Inflammatory Heart Disease

Pericarditis inflammation of the pericardium Causes : may result from bacterial, viral or fungal infection can be assoc. w/ systemic diseases such as autoimmune disorders, rheumatic fever, tuberculosis, cancer, leukemia, kidney failure, HIV infection, AIDS, and hypothyroidism Heart attack (post-MI pericarditis) and myocarditis radiation therapy to the chest and medications that suppress the immune system injury (including surgery) or trauma to the chest, esophagus, or heart.

inflammation of the pericardium

Causes :

may result from bacterial, viral or fungal infection

can be assoc. w/ systemic diseases such as autoimmune

disorders, rheumatic fever, tuberculosis, cancer, leukemia,

kidney failure, HIV infection, AIDS, and hypothyroidism

Heart attack (post-MI pericarditis) and myocarditis

radiation therapy to the chest and medications that

suppress the immune system

injury (including surgery) or trauma to the chest,

esophagus, or heart.

Pericarditis

Pathophysiology Inflammation of the pericardium  Ventricular filling and emptying  Intrapericardial pressure  Arterial pressure Compression of the heart  CO  Venous pressure Pericardial effusion Fluid accumulation (serous, purulent, blood) in the pericardial sac

Acute Pericarditis – result to exudate formation (if severe, can lead to cardiac tamponade) Chronic Pericarditis – result to fibrosing (hardening) of the pericardial sac - the thick fibrous pericardium tightens around the heart and  efficiency as a pump (Constrictive Pericarditis)

Clinical Manifestations Pericardial friction rub Severe precordial chest pain – caused by the inflamed pericardium rubbing against the heart Usually relieved by sitting up and leaning forward Pleuritis type: a sharp, stabbing pain May radiate to the neck, left shoulder & arm, back or abdomen Often intensify with deep breathing and lying flat, and may  with coughing and swallowing Breathing difficulty when lying down Need to bend over or hold the chest while breathing Dry cough Ankle, feet and leg swelling (occasionally) Anxiety  muffled or  heart sounds Fatigue  if severe- rales,  breath sounds Fever

Pericardial friction rub

Severe precordial chest pain – caused by the inflamed pericardium

rubbing against the heart

Usually relieved by sitting up and leaning forward

Pleuritis type: a sharp, stabbing pain

May radiate to the neck, left shoulder & arm, back or abdomen

Often intensify with deep breathing and lying flat, and may  with coughing and swallowing

Breathing difficulty when lying down

Need to bend over or hold the chest while breathing

Dry cough

Ankle, feet and leg swelling (occasionally)

Anxiety  muffled or  heart sounds

Fatigue  if severe- rales,  breath sounds

Fever

Diagnostic tests Chest x-ray Echocardiogram Chest MRI or CT scan show enlargement of the heart from fluid collection in the pericardium, and signs of inflammation. They may also show scarring and contracture of the pericardium (constrictive pericarditis) ECG is abnormal in 90% of pts. w/ acute pericarditis. may mimic the ECG changes of MI. To rule out heart attack, serial cardiac marker levels (CK -MB and troponin I) may be ordered Blood culture CBC, may show increased WBC count Pericardiocentesis, with chemical analysis and pericardial fluid culture

Chest x-ray

Echocardiogram

Chest MRI or CT scan

show enlargement of the heart from fluid collection in the pericardium, and signs of inflammation. They may also show scarring and contracture of the pericardium (constrictive pericarditis)

ECG is abnormal in 90% of pts. w/ acute pericarditis.

may mimic the ECG changes of MI. To rule out heart attack, serial cardiac marker levels (CK -MB and troponin I) may be ordered

Blood culture

CBC, may show increased WBC count

Pericardiocentesis, with chemical analysis and pericardial fluid

culture

Constrictive Pericarditis a chronic form of pericarditis in w/c the pericardium is rigid , thickened , scarred , and less elastic than normal  The pericardium cannot stretch as the heart beats, which prevents the chambers of the heart from filling w/ blood  CO & blood backs up behind the heart symptoms of heart failure The inflamed pericardium may cause pain when it rubs against the heart.

a chronic form of pericarditis in w/c the pericardium is rigid ,

thickened , scarred , and less elastic than normal



The pericardium cannot stretch as the heart beats, which prevents the chambers of the heart from filling w/ blood



CO & blood backs up behind the heart

symptoms of heart failure

The inflamed pericardium may cause pain when it rubs against

the heart.

Causes: most common causes are conditions that induce chronic inflammation of the pericardium : tuberculosis, radiation therapy to the chest, and cardiac surgery. may also result from mesothelioma (a tumor) of the pericardium incomplete drainage of abnormal fluid accumulating in the pericardial sac, which can occur in purulent pericarditis or in post-surgery hemopericardium(bleeding w/in the pericardial sac). S/Sx: dyspnea that develops slowly and progressively worsens Fatigue, excessive tiredness -  CO Weakness weak heart sounds distended neck veins chronic swelling (edema) of the legs, ankles hepatomegaly, ascites

Causes:

most common causes are conditions that induce chronic

inflammation of the pericardium : tuberculosis, radiation

therapy to the chest, and cardiac surgery.

may also result from mesothelioma (a tumor) of the pericardium

incomplete drainage of abnormal fluid accumulating in the

pericardial sac, which can occur in purulent pericarditis or in

post-surgery hemopericardium(bleeding w/in the pericardial sac).

S/Sx:

dyspnea that develops slowly and progressively worsens

Fatigue, excessive tiredness -  CO

Weakness

weak heart sounds

distended neck veins

chronic swelling (edema) of the legs, ankles

hepatomegaly, ascites

Interventions identify the cause, if possible analgesics for pain, anti-pyretics, anti-inflammatory drugs(NSAIDS) such as aspirin and ibuprofen, in some cases, corticosteroids may be prescribed Diuretics- to remove excess fluid Pericardiocentesis - using a 2D-echo-guided needle aspiration or surgically in a minor procedure Antibiotics or antifungal agents(can be instilled directly to the sac) Bed rest, proper positioning, low-Na+ diet If the pericarditis is chronic, recurrent, or causes constrictive pericarditis, cutting or removing part of the pericardium may be recommended ( Pericardiectomy )

identify the cause, if possible

analgesics for pain, anti-pyretics, anti-inflammatory

drugs(NSAIDS) such as aspirin and ibuprofen, in some cases,

corticosteroids may be prescribed

Diuretics- to remove excess fluid

Pericardiocentesis - using a 2D-echo-guided needle aspiration or

surgically in a minor procedure

Antibiotics or antifungal agents(can be instilled directly to the sac)

Bed rest, proper positioning, low-Na+ diet

If the pericarditis is chronic, recurrent, or causes constrictive

pericarditis, cutting or removing part of the pericardium may be

recommended ( Pericardiectomy )

Cardiac Tamponade compression of the heart caused by blood or fluid accumulation in the space between the myocardium and the pericardium  prevents the ventricles from expanding fully, so they cannot adequately fill or pump blood   CO & signs of CHF Causes : Pericarditis caused by bacterial or viral infections Heart surgery dissecting aortic aneurysm (thoracic) wounds to the heart end-stage lung cancer acute MI Other potential causes: heart tumors, kidney failure, recent heart attack, recent open heart surgery, recent invasive heart procedures, radiation therapy to the chest, and SLE

compression of the heart caused by blood or fluid accumulation in

the space between the myocardium and the pericardium



prevents the ventricles from expanding fully,

so they cannot adequately fill or pump blood



 CO & signs of CHF

Causes :

Pericarditis caused by bacterial or viral infections

Heart surgery

dissecting aortic aneurysm (thoracic)

wounds to the heart

end-stage lung cancer

acute MI

Other potential causes: heart tumors, kidney failure, recent heart attack, recent open heart surgery, recent invasive heart procedures, radiation therapy to the chest, and SLE

Clinical Manifestations weak or absent PMI & peripheral pulses distended neck veins muffled or decreased heart sounds  BP, narrowing pulse presure pulsus paradoxus (BP falls when pt. inhales deeply) Anxiety, restlessness, tachycardia, dyspnea,  RR, palpitations Fainting, light-headedness, pallor or cyanosis Chest pain- sharp, stabbing, worsened by deep breathing or coughing signs of CHF CXR, Echocardiogram – pericardial effusion

weak or absent PMI & peripheral pulses

distended neck veins

muffled or decreased heart sounds

 BP, narrowing pulse presure

pulsus paradoxus (BP falls when pt. inhales deeply)

Anxiety, restlessness, tachycardia, dyspnea,  RR, palpitations

Fainting, light-headedness, pallor or cyanosis

Chest pain- sharp, stabbing, worsened by deep breathing or coughing

signs of CHF

CXR, Echocardiogram – pericardial effusion

Interventions an Emergency condition ! Goal : save the patient's life, improve heart function, relieve symptoms, and treat the tamponade Pericardiocentesis (to drain the fluid around the heart) or by cutting & removing part of the pericardium ( pericardiectomy or pericardial window). IV Fluids- to maintain normal blood pressure Dopamine, dobutamine -  BP Oxygen therapy -  workload on the heart Identify and treat cause of tamponade – give antibiotics or surgical repair of injury.

an Emergency condition !

Goal : save the patient's life, improve heart function, relieve

symptoms, and treat the tamponade

Pericardiocentesis (to drain the fluid around the heart) or by

cutting & removing part of the pericardium ( pericardiectomy or

pericardial window).

IV Fluids- to maintain normal blood pressure

Dopamine, dobutamine -  BP

Oxygen therapy -  workload on the heart

Identify and treat cause of tamponade – give antibiotics or

surgical repair of injury.

Myocarditis inflammatory disease of the myocardium that causes infiltration and injury to myocardial tissue Causes: infectious process – viral, bacterial, parasitic infection - invasion of myocardial tissue by organisms or production of toxins (Ex. polio, influenza, rubella) autoimmune reaction – rheumatic fever cardiac damage is char. by thrombus formation, dilation of ventricles, scarring (fibrosis), hypertrophy, disintegration of cardiac muscle cells  heart muscles weaken  signs of heart failure

inflammatory disease of the myocardium that causes infiltration

and injury to myocardial tissue

Causes:

infectious process – viral, bacterial, parasitic infection

- invasion of myocardial tissue by organisms or production of

toxins (Ex. polio, influenza, rubella)

autoimmune reaction – rheumatic fever

cardiac damage is char. by thrombus formation, dilation of

ventricles, scarring (fibrosis), hypertrophy, disintegration of

cardiac muscle cells  heart muscles weaken  signs of heart failure

S/Sx: fever, tachycardia, abnormal heart beats abnormal heart sounds (murmurs, extra heart sounds) pericardial friction rub chest pain fatigue, shortness of breath, orthopnea fainting – often related to arrhythmias peripheral edema other signs suggestive of infection: rashes, sore throat, itchy eyes, swollen joints Interventions: bed rest, low Na+ diet -  cardiac workload, promote healing Digitalis (digoxin) -  myocardial contractility,  HR, to prevent heart failure Diuretics – to control pulmonary or systemic congestion Antibiotics, anti-inflammatory drugs, steroids

S/Sx:

fever, tachycardia, abnormal heart beats

abnormal heart sounds (murmurs, extra heart sounds)

pericardial friction rub

chest pain

fatigue, shortness of breath, orthopnea

fainting – often related to arrhythmias

peripheral edema

other signs suggestive of infection: rashes, sore throat, itchy

eyes, swollen joints

Interventions:

bed rest, low Na+ diet -  cardiac workload, promote healing

Digitalis (digoxin) -  myocardial contractility,  HR, to

prevent heart failure

Diuretics – to control pulmonary or systemic congestion

Antibiotics, anti-inflammatory drugs, steroids

Bacterial Endocarditis infection of the inner lining of the heart (endocardium) caused by direct invasion of bacteria or other organisms leading to deformity of the valve leaflets Causative agents : Streptococcus viridans (found in the mouth) - 50% of cases, Staphylococcus aureus and enterococcus . Less common organisms include pseudomonas, serratia, and candida. Classification: 1. Acute bacterial endocarditis – rapidly progressing infection high fever, murmurs, spleenomegaly, emboli formation follows a rapid course and may severely damage the endocardium early in the disease 2. Subacute bacterial endocarditis – slower progressing infection fever, wt. loss, fatigue, joint pains, headache, malaise has a prolonged course

infection of the inner lining of the heart (endocardium) caused by direct invasion of bacteria or other organisms leading to deformity of the valve leaflets

Causative agents : Streptococcus viridans (found in the mouth) - 50% of cases, Staphylococcus aureus and enterococcus . Less common organisms include pseudomonas, serratia, and candida.

Classification:

1. Acute bacterial endocarditis – rapidly progressing infection

high fever, murmurs, spleenomegaly, emboli formation

follows a rapid course and may severely damage the endocardium early in the disease

2. Subacute bacterial endocarditis – slower progressing infection

fever, wt. loss, fatigue, joint pains, headache, malaise

has a prolonged course

Predisposing factors: Who are at risk? congenital heart defects damaged valves by rheumatic fever, atherosclerosis artificial heart valves may occur after cardiac surgery, invasive procedures (dental procedures, catheterization, prolonged IV therapy) minor surgery, gynecologic examinations, dialysis may follow after acute infection of the tonsils, gums, teeth, skin, lungs, GIT, GUT immunocompromised patients drug abusers (injections)

congenital heart defects

damaged valves by rheumatic fever, atherosclerosis

artificial heart valves

may occur after cardiac surgery, invasive procedures (dental procedures, catheterization, prolonged IV therapy) minor surgery, gynecologic examinations, dialysis

may follow after acute infection of the tonsils, gums, teeth, skin, lungs, GIT, GUT

immunocompromised patients

drug abusers (injections)

Pathophysiology Organism travels in the blood stream forms vegetations (clumps of bacteria, fibrin, cellular debris, platelets) growth of vegetation on heart valves attaches to the endocardial lining of a normal heart or an area of defect (heart valves) Emboli that can lodge to various organs (kidney, coronary artery, spleen, lungs, brain) deforms, thicken, stiffen, perforate the valve leaflets infected clots may break free and travel through the bloodstream Dysfunctional heart valves obstruct blood flow and produce organ damage

Clinical Manifestations Infection – fever, chills, night sweats, malaise, fatigue, anorexia wt. loss, muscle aches, joint pains Cardiac – murmurs (valve dysfunction), tachycardia - advanced – signs of CHF Peripheral Manifestations: Petechiae – small pinpoint hemorrhages in the conjunctiva, mucous membranes, neck, ankles Splinter hemorrhages - small, dark lines under the fingernails Osler’s nodes (red, painful nodes with a white center on the pads of fingers, toes, palms or soles) – a late sign of infection Janeway lesions (flat, painless, red to bluish-red spots on the palms and soles) – an early sign of endocardial infection Roth’s spots ( boat shaped retinal hemorrhages near the optic disc seen in fundoscopy * result from Microemboli

Infection – fever, chills, night sweats, malaise, fatigue, anorexia

wt. loss, muscle aches, joint pains

Cardiac – murmurs (valve dysfunction), tachycardia

- advanced – signs of CHF

Peripheral Manifestations:

Petechiae – small pinpoint hemorrhages in the conjunctiva, mucous membranes, neck, ankles

Splinter hemorrhages - small, dark lines under the fingernails

Osler’s nodes (red, painful nodes with a white center on the pads of fingers, toes, palms or soles) – a late sign of infection

Janeway lesions (flat, painless, red to bluish-red spots on the palms and soles) – an early sign of endocardial infection

Roth’s spots ( boat shaped retinal hemorrhages near the optic disc seen in fundoscopy

* result from Microemboli

Janeway lesions

enlarged spleen – continuous antigenic process Embolic manifestations Lung – hemoptypis, chest pain, shortness of breath Kidney – hematuria Heart – myocardial infarction Brain – sudden blindness, paralysis, meningitis, brain abscess Complications: CHF - most common, due to damage to the aortic, mitral valve Embolic episodes – ischemia and necrosis of organs arrhythmias – atrial fibrillation Glomerulonephritis Stroke Brain abscess Clinical Manifestations (cont.)

enlarged spleen – continuous antigenic process

Embolic manifestations

Lung – hemoptypis, chest pain, shortness of breath

Kidney – hematuria

Heart – myocardial infarction

Brain – sudden blindness, paralysis, meningitis, brain abscess

Complications:

CHF - most common, due to damage to the aortic, mitral valve

Embolic episodes – ischemia and necrosis of organs

arrhythmias – atrial fibrillation

Glomerulonephritis

Stroke

Brain abscess

blood cultures & sensitivity – to identify organism – best test for detection - obtain sample just before & during height of fever 2D Echo – valvular vegetations CBC – high ESR, high WBC, anemia ECG Prevention: Prophylactic antibiotics are often given to people with predisposing heart conditions before dental procedures or surgeries involving the respiratory, urinary, or intestinal tract Continued medical follow-up is advised for people with a history of endocarditis proper oral hygiene Diagnostic tests

blood cultures & sensitivity – to identify organism

– best test for detection

- obtain sample just before & during height of

fever

2D Echo – valvular vegetations

CBC – high ESR, high WBC, anemia

ECG

Prevention:

Prophylactic antibiotics are often given to people with predisposing

heart conditions before dental procedures or surgeries involving

the respiratory, urinary, or intestinal tract

Continued medical follow-up is advised for people with a history of

endocarditis

proper oral hygiene

1. Identify the infectious organism - serial blood cultures 2. Destroy the infectious org., stop the growth of valvular vegetations IV Antibiotics 4-6 weeks (Penicillin, Aminoglycosides) - to ensure high blood levels of medication - to eradicate the bacteria from the chambers & valves repeated blood cultures are done to assess effectiveness of the drug 3. Surgical repair of valvular deformities and congenital defects 4. Provide nutritional supplementation & bed rest 5. Prevent relapse and recurrent fever & infection - good oral hygiene, avoid invasive procedures as possible prophylactic antibiotic therapy, aseptic technique Medical Interventions

1. Identify the infectious organism - serial blood cultures

2. Destroy the infectious org., stop the growth of valvular vegetations

IV Antibiotics 4-6 weeks (Penicillin, Aminoglycosides)

- to ensure high blood levels of medication

- to eradicate the bacteria from the chambers & valves

repeated blood cultures are done to assess effectiveness of the drug

3. Surgical repair of valvular deformities and congenital defects

4. Provide nutritional supplementation & bed rest

5. Prevent relapse and recurrent fever & infection

- good oral hygiene, avoid invasive procedures as possible prophylactic antibiotic therapy, aseptic technique

Nursing Interventions Provide comfort measures,  fever encourage adequate fluids & nutrition CBR if w/ signs of valve dysfunctions (murmurs) assess for signs of heart failure, tachycardia, embolic manifestation provide health teachings: cause of infection, prolonged use of antibiotic, prophylactic antibiotics, preventing recurrence of infection (good oral hygiene), monitor signs of recurrence

Provide comfort measures,  fever

encourage adequate fluids & nutrition

CBR if w/ signs of valve dysfunctions (murmurs)

assess for signs of heart failure, tachycardia, embolic

manifestation

provide health teachings: cause of infection, prolonged use

of antibiotic, prophylactic antibiotics, preventing recurrence

of infection (good oral hygiene), monitor signs of recurrence

Rheumatic Fever an acute or chronic systemic inflammatory process, characterized by attacks of high fever, polyarthritis, severe carditis (valvular damage) Predisposing Factors : Age - 5-15 years old, can also affect elderly socioeconomic factors – Poor persons living in crowded, urban areas (slum areas) are more susceptible due to malnutrition, greater exposure to bacterial infections, less money for medical care and medications Genetic

an acute or chronic systemic inflammatory process, characterized by attacks of high fever, polyarthritis, severe carditis (valvular damage)

Predisposing Factors :

Age - 5-15 years old, can also affect elderly

socioeconomic factors – Poor persons living in crowded, urban areas (slum areas) are more susceptible due to malnutrition, greater exposure to bacterial infections, less money for medical care and medications

Genetic

Etiology: Group A Beta Hemolytic Streptococci the body undergoes an allergic response to invading streptococci the host develops an “autoimmune response” in w/c the streptococcal antibodies attack host tissue follows after an URTI by group A beta- hemolytic strep. – after 18 days, only 2-3 percent develops rheumatic fever Pathophysiology: a diffuse, proliferative & exudative inflammatory process that affects connective tissues in organs through the body ( heart, joints, nervous system, respiratory system) produces permanent & severe heart damage – if valves are involved

Etiology:

Group A Beta Hemolytic Streptococci

the body undergoes an allergic response to invading streptococci

the host develops an “autoimmune response” in w/c the streptococcal antibodies attack host tissue

follows after an URTI by group A beta- hemolytic strep. – after 18 days, only 2-3 percent develops rheumatic fever

Pathophysiology:

a diffuse, proliferative & exudative inflammatory process that affects connective tissues in organs through the body ( heart, joints, nervous system, respiratory system)

produces permanent & severe heart damage – if valves are involved

Rheumatic Heart Disease (RHD) can develop during 1 st – 2 nd week may involve one or all of the layers of the heart myocarditis – temporary loss of contractile power of the heart pericarditis – pericardial friction rub endocarditis – inflammation, ulceration, erosion of valve leaflets Progressive fibrosis (hardening) scarring calcification of valve leaflets – valve stenosis & insufficiency/regurgitation

can develop during 1 st – 2 nd week

may involve one or all of the layers of the heart

myocarditis – temporary loss of contractile power of the heart

pericarditis – pericardial friction rub

endocarditis – inflammation, ulceration, erosion of valve leaflets

Progressive fibrosis (hardening) scarring calcification of valve leaflets – valve stenosis & insufficiency/regurgitation

Clinical Manifestations Polyarthritis – joint swelling, tenderness, redness, limited movement & pain ( fingers, knees, ankles) Cardit is – tachycardia, murmurs, muffled heart sounds, pericardial friction rub, precordial pain, cardiomegaly, signs of CHF fever subcutaneous nodules – small, painless, firm nodules (knees, knuckles, elbows) erythema marginatum – non-pruritic rash, macules on the trunk and inner aspect of extremities, macules join together – looks like chicken wire appearance on skin Chorea (Sydenham’s Chorea, St. Vitus Dance) – nervous disorder, involuntary grimacing and jerky, purposeless movements, late stage of the disease

Polyarthritis – joint swelling, tenderness, redness, limited movement & pain ( fingers, knees, ankles)

Cardit is – tachycardia, murmurs, muffled heart sounds, pericardial friction rub, precordial pain, cardiomegaly, signs of CHF

fever

subcutaneous nodules – small, painless, firm nodules (knees, knuckles, elbows)

erythema marginatum – non-pruritic rash, macules on the trunk and inner aspect of extremities, macules join together – looks like chicken wire appearance on skin

Chorea (Sydenham’s Chorea, St. Vitus Dance) – nervous disorder, involuntary grimacing and jerky, purposeless movements, late stage of the disease

Abdominal pain – engorgement of liver Minor Manifestation – malaise, weakness, wt. loss , anorexia epistaxis,  ESR,  WBC Evidence of streptococcal infection: - (+) ASO- antistreptococcal antibodies titer in the blood - (+) throat culture of Group A streptococcus a person is diagnosed w/ rheumatic fever if he meets 2 major criteria or 1 major and 2 minor criteria, as well as having evidence of a recent streptococcal infection Clinical Manifestations (cont.)

Abdominal pain – engorgement of liver

Minor Manifestation – malaise, weakness, wt. loss , anorexia epistaxis,  ESR,  WBC

Evidence of streptococcal infection:

- (+) ASO- antistreptococcal antibodies titer in the blood

- (+) throat culture of Group A streptococcus

a person is diagnosed w/ rheumatic fever if he meets 2 major

criteria or 1 major and 2 minor criteria, as well as having evidence

of a recent streptococcal infection

Management Goals: Suppression of acute inflammatory process – steroids, aspirin for fever and joint pain Eradication of the streptococcal infection – antibiotics (Penicillin/ Erythromycin) Prevention of disease occurrence To protect the heart against damaging effects of carditis Interventions: bed rest – reduce strain on the heart produced by activity - minimize metabolic needs during acute, febrile state 2. Diet –  protein,  calorie,  Vit.,  sodium - adequate nutrition to promote healing - if w/ CHF – restrict fluids 3. Maintain body alignment

Goals:

Suppression of acute inflammatory process – steroids, aspirin for fever and joint pain

Eradication of the streptococcal infection – antibiotics (Penicillin/ Erythromycin)

Prevention of disease occurrence

To protect the heart against damaging effects of carditis

Interventions:

bed rest – reduce strain on the heart produced by activity

- minimize metabolic needs during acute, febrile state

2. Diet –  protein,  calorie,  Vit.,  sodium

- adequate nutrition to promote healing

- if w/ CHF – restrict fluids

3. Maintain body alignment

Interventions (cont.) 4. Diuretics, digitalis if w/ signs of CHF 5. Prevent recurrence – teach pt. on good nutrition, proper hygiene practices, adequate rest, immediate treatment of sore throat - taking prophylactic doses of Penicillin to prevent recurrence of attacks of RF – 5 years after 1 st attack - take prophylaxis of antibiotics before & after surgery or dental procedures - Severe RHD – Penicillin IM (Penadur) 1-2 x a month or oral penicillin for lifetime