eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Rheumatic Heart Disease: Follow-up

Author: Thomas K Chin, MD, Associate Professor in Pediatrics, Chief of Pediatric Cardiology, University of Tennessee College of Medicine; Consulting Staff, Department of Pediatric Cardiology, St Jude Children's Research Center
Coauthor(s): Eric M Chin, California Institute of Technology; Tariq Siddiqui, MD, Staff Physician, Department of Anesthesiology, University of Louisville Medical Center; Ann-Kristin Sundell, MD, Staff Physician, Department of Pediatrics, East Tennessee State University
Contributor Information and Disclosures

Updated: Oct 10, 2008

Follow-up

Further Outpatient Care

  • Patients usually show significant improvement after initiation of anti-inflammatory therapy. However, they should not be allowed to resume full activities until all clinical symptoms have abated and laboratory values have returned to normal levels.
  • The importance of prophylaxis against recurrent streptococcal pharyngitis and rheumatic fever should be emphasized with each patient. Each recurrent episode of rheumatic carditis produces further valve damage and increases the likelihood that valve replacement will be required. Patients should remain on antibiotic prophylaxis at least until their early twenties. Many physicians believe that lifelong prophylaxis is appropriate.
  • Patients should be examined regularly to detect signs of mitral stenosis, pulmonary hypertension, arrhythmias, and congestive heart failure.

Deterrence/Prevention

  • Primary prevention of rheumatic fever consists of diagnosis and treatment of group A beta-hemolytic streptococcal pharyngitis.

Complications

  • Potential complications include heart failure from valve insufficiency (acute rheumatic carditis) or stenosis (chronic rheumatic carditis). Associated cardiac complications include atrial arrhythmias, pulmonary edema, recurrent pulmonary emboli, infective endocarditis, intracardiac thrombus formation, and systemic emboli.

Prognosis

  • Manifestations of acute rheumatic fever resolve over a period of 12 weeks in 80% of patients and may extend as long as 15 weeks in the remaining patients.
  • Rheumatic fever was the leading cause of death in people aged 5-20 years in the United States 100 years ago. At that time, the mortality rate was 8-30% from carditis and valvulitis but decreased to a 1-year mortality rate of 4% by the 1930s.
  • Following the development of antibiotics, the mortality rate decreased to almost 0% by the 1960s in the United States; however, it has remained 1-10% in developing countries. The development of penicillin has also affected the likelihood of developing chronic valvular disease after an episode of acute rheumatic fever. Before penicillin, 60-70% of patients developed valve disease as compared to 9-39% of patients since penicillin was developed.
  • In patients who develop murmurs from valve insufficiency from acute rheumatic fever, numerous factors, including the severity of the initial carditis, the presence or absence of recurrences, and the amount of time since the episode of rheumatic fever, affect the likelihood that valve abnormalities and the murmur will disappear. The type of treatment and the promptness with which treatment is initiated does not affect the likelihood of disappearance of the murmur. In general, the incidence of residual rheumatic heart disease at 10 years is 34% in patients without recurrences but 60% in patients with recurrent rheumatic fever. Disappearance of the murmur, when it occurs, happens within 5 years in 50% of patients. Thus, significant numbers of patients experience resolution of valve abnormalities even 5-10 years after their episode of rheumatic fever. The importance of preventing recurrences of rheumatic fever is evident.

Patient Education

  • Emphasize the importance of prophylaxis against recurrent streptococcal pharyngitis and rheumatic fever with each patient.
  • For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education article Mitral Valve Prolapse.

Miscellaneous

Medicolegal Pitfalls

The incidence of rheumatic heart disease, the facilities available for identifying and treating the illness, and the caring physicians training and experience with this disorder all vary widely with geographic location. Furthermore, scientific understanding of rheumatic heart remains incomplete. For these reasons, recommending a fixed set of medical-legal guidelines that apply for all situations is difficult.

Special Concerns

The American Heart Association no longer recommends subacute bacterial endocardial prophylaxis in patients with aortic or mitral valve abnormalities secondary to rheumatic heart disease.5

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Clyde Worley, MD, to the development and writing of this article.



More on Rheumatic Heart Disease

Overview: Rheumatic Heart Disease
Differential Diagnoses & Workup: Rheumatic Heart Disease
Treatment & Medication: Rheumatic Heart Disease
Follow-up: Rheumatic Heart Disease
Multimedia: Rheumatic Heart Disease
References
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Further Reading

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Keywords

rheumatic heart disease, acute rheumatic carditis, rheumatic fever, pharyngitis, heart failure, valve insufficiency, pericarditis, chronic rheumatic heart disease, valve stenosis, regurgitation, atrial dilation, arrhythmias, ventricular dysfunction, mitral valve stenosis, valve replacement, pancarditis, group A beta-hemolytic Streptococcus, Streptococcus pyogenes, impetigo, cellulitis, myositis, pneumonia, sepsis, endocarditis, myocarditis, polyarthritis, chorea, subcutaneous nodules, erythema marginatum, chest pain, edema, orthopnea, mitral insufficiency, congestive heart failure, Carey-Coombs murmur, hepatomegaly, arthralgias, epistaxis, Huntington chorea, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, PANDAS, Sydenham chorea, aortic stenosis

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Contributor Information and Disclosures

Author

Thomas K Chin, MD, Associate Professor in Pediatrics, Chief of Pediatric Cardiology, University of Tennessee College of Medicine; Consulting Staff, Department of Pediatric Cardiology, St Jude Children's Research Center
Thomas K Chin, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Society for Pharmacology and Experimental Therapeutics, American Society of Echocardiography, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Coauthor(s)

Eric M Chin, California Institute of Technology
Disclosure: Nothing to disclose.

Tariq Siddiqui, MD, Staff Physician, Department of Anesthesiology, University of Louisville Medical Center
Disclosure: Nothing to disclose.

Ann-Kristin Sundell, MD, Staff Physician, Department of Pediatrics, East Tennessee State University
Ann-Kristin Sundell, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA, Professor, Departments of Pediatrics (Cardiology), Cardiovascular Sciences, and Molecular and Human Genetics, Baylor College of Medicine; Chief of Pediatric Cardiology, Foundation Chair in Pediatric Cardiac Research, Texas Children's Hospital
Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Cardiology, American College of Sports Medicine, American Heart Association, American Medical Association, American Society of Human Genetics, Cardiac Electrophysiology Society, Heart Rhythm Society, New York Academy of Sciences, Society for Pediatric Research, Texas Medical Association, and Texas Pediatric Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Hugh D Allen, MD, Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine
Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
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