Pediatric Rheumatic Heart Disease Medication

Updated: Jun 12, 2019
  • Author: Thomas K Chin, MD; Chief Editor: Syamasundar Rao Patnana, MD  more...
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Medication Summary

Medical therapy is directed at eliminating the group A streptococcal pharyngitis (if still present), suppressing inflammation from the autoimmune response, and providing supportive treatment for congestive heart failure. The treatment and prevention of group A streptococcal pharyngitis outlined here is based on the current recommendations of the Committee on Infectious Disease (American Academy of Pediatrics). See the Medscape Reference article Pediatric Pharyngitis.

Penicillin V is the drug of choice for treatment of group A streptococcal pharyngitis. Ampicillin or amoxicillin may be used instead of penicillin V but have no microbiologic advantage. Tetracyclines and sulfonamides should not be used to treat group A streptococcal pharyngitis. For recurrent group A streptococcal pharyngitis, a second 10-day course of the same antibiotic can be repeated. Alternate drugs include narrow-spectrum cephalosporins, amoxicillin-clavulanate, dicloxacillin, erythromycin, or other macrolides for 10 d. As many as 15% of patients allergic to penicillin are also allergic to cephalosporins.



Class Summary

Antibiotics are used for the initial treatment of group A streptococcal pharyngitis to prevent the first attack of rheumatic fever (primary prophylaxis), for recurrent streptococcal pharyngitis, and for continuous therapy to prevent recurrent rheumatic fever and rheumatic heart disease (secondary prophylaxis).

Penicillin VK (Beepen-VK, Betapen-VK, Pen-Vee K)

DOC for treatment of group A streptococcal pharyngitis. Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached, and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.

Penicillin G benzathine/penicillin G procaine (Bicillin L-A, Wycillin)

Used when PO administration of penicillin is not feasible or dependable. Discomfort of IM injection may be minimized if the penicillin G is brought to room temperature before injection or if a combination of benzathine penicillin G and procaine penicillin G (Bicillin CR) is used. Initial course of antibiotics given to eradicate the streptococcal infection also serves as the first course of prophylaxis. Benzathine penicillin G IM q4wk is recommended for secondary prevention for most United States patients. The same dosage should be used q3wk in areas where rheumatic fever is endemic, in patients with residual carditis, and in patients with high risk.

Erythromycin ethylsuccinate (Ilosone, E.E.S, EryPed)

Used to treat patients allergic to penicillin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.


Anti-inflammatory agents

Class Summary

The manifestations of acute rheumatic fever (including carditis) typically respond rapidly to therapy with anti-inflammatory agents. Aspirin, in anti-inflammatory doses, is the drug of choice. Prednisone is added when evidence of worsening carditis and heart failure is noted.

Aspirin (Anacin, Ascriptin, Bayer Aspirin)

Also called acetylsalicylic acid. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2. Start immediately after the diagnosis of rheumatic fever has been made. Initiation of therapy may mask manifestations of the disease.

Prednisone (Deltasone, Orasone)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. If moderate to severe carditis is indicated by cardiomegaly, congestive heart failure, or third-degree heart block, 2 mg/kg/d PO should be used in addition to, or in lieu of, salicylate therapy. Prednisone should be continued for 2-4 wk, depending on the severity of the carditis, and tapered during the last week of therapy. Adverse effects can be minimized by discontinuing prednisone therapy after 2 wk and adding or maintaining salicylates for an additional 2-4 wk.


Angiotensin-converting enzyme (ACE) inhibitors

Class Summary

These agents are competitive inhibitors of ACE. They reduce angiotensin II levels and thus decrease aldosterone secretion.

Enalapril (Vasotec)

Indicated for chronic aortic and/or mitral regurgitation. Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased plasma renin levels and a reduction in aldosterone secretion. Helps control blood pressure and proteinuria. Decreases pulmonary-to-systemic flow ratio in the catheterization laboratory and increases systemic blood flow in patients with relatively low pulmonary vascular resistance. Has favorable clinical effect when administered over a long period. Helps prevent potassium loss in distal tubules. Body conserves potassium; thus, less oral potassium supplementation needed. Goal is to decrease afterload to left ventricle (by reducing systemic blood pressure and by peripheral vasodilatation).

Captopril (Capoten)

Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.

Rapidly absorbed, but bioavailability is significantly reduced with food intake. It achieves a peak concentration in 1 h and has a short half-life. The drug is cleared by the kidneys.

Impaired renal function requires reduction of dosage. Absorbed well PO. Give at least 1 h before meals. If added to water, use within 15 min.

Can be started at low dose and titrated upward as needed and as patient tolerates.