pediatric cardiology

1. Updates in The Diagnosis
And Management of RF
2015
Magdy Abou El-Kheir ,MD
Prof of pediatrics
Head of Pediatric Cardiology Unit
Mansoura University Children’s Hospital

2. The Requirements for the Development of RF
 Genetically Predisposed Host.
PLUS
 Presence of GABHS.
 Pharyngeal infection not
colonization.
 Persistence of the organism in the
pharynx for a sufficient period (delay
of therapy > 9th day or treatment <
10 days duration) or subclinical
infection.
 Streptococcal immune response
(anti-streptococcal antibodies).

3. Antibiotic Therapy for GABHS
 Goal is bacteriological cure.
 Antimicrobial therapy as early as before 9th
day of illness.
 Duration of therapy (10 days coverage).
– 10 days: oral penicillin (V)/Amoxacillin/1st
generation cephalosporin.
– Single IM, Benzathin penicillin.
– 10 days: erythromycin ethylsuccinate.
– 5 days: Azithromycin.
– 7 days: Clarithromycin,

4. Message to Pediatrician and Cardiologist
 RF is a post streptococcal disease not an acute
event at the peak of GAS infection, so latent period
is a rule.
 Beacteriological cure is the aim.
 No role of serology or APR in the diagnosis of overt
GAS infection .
 Clinical signs of GAS infection are more informative
with no need of culture in most of cases.
 A higher ASO titer at the onset or peak of GAS
infection means nothing to the current problem of
GAS infection

5. Acute rheumatic fever is a multisystem
inflammatory disease secondary to previous
pharyngeal infection by group A beta hemolytic
streptococci

6. What makes a link between the throat
and the heart ?

7. Diagrammatic structure of the group A
beta hemolytic streptococcus
Capsule
Cell wall
Protein antigens
Group carbohydrate
Peptidoglycan
Cyto.membrane
Cytoplasm
Antigen of outer
protein cell wall
of GABHS
induces antibody
and cellular
immune
response in
victim which
result in
autoimmune
damage to heart
valves, joints
sub cutaneous
tissue, joints &
basal ganglia of
brain
Molecular mimicry

8. Manifestations of Rheumatic Fever
 Major manifestations ; Why ?
 Minor manifestations ;Why ?
 Essential manifestation ; Why ?
 Additional manifestation; Why?

9. Major and Minor Manifestations of Rheumatic Fever
 Carditis
 Polyarthritis
 Chorea.
 Erythema Marginatum
 Subcutaneous nodules
 Fever
 Arthralgia
 Elevated acute phase reactants (ESR,
CRP)
 Prolonged P-R interval
PLUS
Evidence of preceding streptococcal infection (Culture, rapid antigen,
antibody rise / elevation)
Minor criteria
Major criteria

10. Sequences of RF Manifestations
20 30 50 100 200
20 30 50 100 200
Subcut. Nodules
Erythema Marginatum
Chorea
Carditis
Arthritis
Abdominal pain
ASO titer
Days since strept. infection

11. Message to Pediatrician and Cardiologist
 RF is primarily a clinical diagnosis supported by
investigatory tools.
 Only order for laboratory markers of ARF once we
have at least a strong suspicion of overt joint or
cardiac involvement.
 Higher ASO titer whatever the level is with or
without positive APR are not related to RF in the
absence of clinical evidence suggestive of RF

12. Jones Criteria are a guide, not a rule; they are not meant
to be an exercise in diagnosis by rote, or a gimmick to
bypass the physician's mind
Jones Criteria set up a sharp boundary between health
and disease and such thing is not existing in nature .
There is no single symptom or physical sign or laboratory
tool or imaging tool that is pathognomonic for rheumatic
fever.
Golden Rules in The Diagnosis of Rheumatic Fever

13.  Over-diagnosis will result in the individual receiving BPG injections
unnecessarily every 2 weeks for a minimum age of 21 years old,
 Under-diagnosis of ARF may lead to the individual suffering a further
attack of ARF, cardiac damage and premature death.
 The Jones criteria 1992 update and WHO additional guidelines 2003
improve the specificity of the criteria at the expense of sensitivity, largely
in response to the falling incidence of ARF in the USA.
 The criteria may not be sensitive enough to pick up disease in high-
incidence populations with the expected consequences of under-
diagnosis are likely to be greater than those of over-diagnosis.
The Need of Accurate Diagnosis of the
Index case of RF

14. 2002-2003 WHO Criteria for the Diagnosis of RF and RHD
Criteria
Diagnosis Categories
Two major or one major and two minor
manifestations plus evidence of a
preceding group A streptococcal
infection.
Primary episode of RF.
Two major or one major and two minor
manifestations plus evidence of a
preceding group A streptococcal
infection.
Recurrent attack of RF in a patient
without established rheumatic heart
disease.
Two minor manifestations plus evidence
of a preceding group A streptococcal
infection.
Recurrent attack of RF in a patient
with established rheumatic heart
disease.
Other major manifestations or evidence of
a group A streptococcal infection not
required.
Rheumatic Chorea.
Insidious onset rheumatic carditis.
Do not require any other criteria to be
diagnosed as having rheumatic heart
disease.
Chronic Valve lesions of RHD
(patients presenting for the first time
with pure mitral Stenosis or mixed
mitral valve disease and/or aortic
valve disease).

15. Reasons beyond updating
 The evolving role of non-invasive cardiac imaging by the
undue diagnostic sensitivity and availability of
echocardiographic modality.
 Previous AHA RF guidelines did not categorize
recommendations using the currently favored
Classification of Recommendations and Levels of
Evidence categories.
 The global distribution of ARF/RHD is clearly
disproportionate from countries and even regions .
 Changing of the clinical pattern of joint involvement.

16. THE CHANGING EPIDEMIOLOGICAL
PATTERN OF RF
 The global distribution of ARF/RHD is clearly
disproportionate. Certain geographic regions and specific
ethnic and socioeconomic groups experience very high
rates of ARF incidence, whereas in other regions, the
disease has virtually disappeared.
 This has led to concern regarding the uniform sensitivity
of the Jones criteria, even as revised over the years,
when applied to geographic areas or to populations within
those areas, or elsewhere, where ARF is hyperendemic

17. Implications of Epidemiological Considerations
 Because the clinical utility of a diagnostic test is
determined by a number of factors, including its pretest
probability and background disease prevalence, and in
view of the heterogeneity in global disease burden:
a single set of diagnostic criteria may no longer be
sufficient for all population groups and in all geographic
regions.
 To avoid overdiagnosis in low incidence populations and
to avoid underdiagnosis in high-risk populations:
variability in applying diagnostic criteria in low risk
compared with high-risk populations is reasonable

18. Bryant, P. A. et al. Circulation 2009;119:742-753
Worldwide prevalence of RHD

19. Consequences 2015
1. It is reasonable to consider individuals to be at low risk for
ARF if they come from a setting or population known to
experience low rates of ARF or RHD (Class IIa; Level of
Evidence C).
2. It is reasonable that where reliable epidemiological data
are available, low risk should be defined as having an
ARF incidence <2 per 100 000 school-aged children
(usually 5–14 years old) per year or an all age prevalence
of RHD of ≤1 per 1000 population per year (Class IIa;
Level of Evidence C).
3. Children not clearly from a low-risk population are at
moderate to high risk depending on their reference
population (Class I; Level of Evidence C).

20. Applying Classification of
Recommendations

21. THE CHANGING PATTERN OF JOINT
INVOLVEMENT
 In the 1992 version of the Jones criteria, mono-articular
arthritis was related to premature administration of
nonsteroidal anti-inflammatory drugs before diagnosis.
 Evidence has been published that in selective high-risk
populations, mono-articular arthritis may be an indicator of
the major manifestation of arthritis.
 Ongoing reassessment of evolving clinical information is
mandatory in any specific patient , because of the
potential for “diagnosis overlap” in application of the Jones
criteria.

22. Revised Jones Criteria 2015
For all patient populations with evidence of preceding
GAS infection :
 Diagnosis of the initial ARF :
2 Major manifestations or 1 major plus 2 minor
manifestations
 Diagnosis of recurrent ARF:
2 Major manifestations or 1 major and 2 minor or 3
minor manifestations

23. Minor criteria 2015
 Low-risk populations :
Polyarthralgia; Fever (≥38.5°C) and ESR ≥60 mm in
the first hour and/or CRP ≥3.0 mg/dL
 Moderate and high-risk populations:
Monoarthralgia, Fever (≥38°C)and ESR ≥30 mm/h
and/or CRP ≥3.0 mg/dL.

24. Major criteria Low-risk versus high
populations 2015
 In all populations :Carditis :Clinical and/or subclinical
 Low risk populations :
Arthritis: Polyarthritis only
 Moderate- and high-risk populations:
Arthritis : Monoarthritis or polyarthritis or
Polyarthralgia

27. Acute Mitral Valvulitis
Rheumatic carditis

28. Acute Aortic Valvulitis
Rheumatic carditis

29. First-Degree AV Block
The rhythm is regular
Prolonged Prolonged P-R interval as a minor manifestation

31. Rheumatic Carditis
- Infective endocarditis.
- Viral myocarditis.
- Innocent murmurs .
- Minor auscultatory findings.
- MVP with or without Marfan’s syndrome.
- Anemia .
- Dilated or hypertrophic cardiomyopathy .
- Cleft mitral valve with or without partial AVSD.
- Bicuspid aortic valve with regurgitation .
- L-transposition of GA.
- Pericarditis .
Differential diagnosis of carditis

32. Sydenham`s Chorea as a disease
- Choreic movement.
- Uncoordinated voluntary motor activity
- Muscle weakness and hypotonia
- Emotional lability and/ or instability

34. Erythema Marginatum
 The lesions of Erythema Marginatum
appear first as a bright pink macule or
papule that spreads outward in a circular
or serpiginous pattern.
 The lesions are multiple, appearing on the
trunk or proximal extremities, rarely on the
distal extremities, and never on the face.
 They are non-pruritic and non-painful,
blanch under pressure, and are only rarely
raised.

35. Subcutaneous Nodules

36. Subcutaneous nodules
 The subcutaneous nodules are round, firm,
freely movable, painless lesions varying in size
from 0.5–2.0 cm. They occur in corps over bony
prominences or extensor tendons. Common
locations are the elbows, wrists, knees, ankles
and Achilles.
 They last for weeks and have a significant
association with carditis.

37. The 5 Emerging Problems in the diagnosis of
Rheumatic Fever in the Last Two Decades
 Changing pattern of joint involvement .
 The evolution of subclinical / silent / echocarditis in the face of
deceasing severity of clinically evident- carditis .
 The variability of the requirement of recent evidence of GAS
infection (higher ASO titer) in relation to Rheumatic Fever in both
the initial attack as well as recurrences .
 The minor criteria need more characterization to enhance their
specificity
 The evolution of post streptococcal reactive arthritis and its relation
to RF

38. I-The Changing Pattern of Joint Involvement
 Typical arthritis of RF is “almost always
migratory” and “lasting 4 weeks”
 Unusual presentation :
– Monoarthritis or polyarthralgia may
occur with increasing frequency if
AIT is initiated before RF is fully
expressed .
– Simultaneous rather sequential joint
involvement may occur .
– Additive rather than migratory .
– Response to ASA may be less
dramatic .

39. The minimal acceptable evidence of joint involvement needed to
be considered as a major criterion and subsequently label
such patient as a “rheumatic” with its life-long implications
is
Single Objective joint involvement and at least one other joint with
arthralgia
The Minimal Requirement for Arthritis as
a Major Manifestation
is

40. Recommendations 2015
 The consideration that monoarthritis may be
part of the ARF spectrum should be limited to
patients from moderate- to high-risk populations
(Class I; Level of Evidence C).
 The inclusion of polyarthralgia as a major
manifestation is applicable only for moderate-
or high-incidence populations and only after
careful consideration and exclusion of other
causes of arthralgia such as autoimmune, viral,
or reactive arthropathies (Class IIb; Level of
Evidence C).

41. Growing pains
Joint pains of subacute
rheumatic fever
Growing pains
Timing Durring entire day,
disappears on getting warm
in bed, worse on first getting
out of bed in the morning.
At end of day or
soon after falling
asleep, free of
pain in morrning
Location In joints. Pain on motion.
Cild points out pain in joints.
Involves joints in upper
extremities.
May cause limping.
In muscles of
thigh or legs. No
pain on motion.
Child vague in
pointing out site
of pain in upper
extremites
unusual.

42. Polyarthritis, Fever and Elevated APR
* RF * Collagen diseases
* PSRA * Infective endocarditis
* Serum sickness * Leukemia / lymphoma
 Evidence of a preceding streptococcal infection
will reduce, but not eliminate, the possibility of
these diseases.
 Such diseases need to be considered before a
definitive diagnosis of RF is made.
 Revision of the initial diagnosis as RF is justified
if the therapeutic response to ASA is absent or
delayed.

43. Probable Rheumatic Fever
– Mono-arthritis or migratory polyarthralgia may occur
with increasing frequency in ARF, so a probable
rheumatic etiology of such pure joint involvement is
established if associated with the following 3
requirements:
1. A significant acute phase response (ESR:30 mm /H, or CRP
30mg/L)
2. Recent evidence of GAS infection by rising titer of ASO (2- 4w),
so that such rise is causally related .
3. Rule out other possible causes of joint involvement.

44. Avoid premature administration of Anti-inflammatory therapy and
stoppage of it even if prescribed in subtherapeutic dose .
Begin Antimicrobial therapy for GAS infection for 10 days to abate
the immune response to streptococcal antigenemia .
Close bed side clinical assessment for evolution of typical joint
involvement and / or clinically evident-carditis (major criteria) .
Diagnose subclinical carditis by Color Doppler echocardiography
initially and within the ongoing two weeks (major criteria) .
Establish a recent evidence of GAS infection by rising titer of ASO
so that such rise is causally related rather a mere coincidence
(probable RF) .
Establish a positive strong inflammatory response by positive APR
:ESR 30mm/h or CRP 30mg/L
So
Advice regular secondary prophylaxis for those with probable ARF
Guidelines for Management of Probable RF

45.  Subclinical or silent rheumatic valve damage detected by echo is
now considered as a part of the spectrum of rheumatic carditis and
should not be ignored in the era of declining severity of carditis in
the last decade.
 In experienced hands rheumatic pathological regurgitation can
usually be distinguished from physiological regurgitation.
 Echo diagnosis of subclinical valve damage can help in making the
diagnosis of ARF
II-The Evolution of Subclinical / Silent / Echocarditis

46. WHY ECOCARDOGRAPHY ?
 The limited diagnostic role for echocardiography in the
diagnosis of carditis was expressed in the Jones criteria
revision of 1992 .
 Echocardiographic techniques and applications,
including quantitative Doppler and color flow mapping,
have evolved worldwide during the past 2 decades.
 Many national and regional guidelines for the diagnosis
of ARF have recently included the use of
echocardiography/ Doppler methodologies.

47.  Evolution of echo-carditis in the absence of overt
clinical findings “subclinical carditis” is a well known
spectrum of carditis in ARF.
 Echocardiography has become a cornerstone in
worldwide screening programs to evaluate the
prevalence of RHD in a given population .
WHY ECOCARDOGRAPHY ?

48. Doppler Findings in Rheumatic Valvulitis
 Pathological mitral regurgitation (all 4
criteria met)
1. Seen in at least 2 views
2. Jet length ≥2 cm in at least 1 view
3. Peak velocity >3 m/s
4. Pansystolic jet in at least 1 envelope
 Pathological aortic regurgitation (all 4
criteria met)
1. Seen in at least 2 views
2. Jet length ≥1 cm in at least 1 view
3. Peak velocity >3 m/s
4. Pan diastolic jet in at least 1 envelope

49. Morphological Findings on Echocardiogram in
Rheumatic Valvulitis
 Acute mitral valve changes
1. Annular dilation
2. Chordal elongation
3. Chordal rupture resulting in flail leaflet with severe mitral
regurgitation
4. Anterior (or less commonly posterior) leaflet tip prolapse
5. Beading/nodularity of leaflet tips
 Aortic valve changes in acute carditis
1. Irregular or focal leaflet thickening
2. Coaptation defect
3. Leaflet prolapse

50. Mimics of rheumatic mitral regurgitation
 Physiological mitral regurgitation
 Myxomatous mitral prolapse
 Congenital mitral valve disease as cleft mitral valve,
double-orifice mitral valve and parachute mitral
valve .
 Endocarditis
 Annular dilation from conditions associated with
left-sided heart dilation, including myocarditis and
cardiomyopathy

51.  Isolated aortic regurgitation is rarely the sole
valvular finding in rheumatic carditis.
 Congenital diagnoses to consider include ;
 Bicuspid aortic valve.
 Spontaneously closed ventricular septal defect with
aortic valve prolapse.
 Subaortic membrane
 Syndromic-related aortic root dilation.
Mimics of rheumatic aortic
regurgitation

52. Patients seen with equivocal manifestations of rheumatic
fever as monoarthritis or polyarthralgia :
The finding of color Doppler evidence of pathologic mitral
regurgitation makes the diagnosis of carditis definite and therefore
missing the index episode of ARF becomes unlikely.
The Diagnostic Utility of CD Evidence of
Carditis

53. Patients presenting with major manifestation of RF ,
the diagnosis of echocarditis has many important
diagnostic and clinical implications :
1. It does confirm the diagnosis of ARF in patients presented with
isolated chorea .
2. It rules out other diagnostic possibilities in the situations of
polyarthritis, fever and positive acute phase reactants .
3. It can provide evidence of early valvular regurgitation and can
confirm suspect carditis .
4. It does exclude non-rheumatic causes of valvular regurgitation in
patients with acute or indolent carditis as MVP or BAV.
5. It determines the need for prophylaxis against infective
endocarditis as well as the duration of secondary prevention of
ARF recurrence .
The Diagnostic Utility of Echo Evidence of
Carditis

54. Recommendations 2015
1. Echocardiography with Doppler should be performed in all cases of
confirmed and suspected ARF (Class I; Level of Evidence B).
2. It is reasonable to consider performing serial echocardiography/
Doppler studies in any patient with diagnosed or suspected ARF even
if documented carditis is not present on diagnosis (Class IIa; Level of
Evidence C).
3. Echocardiography/Doppler testing should be performed (strictly
fulfilling the criteria) to assess whether carditis is present in the
absence of auscultatory findings, particularly in moderate- to high-risk
populations and when ARF is considered likely (Class I; Level of
Evidence B).
4.Echocardiography/Doppler findings not consistent with carditis should
exclude that diagnosis in patients with a heart murmur otherwise
thought to indicate rheumatic carditis (Class I; Level of Evidence B).

55. III-The Diagnostic Utility of High ASO
Titer
 15% of normal children without clinical evidence of
recent GAS infection have a titer exceeding the ULN .
 About 20% of patents with the first attack of RF and
many patients with chorea, all have low ASO titer .
 In most of developing countries, where the incidence of
RF is high and resources are limited, the only test
available is ASO.
 It seems better to diagnose a suspected case with
typical migratory polyarthritis ,despite a normal ASO
titer as RF, after exclusion of other causes .
 A low or non rising ASO titer at the onset of isolated
polyarthritis is a strong negative predictor against RF .

56. Requirement of high ASO
Diagnosis Categories
Relative requirement
Relative requirement
Absolute requirement of rising titer
Absolute requirement of rising titer
Acute carditis ± polyarthritis
Isolated migratory polyarthritis
Polyarthralgia
Monoarthritis
No requirement
No requirement
Rheumatic Chorea.
Insidious onset rheumatic carditis.
Initial Attack of RF
The Diagnostic Utility of High ASO
Titer(>400 units)

57. Every patient with past history of RF, chorea or
established RHD under secondary prophylaxis
should have a base line ASO titer and ESR with
periodic check up for these two parameters at regular
intervals with a minimum of two per year depending
on the presence or absence of the well known risk
factors for recurrence .
Recurrence of RF
The Diagnostic Utility of High ASO Titer
(>400 units)

58. Clinical Significance
ASO / ESR
Successful secondary prevention for
RF
Subclinical GAS infection and failure
of secondary prevention for RF
Subclinical RF recurrence
Maintaining or declining level of ASO,
normal ESR
Rising ASO + normal ESR
Rising ASO + positive APR (CRP)
Clinical RF recurrence
Rising ASO + positive APR (CRP) +
minor(s) or major manifestation(s)
Past History of RF or RHD
Patient with history of RF or RHD with clinical recurrence should receive the
recommended antimicrobial and antinflammatory therapy for recurrent attack of
RF
The Diagnostic Utility of High ASO Titer
(>400 units)

59. Diagnostic Significance of Higher ASOT
in Different Clinical Scenarios
 Normal children in 15 to 20%.
 Recent clinical or subclinical GABHS pharyngitis .
 Recurrent GABHS pharyngitis rather than recurrent viral
throat infections.
 Initial Attack of Rheumatic Fever.
 Recurrent Rheumatic Fever.
 Probable Attack of Rheumatic Fever.
 Post streptococcal reactive arthropathy
 Failure of secondary prevention in patients with past
history of RF, Chorea, RHD.

60. IV-Characterization of The Minor Criteria

61. Upper limits of normal PR interval

62. Rheumatic Fever Recurrences 2015
 With a reliable past history of ARF or established RHD, and
in the face of documented group A streptococcal infection, 2
major or 1 major and 2 minor or 3 minor manifestations may
be sufficient for a presumptive diagnosis (Class IIb; Level of
Evidence C).
 When minor manifestations alone are present, the exclusion
of other more likely causes of the clinical presentation is
recommended before a diagnosis of an ARF recurrence is
made (Class I; Level of Evidence C).

63. Possible Rheumatic Fever
 The clinical presentation may not fulfill these updated
Jones criteria, but the clinician may still have good
reason to suspect that ARF is the diagnosis.
 This may occur in high-incidence settings where, for
example, laboratory tests for acute phase reactants or
for confirmation of recent streptococcal infection are not
available, documentation of clinical features is not clear,
or the history is not considered to be reliable.
 Clinicians should use their discretion and clinical
acumen to make the diagnosis that they consider most
likely and manage the patient accordingly.

64. Recommendations 2015
 Where there is genuine uncertainty, it is reasonable to
consider offering 12 months of secondary prophylaxis followed
by reevaluation to include a careful history and physical
examination in addition to a repeat echocardiogram (Class
IIa; Level of Evidence C).
 In a patient with recurrent symptoms (particularly involving the
joints) who has been adherent to prophylaxis
recommendations but lacks serological evidence of group A
streptococcal infection and lacks echocardiographic evidence
of valvulitis, it is reasonable to conclude that the recurrent
symptoms are not likely related to ARF, and discontinuation of
antibiotic prophylaxis may be appropriate (Class IIa; Level of
Evidence C).

65. -Some patients with PSRA have developed later
episodes of ARF, indicating that the initial
diagnosis should have been atypical ARF.
-Patients should receive secondary prophylaxis for
at least 5 years (high risk populations), or at
least 1 year (low-risk populations) .
-Echocardiography should be used to confirm the
absence of valvular damage before
discontinuing secondary prophylaxis .
IV-Guidelines for Management of PSRA

66.  Intravenous immunoglobulin did not alter the natural history of
carditis. There was no evidence of reduction in the extent and
severity of carditis, and not recommended in treatment of
carditis.
 2-weekly versus 4-weekly intramuscular penicillin. Penicillin
given every two-weeks was better at reducing Rheumatic fever
recurrence and Streptococcal throat infections.
 Intravenous immunoglobulin is recommended for severe chorea
refractory to other treatment with plasmapharesis is another
option in refractory cases to IVIG.
 ACE inhibitors may be used in severe heart failure.
:
-
Updates in the Guidelines in Treatment of RF

67.  Strict bed rest is no longer recommended for most patients with
rheumatic carditis ,only for heart failure or severe acute valve
disease .
 Patients with milder or no carditis should remain in bed only as
long as necessary to manage other symptoms as joint pain or
febrile illness.
 Withholding NSAID's in patients with mono-arthralgia or mono-
arthritis help in confirming the diagnosis of ARF, paracetamol
may be used for pain relief .
 Salicylates are not recommended to treat carditis
 In developing countries ,it is recommended to treat all cases of
carditis (mild to severe) with steroids.
 The use of intravenous methyl-predinsolone may be given in
severe cases of heart failure .
Updates in the Guidelines in Treatment of RF

71. • Suspected cases of RF with typical migratory polyarthritis ,despite a normal
ASO titer should be managed as RF, after exclusion of other causes .
• Serum CRP level of ≥30mg/L or ESR of ≥30mm/hr is needed to satisfy the
minor criterion of elevated acute-phase reactants .
• For diagnosis of RF in case of polyarthralgia or mono-arthritis, establishment
of a significant acute phase response together with a recent evidence of
GAS infection by rising titer of ASO (2- 4w) is essential ,after exclusion of
other causes.
The 10 Key Pearls

72. • Color Doppler evidence of pathologic valvular regurgitation,
diagnosed by a clinician with experience in echocardiography of
patients with RF/RHD ,should be included as a major criteria .
• Intravenous immunoglobulin is recommended for severe chorea
refractory to other treatment but not for carditis.
• Acute cardiac surgery may be the only way to treat life-threatening
carditis refractory to intensive medical therapy.
The 10 Key Pearls

73. • Patients with PSRA should receive secondary prophylaxis for at least 5
years (high risk populations), or at least 1 year (low-risk populations) .
• All cases of carditis (mild to severe) should be treated with steroids.
• Strict bed rest is no longer recommended except in severe carditis with
heart failure or the presence of joint pain.
• Two-weekly injections appeared to be more effective than or 3-weekly or
4-weekly injections.
The 10 Key Pearls

74. • Inferior doctors treat the
patient’s disease.
• Mediocre doctors treat the
patient as a person.
• Superior doctors treat the
community as a whole.
The Role of Physician