RHEUMATIC HEART DISEASE

  • Rheumatic heart disease is inflammatory damage of the heart valves, as a complication of acute rheumatic fever.
  • The mitral valve is the most commonly involved valve, although any valve may be affected. The inflammatory damage in
    rheumatic heart disease results in stenosis or incompetence of the valves, either singly or in combination with other valves.
  • Patients’ rheumatic heart disease may be asymptomatic with the lesion only discovered during routine examination.
    However, some of the patients may present with congestive cardiac failure.
  • Heart murmurs are over the precordium on auscultation, but the murmurs depend on the nature of the damage (whether incompetence or stenosis) and on the specific valves involved.

Complications

The complications for rheumatic heart disease include congestive cardiac failure, pulmonary oedema and bacterial endocarditis.

Investigations

  • Chest x-ray
  • ECG
  • Echocardiography

Management

  • Treat underlying complication, e.g., heart failure, pulmonary oedema.
  • Continue prophylaxis against recurrent rheumatic fever.
  • Advise that infective endocarditis prophylaxis is indicated before or during dental procedures, urinary tract instrumentation, and GIT manipulations.
  • Refer to a specialist
    • All patients with significant heart murmur for evaluation.
    • All patients with increasing cardiac symptoms.

Long-Term Prophylaxis

  • Rheumatic fever: All patients with a history of rheumatic fever should be given prophylaxis for life.
  • Endocarditis prophylaxis In addition to rheumatic fever prophylaxis the following should be done:
    • For dental procedures, give amoxicillin 50mg/kg PO 2 hours before procedure and 25mg/kg PO 6 hours after the initial dose. If the patient has penicillin allergy give erythromycin 1g PO 2 hours before procedure then
      half the dose 6 hours after the initial dose.
    • For lower gastrointestinal and genitourinary procedures give amoxicillin 50mg/kg IM 30 minutes before procedure and 6 hours after the initial dose as well as gentamicin 1.5mg/kg IM 30 minutes before procedure and 8
      hours after the initial dose.

Patient Education

The need for follow up should be strongly emphasized.