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Rheumatic Heart Disease

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Iqra Mazhar

Overview

<p>Rheumatic heart disease (RHD) occurs when rheumatic fever permanently damages the heart valves. It typically starts with a strep throat infection brought on by group A streptococcus bacteria, which ultimately results in rheumatic fever damaging the heart valve.</p>

<p>Recurrent strep infections can make some people&#39;s immune systems attack normal bodily tissues, such as the heart valves, causing inflammation and damage. This condition is known as rheumatic fever. Therefore, rheumatic fever-induced heart valve inflammatory disease and scarring lead to rheumatic heart disease.</p>

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<p>Streptococcus pyogenes (group A streptococcus), a highly transmissible bacteria, cause rheumatic heart disease, which begins as a sore throat. Up to 40 million people worldwide are affected by rheumatic heart disease (RHD), a chronic heart valve illness, that primarily affects young people and children living in low-income or developing countries<sup><a href="#accordion">[1]</a></sup>. The majority of strep infections occur in children.</p>

<p>From 1990 to 2019, nations and regions saw considerable declines in deaths and DALYs attributable to RHD. However, the RHD burden continues to pose a significant issue on a worldwide scale<sup><a href="#accordion">[2]</a></sup>.&nbsp;</p>

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<p>Inflammation brought on by rheumatic fever can potentially harm every component of the heart. This may include the valves, the endocardium, the inner lining, and the outside layer of the heart (pericardium).</p>

<p>&nbsp;</p>

<p>Heart issues related to rheumatic fever include:</p>

<ul>
	<li><a href="https://www.merisehat.pk/disease/pericarditis" target="_blank">Pericarditis</a></li>
	<li>Valvular heart disease</li>
	<li>Heart block</li>
	<li>Endocarditis</li>
</ul>

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<p>The heart valves are most often impacted by rheumatic fever. The development of valvular damage or the manifestation of symptoms may extend several years following an attack of rheumatic fever.</p>

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<p>Rheumatic fever may harm any heart valve, but it most frequently affects the mitral valve, located between the left atrium and ventricle. The injury may result in cardiac valve regurgitation, muscle damage, or valve stenosis.&nbsp;</p>

<ul>
	<li>A valve narrows, causing valve <a href="https://www.merisehat.pk/disease/aortic-stenosis" target="_blank">stenosis</a>, which limits blood flow.</li>
	<li>Blood seeps through the valve in a backward flow, also known as valve regurgitation.</li>
</ul>

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<p>Rheumatic fever&#39;s inflammatory symptoms can harm the heart muscle itself. The injury may make it more difficult for the heart to pump blood efficiently. In time, valve problems can result in heart failure or atrial fibrillation.</p>

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Signs And Symptoms

<p>Rheumatic fever is not a common side effect of strep throat, but it can be avoided by having the infection diagnosed and treated by a doctor. Visit your doctor for a diagnosis if you or your kid also has any of the following symptoms in addition to a sore throat:</p>

<p>&nbsp;</p>

<ul>
	<li>Inflamed and painful lymph nodes</li>
	<li>Red rash</li>
	<li>Having trouble swallowing</li>
	<li>Thick, bloody, nasal discharge</li>
	<li>A minimum fever of 101&deg;F (38.3&deg;C)&nbsp;</li>
	<li>Having red and swollen tonsils</li>
	<li>Tonsils with pus-filled or white patches</li>
	<li>Little red dots on the mouth&#39;s&nbsp;roof Nausea</li>
	<li>Headache</li>
	<li>Vomiting</li>
</ul>

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<p>The symptoms of rheumatic fever are extremely varied. Symptoms typically appear two to four weeks after your child has strep throat. The following signs and symptoms may be present in some, or all affected individuals.&nbsp;</p>

<p>&nbsp;</p>

<ul>
	<li>Small, painless nodules under the skin</li>
	<li>Chest pain</li>
	<li>Lethargy or fatigue</li>
	<li>Rapid fluttering or pounding chest palpitations&emsp;</li>
	<li>Nosebleeds</li>
	<li>Painful or sore joints in the wrists, knees, elbows, and ankles</li>
	<li>Stomach pain</li>
	<li>Pain in one joint that moves to another joint</li>
	<li>Shortness of breath</li>
	<li>Red hot, swollen joints</li>
	<li>Fever</li>
	<li>Sweating</li>
	<li>A slightly raised, flat, ragged rash</li>
	<li>Vomiting</li>
	<li>Jerky, uncontrollable movements of the feet, hands, and face</li>
	<li>Outbursts of crying or inappropriate laughter</li>
	<li>A decrease in attention span</li>
</ul>

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<h5><strong>Children Are Most Often Affected</strong></h5>

<p>Rheumatic fever can affect anyone. Although school-age children are more likely to contract it than adults (5 through 15 years old), rheumatic fever is extremely uncommon in adults and children younger than 3 years old.</p>

<p>Wherever there are plenty of people living together, infectious diseases like group A strep spread more often. If strep throat or scarlet fever is not properly treated, crowded conditions can raise the risk of developing rheumatic fever. Examples of crowded conditions include:</p>

<ul>
	<li>Schools</li>
	<li>Military training facilities</li>
	<li>Daycare&nbsp;centers</li>
</ul>

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<p>If a person who previously had rheumatic fever, contracts strep throat or scarlet fever, it increases their risk of developing rheumatic fever. If your child gets a fever, they might need medical attention immediately. In the following circumstances, get your child&#39;s medical attention right away:</p>

<ul>
	<li>More than 100&deg;F (37.8&deg;C) temperature is appropriate for newborn to 6-week-old infants.</li>
	<li>A temperature of 101&deg;F (38.3&deg;C) or greater needs attention for infants aged six weeks to six months.</li>
	<li>For every young child, a prolonged fever of more than three days</li>
</ul>

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Causes

<p>Group A streptococcus is the bacteria that causes rheumatic fever. This bacterium can also result in scarlet fever or strep throat in a small percentage of cases. As a result of rheumatic fever, the body attacks its tissues. All of the signs and symptoms of rheumatic fever result from this reaction, causing extensive inflammation throughout the body.</p>

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Diagnosis

<p>Rheumatic fever cannot be diagnosed with a single test. Instead, medical professionals can examine for symptoms, review the patient&#39;s medical history, and perform a variety of tests, such as:</p>

<p>&nbsp;</p>

<ul>
	<li>The use of a throat swab to look for group A strep</li>
	<li>&nbsp;A blood test to check for antibodies, to determine whether the patient recently had strep throat</li>
	<li>A test called echocardiography or echo (provides information on the structure and function of the heart), and an EKG (provides information on the rhythm of the heart)</li>
</ul>

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<h4><b>"Rheumatic fever can damage your heart. Head on over to the <a href="https://www.merisehat.pk/page/sehat-scan/" target="_blank">sehat scan </a>to find out your heart rate!"<br><br></b></h4>

Treatment

<p>The likelihood of developing heart disease and other rheumatic fever-related health issues can be significantly reduced with appropriate, frequently long-term, conventional therapy. Complementing traditional care, alternative therapies aim to reduce sickness symptoms and lessen the likelihood of recurring episodes.</p>

<p>Your doctor may advise you to take it easy and take penicillin or other antibiotics to eliminate the streptococcal germs. You might be prescribed long-term medications to stop the infection from coming back. Aspirin or another anti-inflammatory drug, such as ibuprofen or naproxen, as well as a corticosteroid to treat symptoms including fever, arthritic joint pain, inflammation, and other signs and symptoms, may also be prescribed.&nbsp;</p>

<p>If you have rheumatic heart disease, taking antibiotics at specified times, such as before dental procedures or surgery, will also be essential. This can help to prevent the transfer of bacteria into the circulation and the recurrence of heart valve inflammation. If the heart is severely inflamed, surgery to repair the heart valve damage may eventually be required to prevent cardiac failure.</p>

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<p>Long-term consequences of RHD may include stroke, heart failure, and premature mortality. Some more complications are elaborated on below:&nbsp;&nbsp;</p>

<p>&nbsp;</p>

<ul>
	<li><strong>Heart Attack:</strong> A significantly constricted or leaking heart valve may cause this.</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Endocarditis Due To Bacteria:</strong> This infection affects the heart&#39;s inner lining and results from rheumatic fever damaging the heart valves.</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Heart Damage-Related Complications During Pregnancy And Delivery:</strong> Women suffering from rheumatic heart disease should talk to their doctor about their condition before becoming pregnant.</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li><strong>Defective Cardiac Valve:</strong> Surgery to replace or restore the heart valve is necessary to cure this medical emergency.</li>
</ul>

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<p>Rheumatic fever may be brought on by several factors, including:</p>

<p>&nbsp;</p>

<ul>
	<li>
	<p><strong>Genes:&nbsp;</strong>Some individuals may have one or more genes that increase their risk of contracting rheumatic fever.</p>
	</li>
</ul>

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<ul>
	<li>
	<p><strong>A Particular Strain Of Strep Bacterium:&nbsp;</strong>Rheumatic fever is more likely to be caused by specific strep bacteria strains.</p>
	</li>
</ul>

<p>&nbsp;</p>

<ul>
	<li>
	<p><strong>Environmental Elements:&nbsp;</strong>Overcrowding, poor sanitation, and other factors that make it easy for strep to spread among numerous individuals are linked to a higher risk of rheumatic fever.</p>
	</li>
</ul>

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<p>By avoiding strep infections or managing them with antibiotics, rheumatic heart disease can be avoided. Even if you feel better after a few days, taking antibiotics as directed and completing the course as directed, is crucial.</p>

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<h5><strong>Living With Rheumatic Heart Disease</strong></h5>

<p>To monitor the health of your heart, you will require regular follow-up visits with your doctor. You may also need to limit your activity based on the severity of your heart injury. To avoid the recurrence of rheumatic fever, your doctor may advise you to take antibiotics for a prolonged period.</p>

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<p>&nbsp;</p>

<ul>
	<li>
	<h5><strong>Rheumatic Heart Disease And<a href="https://www.merisehat.pk/disease/covid-19" target="_blank"> COVID-19</a></strong></h5>
	</li>
</ul>

<p>According to the World Heart Federation, RHD is a risk factor for severe COVID disease &quot;unique to low-income nations.&quot; The most vulnerable groups are those with more severe valvular heart disease, pulmonary hypertension, and heart failure requiring medication to improve cardiac function; indicating a group of potentially vulnerable people who might be unaware of their heightened risk in the<a href="https://www.merisehat.pk/disease/covid-19" target="_blank"> COVID-19</a> pandemic<sup><a href="#accordion">[3]</a></sup>.</p>

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<p><strong>Suggestions To Overcome <a href="https://www.merisehat.pk/disease/covid-19" target="_blank">Covid-19</a>&nbsp;Associated RHD</strong></p>

<p>In nations where RHD is prevalent, there may be some diagnostic overlap between <a href="https://www.merisehat.pk/disease/covid-19" target="_blank">COVID-19</a> infection and new or recurrent acute respiratory failure, which can manifest as fever, joint pain, and sore throat, but often lacks the apparent respiratory distress and hypoxia linked to COVID-19 infection. Hence to confirm the co-existence of COVID and RHD, efforts should be made to make ultrasound available for cardiac assessment in countries with endemic RHD that are dealing with the COVID-19 pandemic. This would help with enhanced risk assessment for patients presenting with a possible <a href="https://www.merisehat.pk/disease/covid-19" target="_blank">COVID-19</a> infection.</p>

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<ul>
	<li>
	<h5><strong>Penicillin Can Prevent The Progression Of Latent Rheumatic Heart Disease In Children</strong></h5>
	</li>
</ul>

<p>A new study found that regular, inexpensive antibiotic therapy dramatically decreased the probability of underlying rheumatic heart disease progression in kids and teenagers.</p>

<p>The experiment involved 818 Ugandan kids with latent rheumatic heart disease, aged 5 to 17 years. For two years, the individuals either received no therapy or four-weekly injections of penicillin. At the beginning and conclusion of the experiment, everyone had an echocardiography screening, a procedure in which ultrasound waves produce images of the heart.</p>

<p>The results suggest that 1 in 13 children with latent disease who receive treatment for two years, will be prevented from developing more severe disease. These findings were published in the New England Journal of Medicine<sup><a href="#accordion">[4]</a></sup>.</p>

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Key Points

<ul>
	<li>Rheumatic fever is an inflammatory disease affecting many connective tissues, especially the heart.</li>
	<li>Strep infections that are either untreated or under-treated place a person at an increased risk of rheumatic fever and heart disease, e.g., children with repeated strep throat infections are at a higher risk for rheumatic fever and heart disease.</li>
	<li>It is possible that a murmur or rub is heard during a routine physical examination of a patient with rheumatic heart disease.&nbsp;&nbsp;</li>
	<li>Treatment depends on the extent of damage to the heart valves and surgical intervention may be required in some cases to repair/replace the damaged valve.</li>
	<li>Since rheumatic fever is the cause of rheumatic heart disease, the best treatment is to prevent rheumatic fever.&nbsp;</li>
	<li>Prevention of rheumatic fever can be easily achieved by using antibiotics to treat strep infections since untreated or under-treated strep infections place a person at an increased risk of rheumatic fever and heart disease.</li>
</ul>

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[1] Peters F, Karthikeyan G, Abrams J, Muhwava L, Zühlke L. Rheumatic heart disease: current status of diagnosis and therapy. Cardiovasc Diagn Ther. 2020;10(2):305-315. doi:10.21037/cdt.2019.10.07

[2] Ou, Z., Yu, D., Liang, Y. et al. Global burden of rheumatic heart disease: trends from 1990 to 2019. Arthritis Res Ther 24, 138 (2022). DOI:10.1186/s13075-022-02829-3

[3] Andrea Beaton, Liesl Zühlke, Jeremiah Mwangi, Kathryn A Taubert, Rheumatic heart disease and COVID-19, European Heart Journal, Volume 41, Issue 42, 7 November 2020, Pages 4085–4086.