Rheumatic heart

disease
Yusra Pintaningrum
SMF Kardiologi dan Kedokteran Vaskular
FK Universitas Mataram – RSUP NTB
What is the pathogenesis
of acute rheumatic fever?
 ACUTE RHEUMATIC FEVER
•Autoimmune consequence of infection
with Group A streptococcal infection

•Results in a generalised inflammatory

response affecting brains, joints, skin,
subcutaneous tissues and the heart.
Carapetis. Lancet 2005;366:155
 RHEUMATIC HEART DISEASE

•Rheumatic Heart Disease is the

permanent heart valve damage
resulting from one or more attacks
of ARF.
•It is thought that 40-60% of
patients with ARF will go on to
developing RHD.
 RHEUMATIC HEART DISEASE

•The commonest valves affecting

are the mitral and aortic, in that
order. However all four valves
can be affected.
 What is the incidence of
acute rheumatic fever and
rheumatic heart disease?
Incidence of ARF: Population-based Studies

Figure 5: Trend in Incidence of First Attack of Acute

Rheumatic Fever Over Time
40
USA (all ages)
35

Incidence/100,000 population
Martinique (<20yrs)
New Zealand (<30yrs)
Kuwait (5-14yrs) 30
Iran (all ages
25

20

15

10

5
1 2 0
3 4
5 6
7 8
Time (years) 9 10 11
 Diagnosis of
Rheumatic Fever
 Medical management of rheumatic fever
General measures
- Hospital admission
- throat culture (or insome circunstances rapid
streptococcal detection test),
- a measurement of streptococcal antibody titres (eg
ASO or anti DNase B),
- an assessment of acute-phase reactants (eg ESR or
CRP),
- a chest X-ray,
- an electrocardiogram,
- an echocardiogram (if facilities are available).
- A blood culture may help to exclude infective
endocarditis (1).
Suppression of the inflammatory process

-salicylates or corticosteroids until the diagnosis of RF is confirmed.

-Aspirin, 100 mg/kg-day divided into 4–5 doses, is the first line of therapy
and is generally adequate for achieving a clinical response. In children, the
dose may be increased to 125 mg/kg-day, and to 6–8g/day in adults.

-intolerant or allergic to aspirin, naproxen (10–20mg/kg-day)

- corticosteroids are also advisable in patients who do not respond to

salicylates and who continue to worsen and develop
heart failure : Prednisone (1–2mg/kg-day, to a maximum of 80mg/day given
once daily, or in divided doses) is usually the drug of choice or intravenous
methyl prednisolone

- After 2–3 weeks of therapy the dosage may be decreased

by 20–25% each week

- While reducing the steroid dosage, a

period of overlap with aspirin is recommended to prevent rebound of
disease activity
Management of chorea
- self-limiting benign disease, requiring no therapy
- Neuroleptics, benzodiazepines and antiepileptics
Haloperidol, diazepam, carbamazepine
- There is no convincing evidence in the literature that
steroids are beneficial for the therapy of the chorea
associated with rheumatic fever.
What are the clinical
features of strep
sore throat?
 During an episode of ARF, valve
changes can be minor and are still
able to regress.

After recurrent episodes of ARF,

thickening of subvalvar apparatus,
chordal thickening and shortening
and progression to permanent
valve damage is evident.
 What are the
treatment regimens
of streptococcal
sore throat?
Primary Prevention
Secundary Prevention
 Summary
• Rheumatic heart disease is the only truly
preventable chronic heart condition
• Primary prevention:
• Penicillin for suspected strep sore
throat
• Secondary prevention
• Penicillin prophylaxis