• Incidence • Pathophysiology • Assessment and common findings PCCM 86 • Management PCCM 86 • Complications o Vulvular heart disease o Bacterial endocarditis • Prevention of RHD PCCM 86 Primary o Secondary o Tertiary o Refer • Essential health information

1. Rheumatic heart disease
By C Settley

2. Assessment dates for Semester 2
​​Assessments ​Weighting ​Formative ​Summative
​Deferred /
Reassessment
01
10%​
​1 August 2018
3 August 2018​ 7 September 2018​
​02 - slides ​20% ​29 August 2018 31 August 2018​
15 October 2018​
​03 - Assignment ​30%
17 September 2018​
​25 October 2018
12 November 2018​
​04 ​40%
3 October 2018​
​5 October 2018
29 OCtober 2018​
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3. Rheumatic heart disease- pg. 638
• Rheumatic heart disease is a complication of
rheumatic fever in which the heart valves are
damaged.
• It is an inflammatory disease that begins with
strep throat.
• It can affect connective tissue throughout the
body, especially in the heart, joints, brain and
skin.
• The best way to prevent rheumatic fever is to
treat strep throat with antibiotics.
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5. Rheumatic heart disease
Incidence- pg. 638
• Although rheumatic fever can strike people of
all ages, it is most common in children
between 5 and 15 years of age.
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6. Rheumatic heart disease
Pathophysiology- pg. 638
• Rheumatic fever develops in some children and
adolescents following pharyngitis with group A beta-
hemolytic Streptococcus.
• The organisms attach to the epithelial cells of the
upper respiratory tract and produces enzymes allowing
them to damage and invade human tissues.
• After an incubation period of 2-4 days, the invading
organisms elicit an acute inflammatory response with
3-5 days of sore throat, fever, malaise, headache, and
an elevated leukocyte count.
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7. Rheumatic heart disease
Pathophysiology- pg. 638
• In 0.3-3% of cases, infection leads to
rheumatic fever several weeks after the sore
throat has resolved.
• Only infections of the pharynx
have been shown to initiate
or reactivate rheumatic fever.
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8. Rheumatic heart disease
Pathophysiology- pg. 638
• Acute rheumatic heart disease often produces
endocarditis, myocarditis, and pericarditis.
• The mitral valve is most commonly and
severely affected (65-70% of patients), and the
aortic valve is second in frequency (25%).
• The tricuspid valve is deformed in only 10% of
patients and is almost always associated with
mitral and aortic lesions.
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10. Rheumatic heart disease
Pathophysiology- pg. 638
• The pulmonary valve is rarely affected.
• Severe valve insufficiency during the acute
phase may result in congestive heart failure
and even death (1% of patients).
• Pericarditis, when present, rarely affects
cardiac function
– A swelling and irritation of the thin, sac-like
membrane surrounding the heart (pericardium).
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11. Rheumatic heart disease
Assessment & common findings-
pg. 638
• Acute
– History of a sore throat
– Pyrexia
– General malaise
– Joint pains
– Evidence of cardiac involvement, such as
tachycardia
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12. Rheumatic heart disease
Assessment & common findings-
pg. 638
• As condition progresses
– Arthritis
• Inflammation of one or more joints, causing pain and
stiffness
– Acute rheumatic carditis
• Heart murmurs, tachycardia (high during sleep), cardiac
enlargement, congestive cardiac failure
• Arrhythmias (Improper beating of the heart, whether
irregular, too fast or too slow) present and a gallop rhythm
heard on auscultation
• Specific ECG changes: prolonged PR interval and varying
degrees of heart block
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13. Normal vs abnormal PR interval
on ECG
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14. Rheumatic heart disease
Assessment & common findings-
pg. 638
• As condition progresses
– Subcutaneous nodules
• Skin nodules are slightly elevated lesions on or in the
skin.
• They are over 5 mm in diameter.
• The depth of the lesion is more significant than the
width.
• Some are free within the dermis.
• Some are fixed to skin above or subcutaneous tissue
below.
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15. Subcutaneous nodules
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16. Rheumatic heart disease
Assessment & common findings-
pg. 638
• As condition progresses
– Chorea
• A neurological disorder characterized by jerky involuntary
movements affecting especially the shoulders, hips, and
face.
• Sydenham chorea (SD) is a neurological disorder resulting
from infection via Group A beta-hemolytic streptococcus
(GABHS), the bacterium that causes rheumatic fever.
• SD is characterized by rapid, irregular, and aimless
involuntary movements of the arms and legs, trunk, and
facial muscles.
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17. Rheumatic heart disease
Assessment & common findings-
pg. 638
• As condition progresses
– Erythema marginatum
• Erythema marginatum is a type of erythema (redness
of the skin or mucous membranes) involving pink rings
on the torso and inner surfaces of the limbs which
come and go for as long as several months.
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18. Rheumatic heart disease
Assessment & common findings-
pg. 639
• Laboratory findings
– Raised ESR (Erythrocyte sedimentation rate)
– Raised WCC
– Throat swab positive
– Antibodies positive in blood stream
– High titre of antistreptococcal antibodies
– High levels of C reactive protein which shows
presence of inflammation
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19. Rheumatic heart disease
Management- pg. 639
• PREVENTION!!!
• Early treatment of Strep
• Supportive measures to reduce morbidity & mortality
• Bedrest
• Antibiotics, usually Penicillin and anti-inflammatory agents
such as aspirin and glucocorticosteroids
• Tetracyclines (e.g. doxycycline), quinolones (e.g.
ciprofloxacin), macrolides (e.g. clarithromycin),
aminoglycosides (e.g. gentamicin) and glycopeptides (e.g.
vancomycin) are all unrelated to penicillins and are safe to
use in the penicillin allergic patient.
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20. Rheumatic heart disease
Management- pg. 639
• Monitor patient for progression of disease and
signs of worsening cardiac involvement
• Treatment for congestive cardiac failure
should thus be given
• Main problems are: pain, immobility and the
possibility of complications.
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21. Complications- pg. 639
• Valvular heart disease
– All four valves can be stenotic (hardened, restricting
blood flow); the conditions are called tricuspid
stenosis, pulmonic stenosis, mitral stenosis or aortic
stenosis.
– Valvular insufficiency. Also called regurgitation,
incompetence or "leaky valve", this occurs when a
valve does not close tightly.
– Mitral and aortic valves are most commonly affected,
followed by tricuspid valve and rarely the pulmonary
valve.
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23. Aortic valve stenosis
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24. Complications- pg. 640
• Bacterial endocarditis
– Infective endocarditis (IE), also called bacterial
endocarditis (BE), is an infection caused by
bacteria that enter the bloodstream and settle in
the heart lining, a heart valve or a blood vessel.
– IE is uncommon, but people with some heart
conditions have a greater risk of developing it.
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25. Bacterial endocarditis
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26. Bacterial endocarditis
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27. Primary prevention of
rheumatic heart disease- pg. 640
• According to WHO (2004), “The primary prevention of
rheumatic fever is defined as the adequate antibiotic
therapy of group A streptococcal upper respiratory tract
infections (URTI) to prevent an initial attack of acute ARF.
• Primary prevention is administered only when there is
group A streptococcal URTI. The therapy is therefore
intermittent, in contrast to the therapy used for the
secondary prevention of ARF, where antibiotics are
administered continuously.”
• Although, for primary prevention the eradication of group
A streptococcal carriage could be accomplished through
sore throat screening and treatment of pharyngitis by oral
antibiotics or intramuscular antibiotic.
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28. Primary prevention of
rheumatic heart disease- pg. 640
• Moreover, still primary prevention in large-
scale strategy has been neglected in the
developing countries so;
• the targeted subpopulation with high
prevalence of rheumatic heart disease might
be fruitful and efficient than present practice.
• Primary prevention treatment should target
populations with high risk.
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29. Secondary prevention of
rheumatic heart disease- pg. 640
• According to WHO (2004), “Secondary prevention of
rheumatic fever is defined as the continuous
administration of specific antibiotics to patients with a
previous attack RHD.
• The purpose is to prevent infection of the cocci and the
development of recurrent attacks of ARF.
• Secondary prophylaxis is mandatory for all patients
who have had an attack of ARF, whether or not they
have residual rheumatic valvular heart disease.”
• Secondary prevention pursuit to decrease the
recurrent chronic ARF attacks by new group A
streptococcal strains.
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30. Secondary prevention of
rheumatic heart disease- pg. 640
• “The duration of secondary prophylaxis depends
on the patients age, the date of their last attack,
the most importantly the presence and severity
of rheumatic heart disease.”
• Some institutions has suggested for long term or
lifelong antibiotic therapy.
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31. Secondary prevention of
rheumatic heart disease- pg. 640
• Secondary prophylaxis cannot be delivered
effectively within the community if the
programme is not registered
• Education use of health workers with strong local
community links, and integration into existing
primary care networks are paramount to improve
the efficiency of community based secondary
prevention programmes.
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32. Tertiary prevention of
rheumatic heart disease- pg. 640
• Tertiary prevention follows the intervention or
treatment and secondary intervention stage.
• The main objective of tertiary prevention is to
maintain optimal wellness by preserving
relapse of occurrence.
• Tertiary prevention targets the client
stabilization, which is reversible action toward
primary prevention.
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33. Essential health information- pg. 640
– Therapy may have to continue for years to prevent
valvular disease
– Patients should understand the importance of
using medication
– Side effects should be explained
– Antibiotics when going for dental procedures
– Throat and chest infections should be treated
immediately
– Healthy lifestyle is important
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34. • Bacterial endocarditis
• an infection caused by bacteria that enter the
bloodstream and settle in the heart lining, a heart
valve or a blood vessel.
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35. • Myocarditis
• Inflammation of the middle layer of the heart wall.
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36. • Pericarditis
• A swelling and irritation of the thin, sac-like
membrane surrounding the heart (pericardium).
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37. REFERENCE LIST
• https://emedicine.medscape.com/article/891
897-overview#a4
• https://www.slideshare.net/EstherMaryMath
ew/rheumatic-heart-disease-89497407
• Mogotlane, S. Chauke, M. Matlakala,
Mokoena, J. & Young, A. (eds). 2013. Juta’s
complete Textbook of Medical Surgical
Nursing. Cape Town: Juta.
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