Rheumatic Heart Disease (RHD)

1. Rheumatic Heart Disease
INTRODUCTION
 Rheumatic fever is a diffuse inflammatory disease characterized by a delayed response
to an infection by group A beta-hemolytic streptococci (GAS) in the tonsilopharyngeal
area, affecting the heart, joints, central nervous system, skin and subcutaneous tissues.
 It is thought that 40-60% of patients with ARF will go on to developing RHD.
DEFINITION
 Rheumatic heart disease is a chronic condition resulting from rheumatic fever which
involves all the layers of the heart (i.e. pancarditis) and is characterized by scarring and
deformity of the heart valves.
 The commonest valves affecting are the mitral and aortic, in that order. However all four
valves can be affected.
INCIDENCE
 Rheumatic fever is principally a disease of childhood, with a median age of 10 years,
although it also occurs in adults (20% of cases).
 Rheumatic fever occurs in equal numbers in males and females, but the prognosis is worse
for females than for males.
 The disease is seen more commonly in poor socio-economic strata of the society living
in damp and overcrowded place.
 Common in the developing countries like India, Pakistan.
 The incidence of RF in Developing countries is 27-100/1 lac /yr (G.S.Sainani 2006)
 The incidence of rheumatic fever (RF) varies from 0.2 to 0.75/1000/ year in school
children 5–15 years of age (2001 Govt. Census) (Anil Grover,Padamavati S et al, et.al INJ
2002).
ETIOLOGY
 Group A beta-hemolytic streptococcus.
 Rheumatic fever
RISK FACTORS
 Poor socio-economic status: People who are poor and belongs to low socio-economic
conditions are prone to get Rheumatic heart disease.
 Over-crowding: People who are living in a slum or damp area are more prone to get
Rheumatic heart disease.
 Age: It appears most commonly in children between the age of 5 to 15 years.
 Climate and season: It occurs more in the rainy season and in the cold climate.
 Upper respiratory tract infection: Rheumatic fever is an outcome of upper respiratory
tract infection with group A beta- hemolytic streptococcus.
 Previous history of Rheumatic fever: The client with previous history of Rheumatic
fever are at high risk to develop Rheumatic heart disease.
 Genetic predisposition: Rheumatic heart disease shows familier tendency.
PATHOPHYSIOLOGY
Causative agent (Group A Beta-hemolytic streptococci)

2. Untreated Strep throat
Rheumatic fever
All layers of the heart and the mitral valve become inflamed
Vegetation forms
Valvular regurgitations and stenosis
Heart failure
CLINICAL MANIFESTATIONS
Major manifestations
 Carditis
 Polyarthritis
 Chorea
 Erythema marginatum
 Subcutaneous nodules
 Arthritis
Minor manifestations
 Fever associated with weakness, malaise, weight loss and anorexia
 Arthralgia
Laboratory findings
 Positive throat culture for group A beta- hemolytic streptococci.
 Elevated acute phase reactants:
a) Erythrocyte sedimentation rate
b) C-reactive protein
c) Leukocytosis
 Prolonged P-R interval
DIAGNOSTIC EVALUATIONS
 A diagnosis of rheumatic heart disease is made after confirming antecedent rheumatic
fever.
 The modified Jones criteria (revised in 1992) provide guidelines for the diagnosis of
rheumatic fever.
JONES CRITERIA
 2 major or
1 major and 2 minor

3. Jones’ criteria for the diagnosis of Rheumatic fever
Major manifestations
 Carditis
 Polyarthritis
 Chorea
 Erythema marginatum
 Subcutaneous nodules
Minor manifestations
Clinical findings
 Previous rheumatic fever or rheumatic heart disease.
 Arthralgia
 Fever associated with weakness, malaise, weight loss and anorexia
Laboratory findings
 Elevated ESR, C-reactive protein and Leukocytosis
 ECG and echocardiogram to confirm rhythm problems and structural changes (prolonged
P-R interval).
 Chest X-ray shows enlarged heart.
Evidence of Group A streptococcal infection
 Positive throat culture for strep A
 Elevated or rising anti-streptococcal antibody titer
 Recent scarlet fever
IMAGING STUDIES
Chest roentgenography:
 Cardiomegaly, pulmonary congestion, and other findings consistent with heart failure
may be seen on chest radiography.
Doppler-echocardiogram
 In acute rheumatic heart disease, Doppler- echocardiography identifies and quantitates
valve insufficiency and ventricular dysfunction.
 In chronic rheumatic heart disease, echocardiography may be used to track the
progression of valve stenosis and may help determine the time for surgical intervention.
HEART CATHETERIZATION
 In acute rheumatic heart disease, this procedure is not indicated.
 With chronic disease, heart catheterization has been performed to evaluate mitral and
aortic valve disease and to balloon stenotic mitral valves.
ON ECG
 Sinus tachycardia most frequently accompanies acute rheumatic heart disease.
Alternatively, some children develop sinus bradycardia from increased vagal tone.
 Patients with rheumatic heart disease also may develop atrial flutter, multifocal atrial
tachycardia, or atrial fibrillation from chronic mitral valve disease and atrial dilation.

4. Sinus Tachycardia
HISTOLOGIC FINDINGS
 Pathologic examination of the insufficient valves may reveal verrucous lesions at the line
of closure.
 Aschoff bodies (perivascular foci of eosinophilic collagen surrounded by lymphocytes,
plasma cells, and macrophages) are found in the pericardium, perivascular regions of the
myocardium, and endocardium.
 Anitschkow cells are plump macrophages within Aschoff bodies.
 In the pericardium, fibrinous and serofibrinous exudates may produce an appearance of
"bread and butter" pericarditis.
MEDICAL MANAGEMENT
Eradicate infection
 Preventive and prophylactic therapy is indicated after rheumatic fever and acute
rheumatic heart disease to prevent further damage to valves.
 Primary prophylaxis (initial course of antibiotics administered to eradicate the
streptococcal infection) also serves as the first course of secondary prophylaxis (prevention
of recurrent rheumatic fever and rheumatic heart disease).
 An injection of 0.6-1.2 million units of benzathine penicillin G intramuscularly every 4
weeks is the recommended regimen for secondary prophylaxis for most US patients.
 Administer the same dosage every 3 weeks in areas where rheumatic fever is endemic, in
patients with residual carditis, and in high-risk patients.
 Continue antibiotic prophylaxis indefinitely for patients at high risk (eg, health care
workers, teachers, day care workers) for recurrent GABHS infection.
 Patients with rheumatic fever with carditis and valve disease should receive antibiotics
for at least 10 years or until age 40 years.
 Patients with rheumatic heart disease and valve damage require a single dose of antibiotics
1 hour before surgical and dental procedures to help prevent bacterial endocarditis.
 Patients who had rheumatic fever without valve damage do not need endocarditis
prophylaxis.
 Do not use penicillin, ampicillin, or amoxicillin for endocarditis prophylaxis in patients
already receiving penicillin for secondary rheumatic fever prophylaxis (relative resistance
of PO streptococci to penicillin and aminopenicillins.

5.  Alternate drugs recommended by the American Heart Association for these patients
include PO clindamycin (20 mg/kg in children, 600 mg in adults) and PO azithromycin or
clarithromycin (15 mg/kg in children, 500 mg in adults).
Maximize cardiac output
 Corticosteroids are used to treat carditis, especially if heart failure is evident.
 If heart failure develops, treatment, including ACE inhibitors, beta blockers and diuretics,
is effective.
Promote comfort
 Client with arthritic manifestations obtain relief with salicylates.
 Bed rest is usually prescribed to reduce cardiac effort until evidence of inflammation has
subsided.
SURGICAL MANAGEMENT
 When heart failure persists or worsens after aggressive medical therapy for acute
rheumatic heart disease, surgery to decrease valve insufficiency may be life-saving.
 Forty percent of patients with acute rheumatic heart disease subsequently develop mitral
stenosis as adults.
 Cummisurotomy can be done to widen the valve.
 In patients with critical stenosis, mitral valvulotomy, percutaneous balloon valvuloplasty,
or mitral valve replacement may be indicated.
 Due to high rates of recurrent symptoms after annuloplasty or other repair procedures,
valve replacement appears to be the preferred surgical option
NURSING MANAGEMENT
Nursing diagnosis
Pain related to inflammatory response in the joints.
Objectives
The client verbalizes increased comfort as evidenced by reports of reduced discomfort,
expression of joint pain reduction, relaxed body posture and a calm facial expression.
Interventions
 Assess the level of pain, duration, intensity and frequency of pain.
 Complete bed rest and provide comfortable position.
 Provide diversional therapy and psychological support.
 Administer analgesics as needed.
Nursing diagnosis
Decreased cardiac output related to valve dysfunction or HF.
Objectives
Client increases cardiac output as evidenced by regular cardiac rhythm, heart rate, blood
pressure, respiration and urine output within normal limit.
Interventions
 Assess the symptoms of heart failure and decreased cardiac output including diminished
quality of peripheral pulses, cool skin and extremities, increased respiration, increased heart
rate, neck vein distention and presence of edema.
 Assess for heart sounds.
 Monitor intake and output.
 Provide bed rest.
 Administration of cardiac glycosides as prescribed.

6. Nursing diagnosis
Knowledge deficit related to disease condition and long term treatment.
Objective
Patient gains adequate knowledge as evidenced by explaining disease condition,
recognizing need for medication, understanding treatment.
Intervention
 Assess the clients level of knowledge.
 Assess the client’s ability to learn.
 Explain about disease condition and about prophylactic treatment of antibiotics.
 Clarify the clients doubt clearly.
Nursing diagnosis
Anxiety related to disease condition and heart failure
Objectives
Clients shows maximum reduction of anxiety.
Interventions
 Assess the clients level of anxiety.
 Clarify the doubts of the clients by using non medical terms and calm, slow speech.
 Explain all activities, procedures and issues that involves the client.
 Explain about the disease conditions and prophylactic treatment.
 Provide anxiolytics as prescribed.