RHD

INTRODUCTION
RHEUMATIC FEVER
Rheumatic fever is an immunologically
mediated inflammatory disorder,
which occurs as a sequel to group A
streptococcal pharyngeal infection.
 Multisystem disease affecting
connective tissue particularly of the
heart, joints, brain, cutaneous and
subcutaneous tissues
 RF – not a communicable disease but
results from a communicable disease
(streptococcal pharyngitis).
streptococcal pharyngitis
WHAT IS RHEUMATIC HEART
DISEASE?
 Rheumatic heart disease starts as a sore throat
from a bacterium called Streptococcus
pyogenes (group A streptococcus) which can
pass easily from person to person in the same
way as other upper respiratory tract infections.
 Strep infections are most common in childhood.
 In some people, repeated strep infections cause
the immune system to react against the tissues
of the body including inflaming and scarring the
heart valves. This is what is referred to as
rheumatic fever.
 Rheumatic heart disease results then from the
inflammation and scarring of heart valves
caused by rheumatic fever.
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.
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.
Rheumatic heart disease is
the most commonly acquired
heart disease in people under
age 25.
About 300,000 people worldwide
die of rheumatic heart disease
each year.
IN INDIA
 RHD is prevalent in range of 5-
7/1000 in 5-15 age groups.
 About 1 million cases of RHD
 RHD constitutes 20-30% hospital
admissions due to CVD.
 Streptococcal infections
common in children living in
under –privileged conditions and
RF accounts for 1- 3% of the
cases.
ETIOLOGY
Group A beta-hemolytic
streptococcus.
 Rheumatic fever
CAUSES
 Everyday oral activities. Activities such as
brushing your teeth or chewing food can
allow bacteria to enter your bloodstream
 An infection or other medical condition.
 From an infected area, such as a skin sore.
 Gum disease, a sexually transmitted
infection.
 Weakened immune system
 Certain dental procedures
 Some dental procedures that can cut your
gums may allow bacteria to enter
bloodstream.
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
Previous history of Rheumatic
fever
 Genetic predisposition:
Rheumatic heart disease shows
familier tendancy.
PATHOPHYSIOLOGY
Causative agent (Group A Beta-
hemolytic streptococci) Untreated
Strep throat Rheumatic fever
All layers of the heart and the
mitral valve become inflamed
 Vegetation forms
Valvular regurgitations and
stenosis
 Heart failure
VEGETATION
irregular growths made of
germs and cell pieces form a
mass in the heart. These
clumps are called vegetations.
The difference
Normal valve is Transparent,
avascular, thin flexible
membrane.
 RHD: Thick, fibrous scarred
stenotic & fixed (MS/MR) with
Blood Vessels
Valvular changes
Leaflet thickeninig
 Commissural fusion
 Shortening and thickening of
chordae
 Orifice is narrowed
 Valves involved in RHD
 MITRAL Valve is affected in 60 – 70%
 Mitral regurgitation most commonly found in children and
adolescent.
 Mitral stenosis represent longer term chronic disease,
commonly in adults.
 Most common complication in mitral stenosis is atrial
fibrillation.
 AORTIC Valve next most commonly affected
 Generally associated with diseases of the mitral valve.
 Aortic stenosis is one of the most common and most
serious valve disease problems in elderly population.
 Tricuspid and pulmonary valves re much less commonly
affected
 Usually affected in very severs RHD when all valves are
affected.
Most common symptoms
Fever
Swollen, tender, red and extremely painful
joints — particularly the knees and ankles
Nodules (lumps under the skin)
Red, raised, lattice-like rash, usually on the
chest, back, and abdomen
Shortness of breath and chest discomfort
Uncontrolled movements of arms, legs, or
facial muscles
Weakness
MAJOR MANIFESTATION
Carditis
 Polyarthritis
 Chorea
 Erythema marginatum
 Subcutaneous nodules
Sydenham chorea (SC)
SC is characterized by rapid,
irregular, and aimless involuntary
movements of the arms and legs,
trunk, and facial muscles.
 Erythema
marginatum is a rare
skin rash that spreads
on the trunk and
limbs. The rash is
round, with a pale-
pink center,
surrounded by a
slightly raised red
outline. The rash can
appear in rings or
have less regular,
larger, or elongated
shapes.
Subcutaneous nodules
Subcutaneous
nodules are deep-
seated lesions in
the skin, located
in the deep
dermis and
subcutis, often
with minimal
changes
appreciated on
the surface of
the skin.
MINOR MANIFESTATION
Fever associated with weakness,
malaise, weight loss and anorexia
Arthralgia
Lab investigation
High ESR
 Anemia, leucocytosis
 Elevated C-reactive protien
 Elevated ASO or other
streptococcal antibody titer
 Anti-DNase B test
 Throat culture-GABH
streptococci
DIAGNOSIS
 Prolonged P-R interval
Criteria
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
Aschoff cells
Aschoff bodies are nodules found
in the hearts of individuals with
rheumatic fever. They result from
inflammation in the heart
muscle .
IMAGING STUDIES
Chest x ray
Cardiomegaly, pulmonary
congestion, and other findings
consistent with heart failure may
be seen on chest radiography.
ECHO
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.
ECHO
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.
TREATMENT for VALVULAR
HEART DISEASE
MEDICAL:Digoxin
 diuretics
 antibiotic prophylaxis
SURGICAL- closed mitral
commisurotomy, percutaneous
transluminal ballon valvuloplasty,
OTHERS –Ross procedure,
bentalls procedure
MEDICAL MANAGEMENT
 Oral penicillin 500 mg BD x 10 days OR
 A single dose of Benzathine penicillin 1.2 million
units I/M
 Tab. Erythromycin 250 mg BD x 10 days(in case of
penicillin allergy) (the patient should be started on
long-term antibiotic prophylaxis)
 Arthritis , arthralgia : Salicylates or NSAIDS (eg:
aspirin) 80-100 mg/kg/day in 4-5 divided doses x 3-
5wks
 Severe carditis :- Corticosteroids ( prednisolone 1-2
mg /kg/day ;max 60 mg x 4-6 wks, then taper20-25
mg/wk)
 Sydenham’s Chorea :- ▫ Haloperidol -0.5mg/kg/day ▫
Carbamazepine or sodium valproate -15-20
mg/kg/day x1-2 wks
SURGICAL MANAGEMENT
BALLOON VALVULOPLASTY
A valvuloplasty is a procedure to
repair a heart valve that has a
narrowed opening.
Valvuloplasty may also be called:
Balloon valvuloplasty
Balloon valvotomy
Percutaneous balloon
valvuloplasty
Valvuloplasty is done during a
procedure called cardiac
catheterization.
inserts a soft, thin tube (catheter)
tipped with a balloon into a blood
vessel, usually in the groin.
The catheter is carefully guided to the
narrowed valve in the heart.
 Once in position, the balloon is inflated
to widen the valve, improving blood
flow.
The balloon is then deflated, and the
catheter with balloon is removed.
ROSS PROCEDURE
In a Ross procedure, a surgeon
removes the abnormal aortic
valve. The surgeon then replaces
it with the child's own pulmonary
valve. The surgeon uses a valve
from a cadaver donor (conduit) to
replace the pulmonary valve.
BENTALL PROCEDURE
The Bentall procedure is a
surgery to replace part of the
aorta and the aortic valve of
the heart
PREVENTION
COMPLICATIONS
Congestive heart failure
 Infective endocarditis
 Arrhythmias mainly atrial
fibrillation
 Embolic episodes
 cardiomegaly