Rheumatic Heart Disease / Rheumatic Fever

What are rheumatic heart disease and rheumatic fever?

Rheumatic (roo-MAT'ik) heart disease is a condition in which the heart valves are
damaged by rheumatic fever.

Rheumatic fever begins with a strep throat (also called strep pharyngitis). Strep throat is
caused by Group A Streptococcusbacteria. It is the most common bacterial infection of
the throat.

Rheumatic fever is an inflammatory disease. It can affect many of the body's connective
tissues especially those of the heart, joints, brain or skin. Anyone can get acute
rheumatic fever, but it usually occurs in children five to 15 years old. The rheumatic heart
disease that results can last for life.

The incidence of rheumatic fever/rheumatic heart disease is low in the United States and
most other developed countries. However, it continues to be the leading cause of
cardiovascular death during the first five decades of life in the developing world.

What are the symptoms of strep throat?

Symptoms include (but are not limited to):

sudden onset of sore throat

pain on swallowing
fever, usually 101104F
headache
red throat/tonsils
abdominal pain, nausea and vomiting may also occur, especially in children

In some people, strep throat is very mild with just a few symptoms. Also, sore throats are
caused more often by viruses than by a strep infection. Viral throat infections dont raise
the risk of rheumatic fever and are not treatable with antibiotics.

What are the symptoms of rheumatic fever?

Symptoms may include:

fever
painful, tender, red swollen joints
pain in one joint that migrates to another one
heart palpitations
chest pain
shortness of breath
skin rashes
 fatigue
small, painless nodules under the skin

The symptoms of rheumatic fever usually appear about three weeks after the strep throat.

How can I prevent rheumatic heart disease?

The best defense against rheumatic heart disease is to prevent rheumatic fever from ever
occurring. By treating strep throat with penicillin or other antibiotics, doctors can usually
stop acute rheumatic fever from developing.

People who've already had rheumatic fever are more susceptible to recurrent attacks and
heart damage. That's why they're given continuous monthly or daily antibiotic treatment,
maybe for life. If their heart has been damaged by rheumatic fever, they're also at
increased risk for developing infective endocarditis (also known as bacterial
endocarditis), an infection of the heart's lining or valves.

In 2007, the American Heart Association updated its guidelines for prevention of
endocarditis and concluded that there is no convincing evidence linking dental,
gastrointestinal or genitourinary tract procedures with the development of
endocarditis. The prophylactic use of antibiotics prior to a dental procedure is now
recommended ONLY for those patients with the highest risk of adverse outcome
resulting from endocarditis, such as patients with a prosthetic cardiac valve, previous
endocarditis, or those with specific forms of congenital heart disease. The guidelines no
longer recommend prophylaxis prior to a dental procedure for patients with rheumatic
heart disease unless they also have one of the underlying cardiac conditions listed above.

Antibiotic prophylaxis solely to prevent endocarditis is no longer recommended for

patients who undergo a gastrointestinal or genitourinary tract procedure.

Congestive Heart Failure

Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't
pump enough blood to the body's other organs. This can result from
narrowed arteries that supply blood to the heart muscle coronary artery disease
past heart attack, or myocardial infarction, with scar tissue that interferes with the
heart muscle's normal work
high blood pressure
heart valve disease due to past rheumatic fever or other causes
primary disease of the heart muscle itself, called cardiomyopathy.
heart defects present at birth congenital heart defects.
infection of the heart valves and/or heart muscle itself endocarditis and/or
myocarditis
The "failing" heart keeps working but not as efficiently as it should. People with heart
failure can't exert themselves because they become short of breath and tired.

As blood flow out of the heart slows, blood returning to the heart through the veins backs
up, causing congestion in the tissues. Often swelling (edema) results. Most often there's
swelling in the legs and ankles, but it can happen in other parts of the body, too.
Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of
breath, especially when a person is lying down.

Heart failure also affects the kidneys' ability to dispose of sodium and water. The retained
water increases the edema.

How do you diagnose and treat congestive heart failure?

Your doctor is the best person to make the diagnosis. The most common signs of
congestive heart failure are swollen legs or ankles or difficulty breathing. Another
symptom is weight gain when fluid builds up.

CHF usually requires a treatment program of

rest
proper diet
modified daily activities
drugs such as
o ACE (angiotensin-converting enzyme) inhibitors
o beta blockers
o digitalis
o diuretics
o vasodilators

Various drugs are used to treat congestive heart failure. They perform different functions.
ACE inhibitors and vasodilators expand blood vessels and decrease resistance. This
allows blood to flow more easily and makes the heart's work easier or more efficient.
Beta blockers can improve how well the heart's left lower chamber (left ventricle) pumps.
Digitalis increases the pumping action of the heart, while diuretics help the body
eliminate excess salt and water.

When a specific cause of congestive heart failure is discovered, it should be treated or, if
possible, corrected. For example, some cases of congestive heart failure can be treated by
treating high blood pressure. If the heart failure is caused by an abnormal heart valve, the
valve can be surgically replaced.

If the heart becomes so damaged that it can't be repaired, a more drastic approach should
be considered. A heart transplant could be an option.
Most people with mild and moderate congestive heart failure can be treated. Proper
medical supervision can prevent them from becoming invalids.

Rheumatic Heart Disease

By Richard N. Fogoros, M.D., About.com Guide

Rheumatic heart disease is the most dreaded complication of rheumatic fever. The term
"rheumatic heart disease" refers to the chronic heart valve damage that can occur after a
person has had an episode of acute rheumatic fever. This valve damage can eventually
lead to heart failure.
Read more about rheumatic fever - its causes, treatment and prevention.

Acute rheumatic fever often produces inflammation of the heart (carditis). This carditis
affects virtually all parts of the heart - the pericardial, or exterior, surface of the heart
(pericarditis); the heart muscle itself (myocarditis); and the endocardial, or interior,
surface of the heart (endocarditis).

The endocarditis seen in acute rheumatic fever may set off a more chronic process that
can eventually produce heart valve damage. In other words, it can produce rheumatic
heart disease. Once rheumatic valvular disease begins, it tends to continually worsen over
time. Repeated episodes of rheumatic fever can accelerate the deterioration of the heart
valves.

(It is worth noting that the endocarditis seen in rheumatic fever is different from
"infectious endocarditis," since in rheumatic fever the endocarditis is not caused by a
direct bacterial infection of the heart. Rather, the endocarditis in rheumatic fever is
caused by an autoimmune process that affects many parts of the body in addition to the
heart, and is triggered by a reaction to the streptococcal bacteria in strep throat.)

Rheumatic heart disease ends up affecting about half the people who have rheumatic
fever with carditis. Most of the time, rheumatic heart disease is diagnosed 10 to 20 years
after being "triggered" by acute rheumatic fever.

What Cardiac Problems Are Seen With Rheumatic Heart Disease?

Mitral valve disease is the most common cardiac problem seen in rheumatic heart
disease. In rheumatic heart disease, the mitral valve becomes laden with heavy deposits
of calcium, which disrupt the normal function of the valve. Because of these heavy
calcium deposits, the valve often fails to open completely (a condition called mitral
stenosis). The same calcium deposits can also prevent the valve from closing completely,
leading to mitral regurgitation (a "leaky" valve). So, people with rheumatic mitral valves
often have both mitral stenosis and mitral regurgitation.

Aortic valve disease is also common in rheumatic heart disease. Aortic valve damage is
also caused by calcium deposits that disrupt normal valve function. And as with
rheumatic mitral valves, rheumatic aortic valves can develop either stenosis or
regurgitation, or both.

The mechanical valve problems (both stenosis and regurgitation) caused by rheumatic
heart disease can tremendously increase the workload on the heart muscle, and as a result
heart failure frequently develops, often after a period of many years.

Atrial fibrillation is very commonly seen in rheumatic heart disease, especially if the
mitral valve is involved. Blood clots (which can lead to stroke, and which are always a
risk in patients with atrial fibrillation) are a particular risk in people who have both atrial
fibrillation and rheumatic mitral disease. So, virtually all patients with rheumatic mitral
disease and atrial fibrillation ought to be on chronic blood-thinning (anticoagulation)
therapy with Coumadin.

How Is Rheumatic Heart Disease Treated?

The best way to deal with rheumatic heart disease, obviously, is to prevent it. Aggressive
treatment of strep throat (with antibiotics) and of rheumatic fever (should it occur) can
help to limit rheumatic heart disease. Read here about the treatment of rheumatic fever.

Once a person has had rheumatic fever, especially if it has caused carditis, it is critically
important to prevent any more episodes of rheumatic fever. So anyone who has had
rheumatic fever should be on preventative, or prophylactic, therapy with antibiotics to
prevent a recurrence. Here are the American Heart Association's recommendations on
prophylaxis for rheumatic fever.

Anyone who has had acute rheumatic fever should have a physical examination annually
to see if any change has occurred in the heart. A new heart murmur or a change in a
previous heart murmur might indicate that heart valve damage has begun. An
echocardiogram would confirm the presence or absence of heart valve damage.

Once you have been diagnosed with rheumatic heart disease, it is critically important to
have regular monitoring of the condition of your heart valves and your heart muscle,
usually with periodic physical exams and echocardigrams. Since rheumatic heart disease
is usually progressive, the heart valve problems tend to worsen over time -- and at some
point, valve replacement surgery is likely to be required.

The proper timing of this surgery is important and tricky. It is critical to replace the
valves before permanent heart muscle damage occurs, but on the other hand it is
generally not a good idea to replace the valves too early (since artificial valves
themselves may deteriorate over a few decades, and additional surgery may become
necessary). For this reason, people with rheumatic heart disease should generally be
under the watchful eye of an experienced cardiologist.

Sources:

Rheumatic Fever
Rheumatic fever is a serious illness that can follow strep throat, a condition in which a
sore throat is caused by a certain type of streptococcal bacteria (group A beta hemolytic
streptococi, or GABHS). Rheumatic fever is a widespread inflammation that can affect
various parts of the body, including the skin, joints, brain, and heart.

Rheumatic fever is thought to be an autoimmune disorder triggered by the body's immune

response to GABHS during an episode of strep throat. That is, the antibodies that the
body produces to fight the strep infection can become "confused," and begin attacking
various organs within the body. The most serious complication of rheumatic fever is an
inflammation of the heart (called carditis), which can lead to rheumatic heart disease.

Rheumatic fever is seen almost exclusively in children and adolescents. While rheumatic
fever was very common in the United States 100 years ago (and in fact was a leading
cause of death in young people), it is now quite rare in developed countries. Rheumatic
fever remains a major problem, however, in undeveloped countries.

The reduction in rheumatic fever is thought to be due to the aggressive treatment of

suspected strep throat with antibiotics.

Symptoms of Rheumatic Fever

Symptoms of rheumatic fever can include:

Fever, headache, weakness, weight loss, sweating, and other general signs of
illness
Joint pain that moves from joint to joint (that is, "migratory" joint pain)
Chest pain suggestive of pericarditis
Personality changes, especially irritability and short attention span
Involuntary muscle movements (chorea - an involuntary movement disorder, in
which the limbs move in a wormlike, almost graceful way, but completely
involuntarily)
Rash
Doctors will diagnose rheumatic fever if you have at least one of the symptoms listed
above, blood tests or throat culture indicate recent infection with GABHS, and at least
one of the following signs are found:

Carditis (this can be either pericarditis, inflammation of the heart muscle, or

inflammation of the heart valves)
Arthritis involving more than one joint
Chorea
Bumps under the skin (subcutaneous nodules)
Erythema marginatum (a distinctive rash)

Treatment of Rheumatic Fever

Anyone diagnosed with acute rheumatic fever should be treated aggressively. Treatment
includes:
A course of antibiotics to get rid of any GABHS that may be provoking an
ongoing immune response