Rheumatic heart disease is a major global health problem caused by untreated streptococcal infections like strep throat. It often leads to narrowing or stiffening of the heart valves. In India, the prevalence is about 6 per 1000 children aged 5-15, and it is the most common heart disease, accounting for 20-30% of cardiovascular hospital admissions. Nurses play an important role in prevention through health education, screening schoolchildren, and ensuring proper treatment of streptococcal infections to prevent recurrent rheumatic fever and further heart damage.

1. Rheumatic Heart Disease
Presented by:
Harsh Rastogi,
M.Sc. Nursing 1st year,
King George’s Medical University,
Institute of Nursing,
Lucknow.

2. Introduction
• Rheumatic Heart Disease is a major health
problem in the world.
• Rheumatic Heart Disease occurs as a squeal of
rheumatic fever.

3. Incidence
• Global:
▫ RHD is a global problem. The WHO (2011) reported
that about 15 million people suffered from rheumatic
heart disease world-wide.
▫ During 2008, there were 2, 20,000 deaths from RHD.
▫ RHD a major cause of mitral insufficiency & stenosis
in the world.
▫ There is a fall in the incidence & prevalence of &
mortality from RHD in developed countries. This
decrease is mainly due to improvement in socio-
economic conditions rather than the modern
treatment because the fall occurred before the
availability of the modern treatment.

4. Cont…
• Indian:
▫ In India, prevalence of RHD is about 6/1000
children in the age group of 5-15 years. It is also
reported that there are about 1 million RHD cases
in India. RHD is the most common prevalent
heart disease. About 20%-30% of hospitals
admissions due to Cardio-Vascular Disease (CVD)
in India are of RHD.

5. Epidemiology of RHD
• Agent factors:
▫ Agent: RHD occurs as the consequences of RF,
which in turn is caused by infection of the tonsils,
pharynx & adenoids with group A beta hemolytic
streptococci. These cocci are gram positive, non-
motile, non-spore forming & spherical shaped
bacilli, 0.5 μ to 1.0 μ in diameter, arranged in
chains. Recently; virus coxsackie B-4 is suggested
to be the causative organism for RF.

6. Cont…
▫ Reservoir of infection: All the cases & carriers
of streptococcal pharyngitis.

7. Cont…
• Host factors:
▫ Age: Highest among children between 5-15 years
of age. They are the high risk groups.
▫ Sex: Both sexes are equally affected.
▫ Pre-disposing factors: Poverty, low socio-
economic status, poor housing, illiteracy,
ignorance, malnutrition & large families.When the
standard of living improves, the prevalence of the
disease comes down.

8. Pathogenesis
• There appears an ‘Aschoff’s nodule’ which is the
pathognomonic sign is RF. It is peri-vascular
collection of lymphocytes & plasma cells
surrounding a fibrinoid core.
• In the heart, mitral valvulitis is the most
common lesion which later causes fibrosis &
narrowing (stenosis) of the mitral value.
Stenosis of the mitral valve causes its
incompetence.

9. Clinical features
• The following clinical manifestation are seen in
RHD:
• Fever: There is low grade fever which may last for
about 3 months.
• Polyartheritis: Inflammation of the major joints
like ankles, knees, elbow & wrists occurs which
becomes painful. This subsides spontaneously
within about a week. The pain is migratory in
nature, i.e. as it subsides in one joint, it appears in
another joint.
• Carditis: In nearly 60-70% of cases, the heart is
affected. Pericardium, myocardium & valves are
involved. Tachycardia, cardiomegaly & heart failure
can occur. Damage to the mitral valve is permanent.

10. Cont…
• Subcutaneous nodules: These appear as round,
firm & painless nodules under the skin & over bony
prominences such as ankle, elbow or wrist joints.
They disappear after some time. This is also called
“erythema nodosum”.
• Chorea: This occurs as a late manifestation in
which there are jerky, purposeless movements of the
arms, legs & body. It gradually disappears leaving no
residual damage.
• Erythema marginatum: These are pink, non-
pruritic skin rashes which appear on the trunk &
extremities. They appear on their own without
causing any abnormality. They disappear after some
time.

11. Manifestation
• Major manifestation:
• Carditis, polyarthritis, subcutaneous, nodules,
cholera & erythema marginatum.
• Minor manifestation:
• Fever, polyarthralgia, raised erythrocyte
sedimentation rate or leucocytosis.

13. Prevention & control of rheumatic
heart disease; role of nurses
• Primary prevention:
• Health promotion:
• Prevention of malnutrition in children.
• Improving living condition & general sanitation of the
house & surrounding environment. Housing standard
should be improved to avoid over-crowding.
• Health education to people to report sore throat as it can
be due to A beta hemolytic streptococcus which can
cause rheumatic fever. Proper approach to high risk
group such as school-age children. They should be kept
under strict surveillance for streptococcal pharyngitis.
Ideally sore throat swab to confirm the diagnosis should
be cultured. Those found positive should be treated.

14. Cont…
• Specific protection:
• Specific protection is afforded by giving
Benzathine benzyl penicillin to cases of sore-
throat by giving single dose of 1.2 million units
of Benzathine benzyl penicillin intra-muscularly
to all adult cases & 6,00,000 units to children.
• Alternatively oral penicillin should be given for
10 days. If allergic to penicillin, erythromycin is
the drug of choice.
• There is no vaccine for prevention.

15. Cont…
• Secondary prevention:
• Aims at prevention of recurrent attacks of RF,
especially in developing countries.
• Detection of cases that have RF by conducting
survey. They should be treated by 1 dose of 1.2
million units of Benzathine benzyl penicillin to
adults & 6, 00,000 units to children at 3 weeks
interval. This must be continued for at least 5
years or until the child reaches 18 years of age
whichever is later.

16. Cont…
• Nurses can assist in school health survey to detect
cases that have had RF & administering the
treatment as prescribed by the physician.
• For patients with carditis (mild mitral regurgitation)
the treatment should be continued for 10 years after
the last attack or at least until 25 years of age,
whichever is longer.
• More severe valvular disease cases need life-long
treatment.
• Non-medical measures for prevention/control of RF
are improving the living conditions & improving
socio-economic conditions of the people to bring
them out of poverty.

17. Cont…
• Tertiary prevention:
• Disability limitation: Patients, who have
already developed RHD, can have disability due
to joint pains & carditis. These can be prevented
by giving treatment with Aspirin for joint pain &
treatment with Benzathine benzyl penicillin for
life for carditis. Surgical intervention may also
be given in cases of mitral stenosis.

18. Cont…
• Rehabilitation: Patients suffering from RHD
are given social, vocational & psychological
rehabilitation. For example, if the patient has
mitral stenosis, his/her capacity for physical
activities is lowered. He/she has to be
rehabilitated to choose another occupation if
he/she is engaged in occupation requiring hard
physical labor.

20. Write a brief note on Rheumatic Heart
Disease.
-Your friendly neighborhood Spiderman.

21. References
• Park K., Text Book of Preventive and Social
Medicine.18th Edition, Banarsidas Bhanot: 378-
381.
• Singh Simrat Kaur N.J., Community Health
Nursing. 1st Edition, Lotus Publishers. Page No.
522-525.