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1. RHEUMATIC HEART DISEASE
A complication of rheumatic
fever which leaves permanent
damage to the heart valves

2. • RHD is the most serious complication of
rheumatic fever.
• Acute RHD often produces a pancarditis
characterized by
• endocarditis, myocarditis, and
• pericarditis.
• Endocarditis is manifested as valve
insufficiency.

3. • The mitral valve is most commonly
affected in 50-60% of cases, and
• combined lesions of the aortic and mitral
valves occur in 20%;
• Tricuspid involvement occurs only in
association with mitral or aortic disease in
about 10% of cases.

4. • The pulmonary valve is rarely affected.
• Chronic RHD results from single or repeated
attacks of rheumatic fever
• that produce rigidity & deformity of valve
cusps, fusion of the commissures, or
• shortening and fusion of the chordae
tendineae.
• The first clue to organic valvular disease is a
murmur.
•

5. Objective: Describe RHD
•In some children antibodies
produced in response to Gp A β-
haemolytic strep lead to varying
degrees of pancardititis with
associated valve insufficiency in the
acute phase
•The risk is higher with repeated
episodes of acute Rheumatic fever
•,

6. Pathology
RHD Leads to:
valve stenosis,
regurgitation
 atrial dilatation
Arrhythmia and
Ventricular disfunction
Chronic RHD is a major cause of
mitral valve stenosis in children

7. Causes
• RF is thought to result from an
inflammatory autoimmune response.
• develops in children & adolescents 2°
group A beta-hemolytic streptococcal
pharyngitis, &
• only strep infections of the pharynx
initiate or reactivate rheumatic fever In
0.3-3% of cases,
• It leads to RF several wks after the
sore throat has resolved.

8. • The organism spreads by direct contact
with oral or respiratory secretions, and
spread is enhanced by crowded living
conditions.
• Patients remain infected for weeks after
symptomatic resolution of pharyngitis and
may serve as a reservoir for infecting
others

9. • Group A Streptococcus is a gram-positive coccus that
frequently colonizes the skin and oropharynx.
• This organism may cause suppurative disease, such as
pharyngitis, impetigo, cellulitis, myositis, pneumonia, and
puerperal sepsis.
• It also may be associated with nonsuppurative disease,
such as rheumatic fever and acute poststreptococcal
glomerulonephritis

10. DIAGNOSIS - RHD

11. manifestation
 Pancarditis is the most serious and second most
common complication of rheumatic fever
 dyspnea,
 mild-to-moderate chest discomfort,
 pleuritic chest pain,
 edema,
 cough, or orthopnea.
 On exam. a new murmur and tachycardia out of
proportion to fever.
 New or changing murmurs

12. ◦ Apical pansystolic murmur is a high-pitched,
blowing-quality murmur of mitral regurgitation
that radiates to the left axilla.
◦ Apical diastolic murmur is heard with active
carditis and accompanies severe mitral
insufficiency..
◦ Basal diastolic murmur is an early diastolic
murmur of aortic regurgitation and is high-
pitched, blowing, decrescendo, and heard best
along the right upper and mid-left sternal border
after deep expiration while the patient is leaning
forward.

13. Non cardiac manifestation
 Common noncardiac (and diagnostic) manifestations of
acute rheumatic fever include
 polyarthritis, chorea, erythema marginatum, and
subcutaneous nodules.
 Other clinical, noncardiac manifestations include
 abdominal pain,
 arthralgias,
 epistaxis,
 fever, and rheumatic pneumonia.

14. Dx
1. Suspect RHD in a child with previous history of
rheumatic fever who presents with heart failure or has a
heart murmur
2. Dx is important because pcn prophylaxis can prevent
further episodes of rheumatic fever & avoid worse
damage to the heart valves.
3. Presentation depends on the severity
4. Mild d’se may cause few symptoms + a murmur
5. Severe d’se depends on heart damage or presence of
infective endocarditis

15. History
• Chest pain
• Heart palpitations
• Symptoms of heart failure
• Fever or stroke
• Breathlessness on exertion
• Fainting (syncope)

16. Examination
• Signs of heart failure
• Tachycardia (> 160/min in < 12months &
> 120 in 1—5yrs .
• Gallop rhythm
• Tender hepatomegaly
• Tachypnoea
• Oedema
• Raised jugular venous pressure

17. Cardiomegaly
 heart murmur
Signs of infective endocarditis
retinal h’ge
hemiparesis
Oslers nodes
Roth spots
Sleenomegaly

18. investigations
• Chest X- Ray – cardiomegaly with
congested lungs
• Echocardiogram – confirms rheumatic
fever
• Extend of valve damage, and evidence
of infective endocarditis
• Full blood count
• Blood culture

19. • Throat culture
• group A beta hemolytic Streptococcus
are usually negative by the time
symptoms of rheumatic fever or rheumatic
heart disease appear.
• Rapid antigen detection test
• This test allows rapid detection of group A
streptococcal antigen and allows the
diagnosis of streptococcal pharyngitis and
the initiation of antibiotic

20. • Antistreptococcal antibodies

21. Management
• Primary prophylaxis (initial course of antibiotics
administered to eradicate the streptococcal
infection
• Treat RF ASA and steroids
• An inje of 0.6-1.2 million units of benzathine
penicillin G intramuscularly every 4 weeks is the
recommended regimen for secondary prophylaxis
• Give pcn or ampicillin or ceftriaxone plus
gentamycin IV or im for 4-6 weeks for infective
endocarditis

22. • Admit if in heart failure or infective endocarditis
• Treat heart failure if present
• Diuretics to relieve symptoms of pulmonary congestion &
vasodilators
• Surgery
• F/up care -- Ensure vaccinations are upto date, mothly
benzathine, antibiotic prophylaxis after surgery or dental
procedures

23. Mitral insufficiency
• Is the result of structural changes :-
• Loss of valvular substance and shortening,
• Thickening of the chordae tendineae.
• In acute rheumatic fever with severe cardiac involvement,
heart failure is caused by a combination of mitral
insufficiency coupled with inflammatory disease of the
pericardium, myocardium, endocardium, and epicardium.
• Because of the high volume load and inflammatory
process, the left ventricle becomes enlarged.

24. • The left atrium dilates as blood regurgitates into this
chamber.
• Increased left atrial pressure results in pulmonary
congestion and symptoms of left-sided heart failure.

25. Clinical manifestation
• depend on its severity. mild d’se, no signs of heart failure,
auscultation reveals a high-pitched holosystolic murmur at
the apex that radiates to the axilla.
• With severe mitral insufficiency, signs of chronic heart
failure may be noted.
• The heart is enlarged, with a heaving and often an apical
systolic thrill.
• The 2nd heart sound may be accentuated if pulmonary
hypertension is present.
• A 3rd heart sound is generally prominent.

26. • A holosystolic murmur is heard at the apex with radiation
to the axilla.
• A short mid-diastolic rumbling murmur is caused by
increased blood flow across the mitral valve as a result of
the insufficiency.
• Auscultation of a diastolic murmur does not necessarily
mean that mitral stenosis is present.
• The electrocardiogram and roentgenograms are normal if
the lesion is mild.

27. • With more severe insufficiency, the electrocardiogram
shows prominent bifid P waves, signs of left ventricular
hypertrophy, and associated right ventricular hypertrophy
if pulmonary hypertension is present.
• Echocardiography shows enlargement of the left atrium
and ventricle, and Doppler studies demonstrate the
severity of the mitral regurgitation.
• Heart catheterization and left ventriculography are
considered only if diagnostic questions are not totally
resolved by noninvasive assessment.

28. Treatment
• Surgical valvotomy or balloon catheter
mitral valvuloplasty generally yields good
results; valve replacement is avoided
unless absolutely necessary.
• Balloon valvuloplasty is indicated for
symptomatic, stenotic, pliable, noncalcified
valves of patients without atrial arrhythmias
or thrombi.

29. Aortic insufficiency
• Regurgitation of blood leads to volume
overload with dilatation and hypertrophy of
the left ventricle. Combined mitral and
aortic insufficiency is more common than
aortic involvement alone.
Clinical Manifestations.
• Symptoms are unusual except in severe
aortic insufficiency.
• Palpitations, Excessive sweating and heat
intolerance are related to vasodilation,

30. • Dyspnea on exertion can progress to
orthopnea and pulmonary edema;
• angina may be precipitated by heavy
exercise.
• Nocturnal attacks with sweating,
• tachycardia,
• chest pain, and
• hypertension may occur.

31. • The pulse pressure is wide with bounding
peripheral pulses.
• Systolic blood pressure is elevated, and
diastolic pressure is lowered.
• In severe aortic insufficiency, the heart is
enlarged,
• with a left ventricular apical heave.
• A diastolic thrill may be present

32. • The typical murmur begins immediately with the 2nd heart
sound and continues until late in diastole.
• The murmur is heard over the upper and midleft sternal
border with radiation to the apex and the aortic area.
• it has a high-pitched blowing quality and is easily audible
in full expiration with the diaphragm of the stethoscope
placed firmly on the chest and the patient leaning forward.
• A systolic ejection murmur is frequent because of the
increased stroke volume.

33. • The electrocardiogram may be normal, but in advanced
cases it reveals signs of left ventricular hypertrophy and
strain with prominent P waves.
• The echocardiogram shows a large left ventricle and
diastolic mitral valve flutter or oscillation caused by
regurgitant flow hitting the valve leaflets.

34. • Doppler studies demonstrate the degree of
aortic runoff into the left ventricle.
• Magnetic resonance angiography (MRA)
can be useful in quantitating regurgitant
volume.
• Cardiac catheterization is necessary only
when the echocardiographic data are
equivocal.

35. Treatment
• Afterload reducers (ACE inhibitors) and
prophylaxis against recurrence of acute
rheumatic fever and the development of
infective endocarditis.
• Surgical intervention (valve replacement)
should be carried out well in advance of the
onset of heart failure, pulmonary edema, or
angina

36. Tricuspid insufficiency
• is rare after rheumatic fever.
• Tricuspid insufficiency is more common
secondary to right ventricular dilatation
resulting from unrepaired left-sided lesions.
• S+S: prominent pulsations of the jugular
veins,

37. • systolic pulsations of the liver, and a blowing holosystolic
murmur at the lower left sternal border that increases in
intensity during inspiration.. Tricuspid valvuloplasty may
be required in rare cases.

38. Pulmonary valve disease
• Pulmonary insufficiency usually occurs on a functional
basis secondary to pulmonary hypertension and is a late
finding with severe mitral stenosis.
• The murmur is similar to that of aortic insufficiency, but
peripheral arterial signs (bounding pulses) are absent.
• DX: is confirmed by two-dimensional echocardiography
and Doppler studies

39. Pericarditis
• Is inflammation of the pericardium
• Causes
• Infections: Viral e.g coxsackie,EBV, bacteria;-strep,
fungal: histoplasmosis, parasitic: toxoplasmosis
• Connective tissue
• Rheumatic arthritis, Rheumatic fever, SLE, Sarcoidosis
• Metabolic: hyperuricaemia, hypothyroidism
• Malignancy
• Radiotherapy

40. Clinical features
• Precordial pain-
• sharp, exacerbated by lying down, relieved
by sitting or leaning forward, referred to the
left shoulder
• others
• Cough, Dyspnoea and Fever
• o/e : pericardial rub, distant heart sounds,
pulsus parradoxus

41. • Investigations : echocardiogram, ECG
• Pericardiocentesis, C/S
• Blood serology for viral studies
• ASOT
• Mnx:
• Antibiotics, analgesics, anti-inflammatory,
pericardiocentesis