This presentation is intended for nurses

1. RHEUMATIC HEART DISEASE
Presented by:
Dhrishya Sasidharan Nair
GN, CCU

2. OBJECTIVES

3. CASE SCENARIO
• Mrs. X , 28 years visited the cardiologist with complaints of palpitation,
dizziness & shortness of breath while doing household work.
• On assessment: vitals: HR 92/mt, BP 106/72 mmHg, spo2 96%,
Murmur heard on auscultation , history of recurrent sore throat since
childhood, no other medical history. ECG shows first degree heart block.
• ECHO revealed LVF with mitral stenosis, EF 35%
• Lab tests were run & was Diagnosed as RHD.

4. INTRODUCTION
• Rheumatic heart disease ( RHD) is the most common
acquired heart disease in children especially in
developing countries
• RHD is a chronic heart condition caused by rheumatic
fever that can be prevented and controlled

6. SORE
THROAT
KILLS !!

7. HOW??
STREP THROAT
RHEUMATIC FEVER
RHEUMATIC HEART DISEASE

8. WHAT IS RHEUMATIC FEVER??
• Rheumatic fever is an immunologically
mediated inflammatory disorder which
occurs as a sequel to group A
streptococcal pharyngeal infection
• Multisystem disease affecting
connective tissue particularly of the
heart, joints, brain, cutaneous &
subcutaneous tissue.

11. • Rheumatic Fever is not a
Communicable Disease but
results from a
Communicable Disease.
• Acute rheumatic fever &
rheumatic heart diseases
are 100% preventable!!

12. CAUSES
• Everyday oral activities
• Infection
• Weakened immune system
• Certain dental procedures

13. PATHOGEN
• Group A beta hemolytic Streptococci
• Cox sackie virus type B4

14. Immune cross
reaction
Or
Molecular
Mimicry
HOW DOES IT AFFECT ??

16. PATHOPHYSIOLOGY
Body produces antibody against streptococci
These antibodies cross react with human tissues because of
the antigenic similarity between streptococcal antigens &
human connective tissue ( Molecular Mimicry)
This will cause immunologically mediated inflammation &
damage to tissues with antigenic similarity ( joints, heart,
skin, brain & subcutaneous tissue)
Rheumatic fever

18. How is it manifested?
J
O
N
E
S
Oints
Heart
Odules
Rythema
chorea

21. 1.MIGRATORY POLYARTHRITIS ( J )
• Most common feature, seen in more than 90% of
cases with RF.
• Painful, migratory
• Usually more than 5 large joints are affected-
(knees, ankles, wrist, elbow, shoulders)

22. 2.

23. 3. N- SUBCUTANEOUS NODULES
• Small painless mobile hard lumps
beneath the skin
• Most common along extensor
surfaces of joints
• Appears 4 weeks after onset of RF
• Delayed sign, often disappears
without residual damage.
• Often associated with carditis.

24. 4. E- ERYTHEMA MARGINATUM
• Occurs in less than 7% of
cases with RF
• It forms wavy lines or rings with
sharp edges
• More on trunks & limbs, never
on face
• Non Itchy
• Worsens with heat application

26. MINOR MANIFESTATIONS
1) Clinical findings
• Previous rheumatic fever/ RHD
• Arthralgia
• Fever associated with weakness, malaise, weight loss and
anorexia.
2) Laboratory findings
• Elevated ESR, CRP & leukocytosis
• ECG & echocardiogram to confirm rhythm problems and
structural changes
• Chest X ray shows enlarged heart

27. DIAGNOSIS

28. CRITERIA TO DIAGNOSE RHEUMATIC
FEVER

29. • Rapid Antigen
detection test
• Throat culture
• Antistreptococcal
antibodies
LABORATORY DIAGNOSIS

31. ECHO

32. CHEST X RAY

38. REMEMBER!!
”RHEUMATIC FEVER LICKS
THE JOINTS & EATS THE
HEART ”

40. • It is a chronic condition resulting from rheumatic fever that is
characterized by scarring and deformity of the heart valves.
• It is the permanent heart valve damage resulting from one or
more attacks of RF.
• It is estimated that 40-60% of patients with RF will go on
developing RHD
• Sadly RHD can go undetected, with the results that patients
presents with debilitating heart failure.
Rheumatic heart disease

41. TYPES ??
• ACUTE RHEUMATIC HEART DISEASE
Rheumatic pericarditis
Rheumatic myocarditis
Rheumatic endocarditis
• CHRONIC RHEUMATIC HEART DISEASE

42. HEART WALL LAYERS
Pericardium
Endocardium
Myocardium

43. Myocarditis
Pericarditis
Endocarditis
Pericarditis
Fibrinous
pericarditis

45. PERICARDITIS
• Sharp, cutting pain, relieved on leaning
forward
• Pericardial friction rub- Due to inflammed
pericardium rub
Is it chronic or irreversible?
• No long term complications as when
rheumatic fever subsides the fibrin strands
are cut down by plasmin & all fibrin threads
are reabsorbed.
• Heals completely.

46. MYOCARDITIS
Myocarditis
Aschoff
bodies

48. MYOCARDITIS CONTD…
• Myocarditis during acute rheumatic fever is lethal as
myocardium becomes loose , flabby & doesn’t
contract well
• Mortality during acute phase of rheumatic fever is
mostly due to MYOCARDITIS
• But once rheumatic fever subsides, Myocarditis
doesn’t leave long term damage.
Congestive heart failure

49. RHEUMATIC ENDOCARDITIS
• Acute stage of rheumatic valvulitis shows thickening
& loss of translucency of valve cusps with the
development of verrucacea ( vegetations, warty )
along the line of closure.

50. Fibrin & platelet
aggregates
Rheumatic/
Sterile
vegetationRheumatic
vegetations
are not caused
by microbes &
hence will not
break or cause
emboli..

51. Fibrin & platelet
aggregates
Fibrin & platelet
aggregatesadhesions & fibrosis

52. ENDOCARDITIS

53. MITRAL VALVE- NORMAL & DISEASED

54. CLOSING OF VALVES- COMPARISON

57. WHICH TYPE OF CARDITIS
PROGRESSES TO CHRONIC RHD?
• Rheumatic pericarditis
• Rheumatic endocarditis
•
• Rheumatic myocarditis

58. CHRONIC RHD
Endocarditis heals by progressive fibrosis
Scarring of valves
Development of chronic valvular deformities
Clinically manifest decades after the acute
process

59. • Leaflet thickening
• Commisural fusion
• Shortening , thickening
& fusion of chordae
tendinae
• Orifice narrowed
CHRONIC RHD FEATURES

61. CHRONIC RHD CONTD…

64. TREATMENT

66. SURGICAL MANAGEMENT

67. COMMISUROTOMY

68. BALLOON VALVOTOMY

69. VALVE REPAIR

70. VALVE REPLACEMENT

71. TAVI ( TRANS CATHETER AORTIC
VALVE REPLACEMENT)

72. NURSING
MANAGEMENT

83. QUIZ- NAME IT
Aschoff body
seen in
myocarditis

84. WHICH AMONG THE FOLLOWING IS KNOWN AS
FISH-MOUTH STENOSIS?
• 1 2
Mitral stenosis Aortic stenosis

85. QUIZ CONTD…
• Highest mortality rate among children during acute
rheumatic fever is mostly due to
• Does a patient regularly receiving Inj.Benzyl Penicillin
since 3 years need a test dose before next
administration?
Myocarditis
YES

86. GIVE THE OTHER NAME FOR FIBRINOUS
PERICARDITIS ?
BREAD &
BUTTER
PERICARDITIS