Rheumatic fever is quite common in developing countries and it has well known cardiac complications. So it's very important to know rheumatic fever, hopefully, this presentation will fill the needs. If you think it's helpful then share it.

2. Drug Treatment of
Rheumatic Fever &
Rheumatic Heart
Disease
By
Dr. Amit Kumar Tarafder
BSMMU

3. Why should we recall few
things related to RF?
• Its etiology is well known and it is definitely preventable.
• Proper and early diagnosis and treatment can reduce the
mortality and morbidity.

4. Recall
Rheumatic Fever:
Acute rheumatic fever (ARF) is an
autoimmune inflammatory process
that develops as a sequel of
streptococcal infection.
• Usually affects 5-15 years of age.
• Common cause of acquired heart
disease in adolescent and
childhood.

5. Clinical features at a glance

6. • Universally, the most common major manifestations during
the first episode of ARF (the “major criteria” for diagnosis)
remain carditis (50%–70%) and arthritis (35%–66).
• Followed in frequency by chorea (10%–30%), which has
been demonstrated to have a female predominance, and then
• subcutaneous nodules (0%–10%) and
• erythema marginatum (<6%), which remain much less
common but highly specifc manifestations of ARF.

8. Unavailability of tests that allows a specific diagnosis of ARF,
we depend on the criteria formulated by T. Duckett Jones in
1944
It has been revised by AHA (2015)

12. • Laboratory evidence of a preceding group A streptococcal
infection is needed whenever possible. Without it, the
diagnosis of ARF is in doubt, except in patients with chorea,
which may be the sole initial manifestation of ARF.
• The AHA suggests that diagnostic criteria may be applied
differently, depending on rate of ARF or rheumatic heart
disease (RHD) in the population to help avoid over diagnosis in
low-incidence populations and under diagnosis in high-risk
ones.
(The AHA defines low risk as an ARF incidence of <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. )

13. Carditis (Which needs further
Emphasis)

14. Carditis(Clinicaland/orsubclinical(ie,detected
byechocardiography))
• It is the most serious manifestation.
• Occurs within first 2-3 weeks. But seldom later.
• Duration of carditis ranges from 6 weeks to 6 months.
• Occur in 40-50% of patients with initial attack.
• Involves endocardium myocardium and pericardium to
varying degree.
• It may cause no symptom and diagnosed in the course of
examination presented with fever and joint pain.
• Present with an organic murmur in patients with chorea.
• Asymptomatic presentation is known as silent carditis
and valvular disease may be discovered after wards.

15. Layers of the heart involved Findings
Pericarditis
5-10%
Develop chest pain fever pericardial
rub and pericardial effusion
Myocarditis
Difficult to diagnosis clinically
Suggested by tachycardia and cardiac
enlargement.
Dyspnea, edema, gallop rhythm is
common
Endocarditis Give rise to murmur
Carditis according to the
layers involved

16. Overview of manifestation of
carditis
• Newly developed organic heart murmur or change in
the character
• Cardiomegaly
• Pericarditis
• CCF

17. Severity of carditis
Severity Condition
Mild carditis Valvular insufficiency but no
cardiomegaly
Moderate carditis Valvular insufficiency with
cardiomegaly
Severe carditis When associated with Congestive
cardiac failure

18. Valvulitis
Although the carditis of ARF has been considered to be a
pancarditis and can involve the endocardium,
myocardium, and pericardium, valvulitis is by far the
most consistent feature of ARF.
In acute condition small thrombi form along the lines of valve
closure.
In chronic disease there is thickening and fibrosis of the valve
resulting in stenosis, or less commonly,
regurgitation

19. Doppler evidence of Rheumatic
valvulitis

20. Morphological findings on
ECHO

21. Management of Acute RF
• General measures and rest
• Antimicrobial treatment
• Analgesics and anti inflammatory treatment
• Appropriate therapy for CHF
• Management of chorea

22. General Measures
• Bed rest preferably in a hospital and monitored closely for
carditis. If already present, be alert for signs of heart failure.
Cardiac Status Management
No carditis Bed rest for 2 wks and gradual ambulation for 2
wks even if on salicylates.
Carditis but no cardiomegaly Bed rest for 4 wks and gradual ambulation for 4
wks.
Carditis with cardiomegaly Bed rest for 6 wks and gradual ambulation for 6
wks.
Carditis with heart failure Strict bd rest for as long as heart failure is present
and gradual ambulation for 3 months.

23. Continued
However it is preferable to ensure adequate rest till the
following clinical and laboratory criteria are met:
• Normal body temperature
• Disappearance of joint symptoms and signs
• Absence of tachycardia at rest specially during sleep
• Disappearance of signs of heart failure
• Return of heart size to normal in chest x ray
• Return of ESR to less than 25mm in 1st hour
• CRP become negative
• PR intervel in ECG returns to normal
• Disappearance of subcutaneous nodule (if any)

24. Antimicrobial treatment
(Streptococcal eradication)
NB: None of the regimens has been shown to alter the cause or the severity of
residual valvular disease

25. Analgesics and anti inflammatory
treatment
• Anti-inflammatory agents, including salicylates and
corticosteroids in appropriate dose, provide dramatic
improvement in symptoms such as arthritis and fever soon
after starting treatment.
• There is no good evidence that steroids are superior to aspirin
in terms of altering the natural history of the disease.
• Some believe that they do result in more rapid resolution of
carditis and can be lifesaving, but this is unproven.

26. Continued
Clinical
Manifestations
Drug Dose
Arthralgia Analgesics only
Arthritis Aspirin
(Salicylates)
100 mg/kg/d in 4 divided dose (not
exceeding 4 gm/day) for weeks and 75
mg/kg/day for 4-6 weeks.
Carditis Prednisolone 2mg/kg/day for 2 weeks and taper of 2
weeks.
Aspirin
(Salicylates)
75mg/kg/day for 6 weeks
Anti-inflammatory agents are usually used in high dose for approximately 2
weeks, then decreased by approximately 20% each week, depending on
clinical response and laboratory measurement of inflammatory markers.
When tapering steroids, it is recommended to overlap with aspirin to prevent
the rebound of disease. [(75mg/day) for 6 wks.]

27. Continued
• Steroids or salicylates should not be used in arthralgia. It can
mask the migratory polyarthritis.
• Simple acetaminophen may be used .

28. Treatment of heart failure
• Most cases of heart failure due to carditis are controlled by
adequate bed rest and steroids.
• If not diuretics and digitalis
• Slow digitalization is recommended.

29. Treatment of chorea
• Kept under observation in a quite environment.
• Mild form:
• Prevent fall from bed
• Avoidance of stress
• Severe form
• Anticonvulsant drugs may be needed
Drug Dose
Phenobarbitone 15 to 30 mg every 6-8 hours
Haloperidol 0.01-0.03 mg/kg/day in two divided dose
Cholpromazine 0.5 mg/kg every 4-6 hours
Patients with Chorea even in the absence of other manifestations of Jones
criteria should be put on long term prophylaxis.

30. The course of rheumatic fever
• It varies greatly
Percentage of patients Duration
75% Within 6 weeks
90% Within 2 months
Less than 5% Persists more than 6 months
Intractable form of carditis and
Sydenhams Chorea
May persist as long as several years
Once acute rheumatic fever has subsided and more than 2 months have
elapsed after withdrawal of treatment, rheumatic fever does not occur in
the absence of new streptococcal infections.

31. Rheumatic Heart disease
Acute rheumatic heart disease often produces a
pancarditis characterized by endocarditis, myocarditis, and
pericarditis. Endocarditis is manifested as valve
insufficiency.
Chronic manifestations due to residual and progressive
valve deformity with previous rheumatic heart disease.

32. Frequencies of valve
involvement
Valves involved Percentage of cases
Mitral valve 50%
Mitral and Aortic valves 40%
Mitral Aortic and Tricuspid valve 5%
Aortic valve alone 3%
All other combination 2%

33. Treatment of valvular heart
disease
Every treatment modality and special condition is beyond the
scope of this presentation.
In short it can be described as follows.
• Prevention of disease:
• General measures
• Drug prophylaxis.
• Primary prophylaxis
• Secondary prophylaxis
• Treatment of specific valvular conditions.

35. General Measures
• Improvement of socio economic condition
• Avoidance of over crowding
• Health education

36. Health Education
• Educating the parents regarding recognition and treatment of
streptococcal sore throat.
• Raising consciousness of the doctor and patient regarding role
of prophylactic drugs in prevention of RF.
• Educating the teachers and community leaders.
• Mass medial like television radio and newspaper may be
utilized.

37. Drug Prophylaxis

38. Primary Prophylaxis
• Consists of early treatment of upper respiratory tract infection
due to group A beta hemolytic streptococci to prevent an
initial attack of RF
• To eliminate streptococcus from throat it is essential to
achieve bactericidal concentration of the antibiotics for at
least 10 days.

39. Doses and Administration of
drugs for primary prophylaxis
Antibiotic Route of
administr
ation
Dose
Benzathine Penicillin
Given as single
IM 12,00,000 units for adults and children
over 30 KG
9,00,000 units for children of 25-30 kg
6,00,000 units for children below 25 kg
Phenoxymethyl Oral 250 mg four times daily for adults and
children over 25 kg for 10 days
125 mg four times daily for children less
than 25 kg for 10 days
Allergic to penicillin
Use Erythromycin
Oral 250 mg four times daily for adults and
children over 25 kg for 10 days
40mg/kg/day divided in four dose for
children less than 25 kg for 10 days

40. ….
• Tetracycline and sulfa drugs are not used for primary
prevention of RF because many group A streptococci are
resistant.

41. Secondary Prophylaxis
• To a patient who have had rheumatic fever or is already
suffering from rheumatic heart disease in order to prevent
colonization and or infection with Group A beta hemolytic
streptococci and the subsequent attack of Rheumatic fever.
• Murmur disappeared with regular secondary prophylaxis.
• It is cost effective in reducing morbidity and mortality.

42. Secondary Prophylaxis
Mode of
administrat
ion
Penicillin Sulphadiazine
Intramuscul
ar
Benzathine Benzyl Penicillin
One injection once every four weeks
For children over 25 kg: 12,00,000 unit
For children below 25 kg: 6,00,000 unit
Oral Phenoxy methyl penicillin
250 mg twice daily
For patients allergic to
penicillin
For children over 25 kg: 1gm
daily
For children below 25 kg:
0.5gm daily
For patients allergic to both penicillin and sulphadiazine:
Erythromycin 250 mg twice daily

43. Continued
• In situations of high susceptibility injection may be give 3
weekly

44. Secondary prophylaxis
• The younger the child at the presentation of initial attack the
greater is the chance of recurrence.
• Prophylaxis should be continued throughout pregnancy but
sulphadiazine is to be avoided in such cases.

45. Duration of secondary
prophylaxis
Condition Duration of prophylaxis Follow up
Patients without carditis 5 years or until the age
of 22 years
(whichever is longer)
Once a year for delayed
development of valve
lesion
Anytime for recurrence
of RF
Patients with cardiac
involvement
(carditis but no residual
valvular lesion)
Up to 30 years of age or
10 years from the last
attack
(whichever is longer)
RF with carditis with
residual valvular lesion
including whose with
artificial valve
Life long Once a year to monitor
valve lesion
Anytime for recurrence
of RF

46. Management of Specific Valves
• General management
• Medical therapy
• Intervention
• Surgery

47. Stages of VHD

48. Medical therapy (AS)
COR Condition Level of
evidence
Class I Hypertension in patients at risk for developing AS
(stage A) and in patients with asymptomatic AS (stages B and
C) should be treated according to standard GDMT, started at a
low dose, and gradually titrated upward as needed with
frequent clinical monitoring.
B
Class
IIb
Vasodilator therapy may be reasonable if used with invasive
hemodynamic monitoring in the acute management of
patients
with severe decompensated AS (stage D) with New York Heart
Association (NYHA) class IV heart failure (HF) symptoms.
C
Class
III
Statin therapy is not indicated for prevention of hemodynamic
progression of AS in patients with mild-to-moderate calcific
valve disease (stages B to D).
A

49. Medical therapy (AR)
COR Condition Level of
evidence
Class I Treatment of hypertension (systolic BP >140 mm Hg) is
recommended in patients with chronic AR (stages B and C),
preferably with dihydropyridine calcium channel blockers or
angiotensin-converting enzyme (ACE) inhibitors/angiotensin
receptor blockers (ARBs).
B
Class IIa Medical therapy with ACE inhibitors/ARBs and beta blockers
is reasonable in patients with severe AR who have symptoms
and/ or LV dysfunction (stages C2 and D) when surgery is not
performed because of comorbidities.
B

50. Medical therapy (MS)
COR Condition Level of
evidence
Class I Anticoagulation (vitamin K antagonist [VKA] or heparin) is
indicated in patients with
1) MS and AF (paroxysmal, persistent, or permanent),
2) MS and a prior embolic event, or
3) MS and a left atrial thrombus.
B
Class IIa Heart rate control can be beneficial in patients with MS and
AF and fast ventricular response.
C
Class IIb Heart rate control may be considered for patients with MS
in normal sinus rhythm and symptoms associated with
exercise.
B

52. Medical therapy (MR)
COR Condition Level of
evidence
Class IIa Medical therapy for systolic dysfunction is reasonable in
symptomatic patients with chronic primary MR (stage D) and
LVEF less than 60% in whom surgery is not contemplated.
B
Class III Vasodilator therapy is not indicated for normotensive
asymptomatic patients with chronic primary MR (stages B
and C1) and normal systolic LV function.
B

53. Learning
• Do not ignore pharyngitis or tonsilitis in children the age of 4-
15 years of age.
• Accurate diagnosis and treatment of streptococcal pharyngitis
reduce the incidence of RF and RHD.
• Primary prevention of RF is not only decrease the morbidity
and mortality in children but also will be economically
beneficial for family as well as nation.
• Cost of primary prevention is Approx. taka 60 for 10 day.
• Secondary prevention is Approx. taka 300/year
• Surgical correction requires about taka 3,00,000 tk.