cardiac patients must be
Role of Paramedics:
Must know
-doses and how to dilute the
Benzathine penicillin
- be trained for IM injection
and learn precautions.
- how to do sensitivity test.
-be trained in recognizing and
managing Anaphylaxis.
-t be trained to handle life
support .
-Record Keeping.
-RHD card: entry of every inj
like in Vaccination./INR
monitoring Card
considered as physically
handicapped and given
facilities for treatment.
Introduce insurance
policies.
35
APENDIX
:ACRONYMS AND ABBREVIATIONS
2DE
two-dimensional echocardiography
anti-DNase B
anti-deoxyribonuclease B
ARF
ASO
anti-streptolysin O
AVA
BP
blood pressure
BPG
benzathine penicillin G
CRP
C-reactive protein
ECG
electrocardiogram
ESR
GAS
group A streptococcus
HR
heart rate
INR
IVIG
intravenous immunoglobulin
LMWH
LVEF
LVEDD
LVESD
LVOT
MVA
NHFA
NSAIDs
NYHA FC
PAS
PBMV
RHD
RR
respiratory rate
Str
Streptococci
TDD
UFH
unfractionated heparin
ULN
velocity
WHO
INR: International Normalized Ratio = (x/y)z , where x = Prothrombin Time of sample (sec)
y = Mean Normal Prothrombin Time (sec) ;z = [ ISI of Thromboplastin}]
36
79-83
ICMR
Delhi
Year
19821990
Age (yrs)
515
Population studied
13,509
Padmawati
Grover et al
Lalchandaniet al
Jose and Gomathi
et al
Delhi Urban
Rajpurrani
Kanpur
Vellore
1984-1994
1988-91
2000
2001-2002
5-10
5-15
7-15
5-18
40,000
31,200
3953
229,829
3.9
2.1
4.5
0.68
Soman et al**
Ernakulam
2002-04
5-16
25 033
0.12*
Author
Place
Mishra et al
Gorakhpur
2003-2006
4-18
118,212
0.5
** Unpublished data of the Jaivigyan ICMR rheumatic fever and rheumatic heart disease in Ernakulam district
37
Diagnosis of RHD
Reliable auscultation is sufficient for the diagnosis of RHD in most of cases. However , some case may require
confirmatory echo.
Definite: Isolated MS. MS/M R. MS or MR with AR. Isolated MR with documented h.o ARF. Isolated MR(echo)
Probable: Isolated AR(Bicuspid AV excluded on echo).Clinical exclusion of Marfans syndrome.
Suspected: Rest of case can be referred to cardiologist for echo confirmation.
All suspected valvular lesion in absence of special clinical setting like Marfans syndrome should be taken as rheumatic
and should be subjected to further investigation.
Table3: Investigations:
White blood cell count/ Erythrocyte sedimentation rate/ C-reactive protein
Blood cultures if febrile
Electrocardiogram (repeat in 2 weeks and 2 months if prolonged P-R interval or other rhythm abnormality)
Chest x-ray if clinical or echocardiographic evidence of carditis
Echocardiogram (consider repeating after 1 month if negative)
Throat swab (preferably before giving antibiotics) culture for group A streptococcus
Anti-streptococcal serology: both anti-streptolysin O (anti-DNase B titers) if available (repeat 1014 days later if first test not
confirmatory)
Rapid group A strep Ag tests : Can be done in 5 minutes with specificity of 98%.All rapid group A strep tests require a sample from
the infected patient's throat. The sample is obtained by depressing the tongue and swabbing the back of the throat and tonsils,
while avoiding the tongue, saliva and lips. Swabs made of rayon or Dacron should be used. Swabs containing cotton, calcium
alginate, or wooden shafts, or that have been placed in transport medium containing charcoal are not recommended.(Not available
)
38
MS
Loud
Loud P2
Normal S2
S3
S4
Murmur
Syst/Diastolic
Radiation of
murmur
Best heard on
precordium
Chest X-Ray
findings
ECG findings
MR
Soft/Absent
Wide Variable split
(A2 advances)
Low pitch
If Ac Severe MR +
Opening snap followed Holosystolic murmur
by delayed diastolic
+MDR
murmur with pre
systolic accentuation
Axilla
At apex pt in Lt lat.
position
AS
Narrow paradoxical
split
If LV H
S4+(severe AS)
ESM
AR
soft
A2 delayed or
accentuated
S3 s/o Significant LV
dysfunction
High pitch blowing
Decrescendo+ ESM
+Graham steel M
Carotid Artery
Apex increased by
isometric strain
decreased by Valsalva
Straightening of left
LA enlargement
Heart border Prominent Pulm venous
MPA .Prominent upper congestion. Interstitial
lobe veins.
edema
Kerley s B line
Valve calcification
P Mitrale, RVH
LA enlargement.AF may LVH LV strain pattern LVH
be present+
T inversion Lead1AVL LV strain+
LVH+LAD
Lt Precordial lead
QRS prolongation.
39
Physiological regurgitation is characteristically localized at the region immediately below or above the plane of valve
leaflets (or within 1.0 cm), and the signals are short and the maximum regurgitant area small.
The appearance of physiological valvular regurgitation in healthy subjects with structurally normal hearts varies with the
devices, sensitivity, penetration power and techniques used, with changes in systemic and
pulmonary vascular resistance and pressure, and with body habitus and age.
92- 95%
20-25 %
5-8%
Tricuspid valve
7-9 %
Pulmonary valve
Very rare
Table9.Warfarin Sodium: Monitoring and Dosage Adjustment(Use standardized lab for the INR
monitoring)
INR
Action
>10.0
7.0-10.0 Stop warfarin for 2 days; decrease weekly dosage by 25% or by 1 mg/d for next week (7 mg total); repeat
PT in 1 week.
4.5-7.0 Decrease weekly dosage by 15% or by 1 mg/d for 5 days of next week (5 mg total); repeat PT in 1 week.
3.0-4.5 Decrease weekly dosage by 10% or by 1 mg/d for 3 days of next week (3 mg total); repeat PT in 1 week.
2.0-3.0
No change.
Increase
1.5-2.0 weWeekly dosage by 10% or by 1 mg/d for 3 days of next week (3 mg total); repeat PT in 1 week.
Increase
<1.50 weWeekly dose by 15% or by 1 mg/d for 5 days of next week (5 mg total); repeat PT in 1 week.
40
(ICMR guidelines )
Suspected RHD
Carditis
Poly Arthritis
Salcylates
100mg/kg
72hrs Dramatic
improvement
Contd x 2wks
Taper: 5080mg/kg(upto12 wks)
Monitor
for Rh.
Activity
/rebound
NO
Onset of carditis Do
echo if available
Chorea
Yes ------------------
Monitor Carditis
No
Carditis
Mild
carditis
Echo if required
SECONDARY PROPHYLAXIS
No
carditis
Mod to severe
Salcylate
(same as in arthritis)
Decreased INR:
Carbamazepine,Barbiturates
Rifampicin
Green pea
Phenytoin first increases then decreases the INR
41
s
.Dietary restriction is utmost important once the anticoagulants are started. Vegetables particularly rich in Vit K counter the effect
of Warfarin which has its action through vit K inhibition. If we know the vit K content of food Item we can make a flexible menu by
adjusting the dose of warfarin . Making food more palatable is important for growing child whos nutritional requirements are
much more than adults. For values see : home page www.cardioiap.org
Table 12:Clinical Evaluation Prosthetic heart valve:
Aortic prosthetic valves:
Accentuated Sounds(Inflow valve-S1 ; Outflow valve S2)
Ejection Systolic Murmur: All prosthetic AV have ESM because of their smaller orifice size. Loudest sound is produced by
Caged ball and small porcine valves.
Low Grade diastolic murmur : Tilting disc valves and bileaflet valves do not occlude their outflow tract completely when
closed, allowing some back flow.
. Suspect prosthetic aortic valve failure in a patient with Muffling of sounds, a greater than 2/6 diastolic murmur. Caged ball
and tissue valves cause no diastolic murmur since they completely occlude their outflow tract in the closed position.
Consider any degree of diastolic murmur in these patients pathologic until proven otherwise.
Mitral prosthetic valves:
Low Grade Systolic murmur:Caged ball valves may cause a low-grade systolic murmur due to the turbulent flow caused by
the cage projecting into the left ventricle. Consider any holosystolic murmur greater than 2/6 pathologic in a patient with an
artificial mitral valve.
Short diastolic murmurs: may be heard with bioprostheses and, occasionally, with the St. Jude bileaflet valve. These are
best heard at the apex with the patient in the left lateral decubitus position.
Absence of a normal valve closure sound (clicks) or presence of an abnormal regurgitant murmur is an important clue to the
presence of prosthetic valvular failure.
Subacute valve failure may present with hemolytic anemia or gradually worsening of CHF.
Patients with acute valvular failure present with cardiogenic shock and severe hypotension.
Evidence of poor tissue perfusion is present, including diminished peripheral pulses, cool or or mottled extremities, confusion
or unresponsiveness, and decreased urine output mottled extremities, confusion or unresponsiveness, and decreased urine
output.
42
Silastic ball impregnated with barium that is mildly radiopaque (but not in all models)
Medtronic-Hall tilting disc valve Radiopaque base ring Radiopaque struts that project into base ring:
3 small ones and 1 large hook-shaped one Occluder disc that is mildly opaque
But often cannot be seen. The base ring and two struts are radiopaque.
St. Jude medical bileaflet valve Mildly radiopaque leaflets are best seen when viewed on end. Seen as radiopaque lines
. Base ring is not visualized on most models. when
Carbo Medics bileaflet valves: Valve housing and leaflets are radiopaque and easily visible.
Carpentier-Edwards porcine valve: The tall serpiginous wire support is the only visualized portion.
Hancock porcine valve :The radiopaque base ring is the only visible part in some models.
Other models have radiopaque stent markers with or without a visible base ring.
43
High-risk category
*Prosthetic cardiac valves, including bioprosthetic and
homograft valves
*Previous bacterial endocarditis
Moderate-risk category
*Acquired valvular dysfunction (eg, rheumatic heart
disease)
*Dental extractions
retraction cord3
*Fluoride treatments
*Taking of oral radiographs
*Orthodontic appliance adjustment
*Shedding of primary teeth
44
Respiratory tract:
Respiratory tract:
*Endotracheal intubation
Gastrointestinal
tract1:
Gastrointestinal tract:
Genitourinary tract:
*Prostatic surgery
*Vaginal hysterectomy2
*Cystoscopy
*Vaginal delivery3
*Urethral dilation
*Cesarean section
-In uninfected tissue:
*Urethral catheterization
*Uterine dilatation and curettage
*Therapeutic abortion
*Sterilization procedures
*Insertion or removal of intrauterine devices
Other:*Cardiac catheterization, including balloon angioplasty
*Implanted cardiac pacemakers,implanted defibrillators, and coronary stents
*Incision or biopsy of surgically scrubbed skin, Circumcision
45
Table19:Endocarditis Prophylactic Regimens for Dental, Oral, Respiratory Tract and Esophageal Procedures
Situation
Agent
Regimen*
Amoxicillin
Adults: 2 g
Children: 50 mg per kg
Taken orally one hour before the procedure
Ampicillin
Adults: 2 g
Children: 50 mg per kg
Given IM or IV within 30 minutes before the procedure
Clindamycin (Cleocin)
Adults: 600 mg
Children: 20 mg per kg
Taken orally one hour before the procedure
or
Cefadroxil (Duricef)
or cephalexin
(Biocef, Keflex)
Adults: 2 g
Children: 50 mg per kg
Taken orally one hour before the procedure
or
Azithromycin (Zithromax)Adults: 500 mg
or clarithromycin
Children: 15 mg per kg
(Biaxin)
Taken orally one hour before the procedure
Patient is allergic to penicillin and is unable to take oral medication Clindamycin
Adults: 600 mg
Children: 20 mg per kg
Given IV within 30 minutes before the procedure
or
Cefazolin (Ancef, Kefzol) Adults: 1 g
Children: 25 mg per kg
Given IM or IV within 30 minutes before the procedure
46
Pregnancy with
Obstructive lesion(MS/AS)
Hemodynamically Unstable
Cardio version
47
Anti coagulation:
Target INR 2-3
Principle as for prosthetic valve
Drugs
Indications
Doses
Comments
Str pharyngitis
ARF
Secondary prophylaxis
Antibiotics
Benzathine Pen
Penicillin V p/o
Sec prophylaxis
250 mg BD children
Follow up protocol
Erythromycin ethyl
48
10days
to penicillin)
Sec Prophylaxis
20mg/kg BD
Follow-up protocol
Azithromycin
12.5mg/kg
5 days
Cephalexin
10 days
Codeine p/o
Arthritis or
arthralgia mild
or NSAID started
or until diagnosis
confirmed
medical supervision
same
0.51.0mg/kg/dose (adults
or NSAID started
See page no 18
Confirmed ARF
Naproxen p/o
Prednisolone
intolerant)
bid
See Page no 18
Diuretic Therapy
Frusemide po/IV (can also be Heart failure
given IM)
(max 6mg/kg/dose)
Adults: 2040mg/dose 1224 hrly,up to
250500mg/day
Spironolactone p/o
same
49
Same
Same
Same
Same
Same
Same
up to 1mg/kg/dose
Adults: 2.520mg once daily
(max 40mg/day)
Digoxin
Digoxin po/IV
Children:
Fibrillation
Clinical decision
Management of Chorea
Carbamazepine
Severe chorea
720mg/kg/day (710mg/kg/day
Valproic acid po
Same
Usually 1520mg/kg/day
Same
Same
0.5-2.5mg tid
Same
Pimozide
Chorea
0.2 mg/kg/d
Same
50
Flecainide
AF (Pharmacological conversion)
50-100mg/m2/day or 6-9mg/kg/day in
three divided doses
Propanolol
AF (rate control)
Atenolol
AF (Rate control)
Metoprolol
Rate control AF
Sotalol
Amiodarone
2-8mg/kg/d bid
Pharmacological cardioversion
Diltiazem
AF(adult)
loading:10-15mg/kg/d
0.25mg/kg/iv over 2 min. Maintenance
:2mcg/kg/min 120 360 mg /day
D-C shock
AF
CHF(uncontrolled)
2-20mcg/kg/min inf
Dobutamine
CHF(uncontrolled)
0.5-1mcg/kg/min inf
Milrinone
CHF(uncontrolled)
0.5-1mcg/kg/min inf
Nitroprusside
CHF(uncontrolled)
AF/Prosthetic valve
Ped: 0.05-0.3 mg/kg/d dont exceed
adult dose.
Adults: 5-15mg/d po 3-5 d then
maintenance 2-10mg/d with INR
monitoring.
51
Heparin
Tissue plasminogen
activator(t-PA)
Urokinase
Blood fibrinogen
level,activated PTT and fibrin
degradation product must be
monitored. Echo review must
be done
Monitor Fibrinogen, TCTthrombin clotting time,,APTT
PT
Streptokinase
52
Same
53
54
providers in the area, who are likely to encounter patients with RF or RHD, should be instructed to provide the details of
the patients to the registry project. This generally includes general practitioners, physicians, pediatricians and,
cardiologists. All the doctors should be given refresher training on the revised guidelines of diagnosis and treatment of RF
and RHD through training workshops. Further refresher sessions should be given utilizing the various organizational
meetings of doctors and their organizations. Government doctors were further briefed in their monthly conference at the
District Medical Office. General Practitioners should be addressed during the monthly meetings of the local branches
Indian Medical Association (IMA). Other forums that could be utilized to reach out to the doctors include the local
branches of Indian Academy of Paediatrics,), Qualified Private Medical Practitioners Association (QPMPA) and, local
chapter of the Cardiological Society of India (CSI). The Registry Project team should go round the area, with short
presentations and the training modules, to meet the busy practitioners who are not reached through the other means.
Handbooks containing clear guidelines for referral and prepaid postal envelopes will have to be given to all the doctors
that were replenished on a regular basis. All possible modes of communication have to be made available for referral to
the project office (ordinary mail, email, phone, fax, cell phone). After establishing the networking and referral pathways
with the doctors, an intense community awareness campaign should be launched in the area, to ensure all the probable
cases to visit/revisit the nearest doctor. Health awareness sessions for the Anganwadi teachers of the Integrated Child
Development Schemes , schoolteachers, functionaries of the State Poverty Eradication Mission (SPEM) health workers
will have to be done as part of the community mobilization. Health Seminars, photo exhibitions, poster stories, quiz
programs, tele-documentary in local vernacular starring popular serial actors etc can be used to pass the message to the
general public.
Reporting: All the suspected cases referred by doctors should be seen by cardiologists at the referral institute and will
need to be investigated. Echocardiograms will need to be performed when necessary. Feedback detailing the treatment
and follow-up options should be given back to the referring doctor and the patient separately. Penicillin prophylaxis (3
weekly Benzathine penicillin) should be administered free of cost if warranted and requested for by the patient.
From every major hospital in the area, the lists of patients who are on penicillin prophylaxis should be obtained. This
along with the scrutiny of hospital records, wherever permitted helped identification of RHD patients who were already
diagnosed and were on penicillin prophylaxis.
Data collection: Once the project office receives a referral letter, the address of the patient should be crosschecked and
entered in the records and letter of acknowledgement was sent to the referring doctor. The concerned patient /family
need to be contacted by project staff over phone or in person. A convenient date can be fixed for a hospital visit. On the
day of the visit, the patient/family should be interviewed by the project medico social workers. They should then briefed
about the disease entity and its management. The mandate and the purpose of the registry project should also be
explained to them. The cardiologist should see all patients, and if necessary echocardiogram evaluation should be done.
Entry to the registry should be made after confirmation of diagnosis. An additional register containing a list of all
referred/suspected cases should also be maintained.
The data base should be computerized preferably using Epiinfo soft ware.
Training materials to be prepared (they are already available but translations to local language will have to be arranged):
An introductory brochure that will need to be distributed by the field staff to health professionals in the project
area. (Sample in annexure 1)
A training/orientation module for the doctors
A map of the selected project area should be prepared and distributed to the doctors
Training material for Health Workers in local language should be prepared and printed.
Reporting format:
Business Reply Post cards indicating the basic information on the cases that they would like to report to the
registry should be printed for distribution to doctors.
A modified version of the reporting form (available at existing registry centers)
Register to monitor secondary prophylaxis
Reports of all centers have to follow a standardized format
55
Workshop for Doctors: A series of orientation workshops (primarily targeting Physicians and Pediatricians) and doctors in
PHC should be planned. The purpose of the meetings is to brief all the participating doctors about the project and to
define their roles.
The training modules and all the forms should be distributed to all the participants during the workshops. Teaching
material for these workshops is available on CD.
Anganwadi Workers and Community Health Volunteers Training: A list of the Anganwadi in the project area should be
made available. A meeting with ICDS Supervisors to chart out a plan regarding the training programme is desirable.
Efforts should be made to involve all the community health volunteers in the area in the training process.
School survey: A list of schools in the project area (with details of No of students and teachers) should be prepared based
on the information from District Education Office. A random sampling of the schools should be carried out to select 25,000
School Children. This should be a stratified sample and should represent the school profile in the district in terms of
government and private schools.
School teachers and Community Leaders training
School teachers and Community Leaders should also be made aware of the program through special training
sessions.
Community Awareness through Media:
1.
Documentary on RF / RHD for telecast in various health education meetings and in the media. To intensify
public health education a documentary should be made in the local language (dubbed versions of the ones that have been
made may also be acceptable). This documentary film should be short lasting about minutes.
2.
Regular press briefings
3.
Bit notices
4.
Health exhibitions
5.
Health camps
56
Chapter I
1.
English PC. Rheumatic fever in America and Britain. A biological, epidemiological and medical
history. New Jersey: Rutgers University Press; 1999. p. 17-52.
2.
3.
Stollerman, G.H. et al, Relationship of immune response to group A streptococci to the course of
acute, chronic and recurrent rheumatic fever. Am J Med, 1956. 20: 16369.
Richard Bright.. Cases of spasmodic disease accompanying affections of the pericardium. Medico-
4.
6.
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