Rheumatic Heart Disease

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Introduction

A complication of rheumatic fever and common cause of cardiac failure in Nigeria. In Africans, 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 murmursDifferential Diagnoses
  • Constrictive pericarditis
  • Endomyocardial fibrosis
  • Dilated cardiomyopathy

Complications

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

Investigations

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

Treatment goals

  • 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-muscularly monthly for life
  • Other measures:
    • Valve replacement
    • Valve repair
    • Treat endocarditis

Notable adverse drug reactions, contraindications and caution

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

Prevention

  • Personal hygiene and good sanitation to prevent recurrence of rheumatic fever.