Rheumatic heart disease is caused by a prior streptococcal throat infection and leads to damage of the heart valves over time. It is a major public health problem globally and in India, where there are approximately 1 million cases. The Jai Vigyan Mission Mode project in India conducted epidemiological studies of streptococcal infections and established registries for rheumatic fever and rheumatic heart disease. Rheumatic heart disease is diagnosed using revised Jones criteria and treated with long-term antibiotic prophylaxis to prevent recurrent streptococcal infections and further valve damage. Prevention through proper treatment of streptococcal infections is critical to reducing the burden of rheumatic heart disease worldwide.

1. Rheumatic Heart
Disease
DR. SAMARJEET KAUR
ASSOCIATE PROFESSOR
DEPTT. OF COMMUNITY MEDICINE
GSVM MEDICAL COLLEGE KANPUR

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Rheumatic Fever
• Febrile disease
• Affecting connective tissues particularly in the heart and joints
• Initiated by infection of the throat by group A beta haemolytic
streptococci.
• Rheumatic fever often leads to RHD
• Consequences of RHD: continuing damage to the heart;
increasing disabilities; repeated hospitalization, and premature
death usually by the age of 35 years or even earlier.
• RHD is one of the most readily preventable chronic disease.

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Problem Statement
• Globally, over 15 million cases of RHD with 500,000 new cases
every year.
• In the year 2008, 230,000 deaths occurred due to RHD, which
is about 0.4% of total deaths.
• In India the prevalence of RHD is 5-7 per thousand in 5-15
years age group.
• There are about 1 million RHD cases in India

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• Jai Vigyan Mission Mode project on Community control of
RF/RHD carried out in India by ICMR
• The project had four main components:
1. To study epidemiology of streptococcal sore throats
2. To establish registries for RF/RHD
3. Vaccine development for streptococcal infection
4. To conduct advanced studies on pathological aspects of
RF/RHD.

5. Epidemiological
Factors

6. Agent Factors
• Onset of RF is usually preceded by a streptococcal sore
throat
• Group A streptococcus (GAS) is the causative agent
• Some strains of GAS have “rheumatogenic potential”
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Host and Environmental factors
• Age –disease of childhood and adolescence (5-15 years); there
is high incidence of “juvenile mitral stenosis” in India (initial
attack of RF occurs at a young age, progresses to valvular
lesion faster, and is associated with pulmonary arterial
hypertension.
• Sex- both sexes are affected equally (prognosis is poor in
females)
• Immunity- toxic immunological hypothesis is the most prevalent
concept
• Socio economic status
• High-risk group

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Clinical features
• Fever- present at the onset of acute illness, lasts for 12 weeks
or longer and has tendency to recur.
• Polyarthritis
• Carditis
• Nodules
• Brain involvement
• Skin

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Arthritis
• Most common manifestation. (90%)
• Large joints (knee, elbow, ankle, wrist)
• Poly arthritis- succession or simultaneous
• Migratory in nature
• Swelling, heat, redness, severe pain, tenderness, limitation of movement
• Responds dramatically with salicylates
• Subsides without residual deformity
• Lasts 1-5 weeks

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Carditis
• Occurs in 50% of patients
• Tachycardia ( out of proportion to fever)
• Heart murmur of MR or AR or both
• Pancarditis ( pericarditis, myocarditis, endocarditis)
• 1 Endocardial-
•- MR or AR murmurs indicative of dilatation of valve with or without
associated valvulitis
- Short mid-diastolic murmur (Carey-Coombs) may be present
- Changing quality of heart sounds

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2. Myocardial-
- Tachycardia even at rest.
- Arrhythmias or ectopic beats
- Cardiomegaly- on physical exam, CXR or ECHO
- Congestive cardiac failure – right or left sided
3. Pericardial-
- Pericarditis
- Pericardial effusion

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• ECG Changes-
- Changing contour of P waves
- Inversion of T waves
- Prolongation of PR interval
• Sign of CHF (gallop rhythm, cardiomegaly, distant heart sound)
• Maybe self-limiting or may lead to slowly progressive valvular deformity
• Mitral valve attacked in 75% of cases, aortic in 30% ( but rarely as the sole
valve), tricuspid and pulmonary in < 5% of cases

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Chorea
• Sydenham’s chorea (St vitus’ dance) in 15%
• More common in prepubertal girls (8-12 yrs)
• Neuro psychiatric disorder
• Neurological - Choreic movement and hypotonia
• Psychiatric - emotional lability, hyperactivity,
• separation anxiety, OCD
• Begins with emotional lability replaced by choreic movement and
then motor weakness
• Elevated titer of anti-neuronal antibody

18. Erythema marginatum
• In less than 10 % cases.
• Non-pruritic, serpiginous, or
annular erythematous rashes.
• Trunk and inner proximal
portion of extremities
• Never seen on face
• Evanescent, disappears on
exposure to cold
• Shape of rings or crescents with
clear centers
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Subcutaneous Nodules
• 2- 10 % of cases
• Common in cases with recurrences
• Hard, painless, nonpruritic, freely movable swelling of 0.2 to 2 cm
• Extensor surface of both legs, small joints, scalp, spine
• Not transient, lasting for weeks
• Are recurrent
• Indistinguishable from rheumatoid nodules

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Diagnosis
• 2015 WHO criteria for the diagnosis of RF and RHD are based
on revised Jones criteria
• In the revised Jones criteria, a low, medium, and high-risk
population was identified.
• Low-risk population- ARF occurs <=2/100,000 school-age
children
RHD <= 1/1000 patients at any age during
one yr

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Modification
1. In the major criteria
• Low-risk population: clinical and/or subclinical carditis. AHA
recommends that all the patients with suspected RF undergo
Doppler echocardiographic examination, even if no clinical
signs of carditis are present.
• Medium and high-risk population: also clinical and/or
subclinical carditis and arthritis – monoarthritis or polyarthritis,
possibly also with polyarthralgia.

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2. In minor criteria:
• Low-risk population: the parameters of inflammation and the
level of fever were defined precisely.
• Medium and high-risk population: mono arthralgia, also with
defined parameters of inflammation and level of fever.

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27. Prevention

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Primary prevention

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Secondary prophylaxis
• Benzathine penicillin G 1.2 million units given intra muscularly
every 21st day after sensitivity testing
• Alternative method if any reaction to penicillin:
(1) Oral penicillin V 250 mg twice daily
(2) Oral sulfadiazine 1 gm once daily
(3) Oral sulfisoxazole 0.5 gm once daily
(4) Oral erythromycin ethyl succinate 250 mg BD

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Duration of prophylaxis for secondary
prevention

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39. thank you