Group A streptococci are the most common cause of strep throat, especially in children ages 5-15. About 15-20% of sore throats are caused by streptococci. Patients with a true streptococcal infection are at risk of developing rheumatic fever or spreading the infection to others. The Jones Criteria provide guidelines for diagnosing acute rheumatic fever based on major and minor symptoms and evidence of a prior streptococcal infection. Echocardiography can help identify carditis that is not clinically apparent, increasing the detection of rheumatic heart disease. Rheumatic fever and rheumatic heart disease remain major public health problems in many developing nations.

3.  Group A streptococci are the most commonbacterial
cause of pharyngitis, with a peak Incidence in
children 5–15 years of age.
 15–20% of sore throats are caused by group A
streptococci.
 A patient with a true infection is at risk of developing
RF and of spreading the organism to close contacts,
while this is not thought to be the case with carriers.
 Positive throat culture rate for Gr A streptococci are
around 13.5% in Northern India in sore throat cases.

4.  1.Agent: virulence
 2. Host: Genetic susceptibility[3-5%]
 3. Environment: Challenged socioeconomic
HOTSPOT
 Kyrgyzstan
 Highest incidence of RF/RHD
 543/100,000 population per year

11.  Jones Criteria, as revised in 2015 by the
American Heart Association (AHA)
 Intended for diagnosis of the initial attack of
acute rheumatic fever and recurrent attacks.
 There are 5 major and 4 minor criteria and a
requirement of evidence of recent GAS infection.

 The 2015 revision includes separate criteria for
Low-Risk populations (defined as those with
incidence ≤2 per 100,000 school-age children
per year orall-age rheumatic heart disease
prevalence of ≤1 per thousand population)
 Moderate/High-Risk populations (defined as
those with higher incidence or prevalence rates)

13.  Diagnosis of recurrent acute rheumatic fever can
also be made only in the Moderate/High Risk
population by presence of 3 minor criteria with
evidence of preceding GAS infection.
 A major change from previous versions expands
the definition of the major criterion–carditis–to
include subclinical evidence (i.e., in the absence
of a murmur, echocardiographic evidence of
mitral regurgitation [MR]

14.  Even with strict application of the Jones criteria,
overdiagnosis as well as underdiagnosis.
 3 situations where diagnosis without strict
adherence to the Jones criteria:
 (1) when chorea occurs as the only major
manifestation of acute rheumatic fever
 (2)when indolent carditis is the only manifestation in
patients who firstcome to medical attention only
months after the apparent onset of acute rheumatic
fever.
 (3) in a limited number of patients with recurrences
of acute rheumatic fever in particularly high-risk
populations

15.  Most serious
 CRHD
 Pancarditis
 The incidence of carditis during the initial attack of RF
 50%-No echo
 91%-with echo
 Varies with the age
 ◦ 90% to 92% of children <3 years
 ◦ 50% of children 3 to 6 years of age
 ◦ 32% of teenagers aged 14 to 17 years
 ◦ 15% of adults
 Myocarditis in the absence of valvulitis is unlikely to be
rheumatic in origin

16.  In India, rheumatic fever is endemic and
remains one of the major causes of
cardiovascular disease,
 Accounting for nearly 25-45% of the acquired
heart disease.
 PRIMARY ATTACK RATE OF RF FOLLOWING
STREPTOCOCCAL PHARYNGITIS
 EPIDEMICS: 3%
 SPORADIC:0.3%

25. 2012 World Heart Federation (WHF) guidelines

26.  CHF - 5% to 10% during initial attack
 increases with repeated carditis
 Pansystolic murmur at apex
 Transient apical mid-diastolic murmur
 (Carey-Coombs) may occur in association
with the murmur of mitral regurgitation

30. THE ECHOCARDIOGRAPHIC
CRITERIA HAD SENSITIVITY OF
81% AND SPECIFICITY OF 93%
THE EFFICACY OF ECHOCARDIOGRAPHIC CRITERIONS FOR THE
DIAGNOSIS OF CARDITIS IN ACUTE RHEUMATIC FEVER .B
VIJAYALAKSHMIA1 C1, RAJAN O.VISHNUPRABHUA1, NARASIMHAN
CHITRAA1

32.  Echocardiographic demonstration of valvular
regurgitation is not a prerequisite for the
diagnosis of rheumatic carditis and should
not be considered a limitation where the
facilities are not available.
 INITIALLY, data do not allow subclinical
valvular regurgitation detected by
echocardiography to be included in the Jones
criteria, as evidence of a major manifestation
of carditis.

34.  Mitral regurgitation can be alone or with other
lesions
 As high as 70% of MR in initial attack can
disappear over a period of time.
 Severity of MR directly proportional to
subsequent RHD
 Severity of LV dysfunction related to extent of
valvulitis
 Acute mitral valvulitis shows mitral annulus
dilatation,
chordal elongation, and anterior leaflet prolapse,
with varying degrees of MR and rarely chordal
rupture.

37. AORTIC REGURGITATION
 Isolated aortic disease occurs
in 2% of cases
 Asymptomatic patients with normal LV
systolic function
 Progression to symptoms &/or LV dysfn: 6%
 Progression to asymptomatic LV dysfunction
< than 3.5% per year
 Asymptomatic patients with LV dysfunction
 Progression to symptoms: more than 25% per
year
 If AS is present with MV, involvement it is
likely to be rheumatic

49. THANK YOU
HAVE A
NICE DAY