Rheumatic Heart Disease

Introduction

Rheumatic heart disease is a complication of rheumatic fever – a common cause of cardiac failure in Nigeria.
In Africa, it manifests later compared to Caucasians.
The mitral valve is most affected, followed by the aortic, then the tricuspid
The lesions can occur in various combinations of regurgitation and stenosis

Clinical features

  • Exertional dyspnoea
  • Paroxysmal nocturnal dyspnoea
  • Orthopnoea
  • Leg and abdominal swelling
  • Cough with production of frothy sputum
  • Pedal and sacral oedema
  • Small volume pulse, which may be irregular
  • With or without tachycardia
  • With or without hypotension
  • Raised JVP
  • Displaced apex
  • Left ventricular hypertrophy
  • Right ventricular hypertrophy
  • Thrills
  • Palpable P2
  • Soft S1; loud P2
  • S3 or S4
  • Systolic/diastolic murmurs

Differential diagnoses

  • Constrictive pericarditis
  • Endomyocardial fibrosis
  • Dilated cardiomyopathy

Complications

  • Arrhythmias e.g. atrial fibrillation, heart block
  • Cardiac failure
  • Embolic phenomena
  • Endocarditis

Investigations

  • Chest radiograph
  • Electrocardiography
  • Echocardiography
  • Coronary angiography
  • Electrolytes, Urea and Creatinine

Treatment objectives

  • Relieve symptoms
  • Prevent recurrence of rheumatic attack
  • Repair and replace affected valves

Non-drug treatment

  • Bed rest
  • Low salt diet

Drug treatment

  • Treat for heart failure if present
  • Use anticoagulants if necessary
  • Prophylaxis against endocarditis (see Infective Endocarditis).
    • Benzathine penicillin 720 mg (1.2 million units) intra musculary monthly for life

Other measures:

  • Valve replacement
  • Valve repair
  • Treat endocarditis

Notable adverse drug reactions, caution

  • Penicillin may cause hypersensitivity reaction/ anaphylaxis
  • Caution in patients with a history of
    penicillin allergy

Prevention

Personal hygiene and good sanitation to
prevent recurrence of rheumatic fever