designed n documented by DR.Karan R Rawat www,jeevan-rekha.com

1. DR.C.R.RAWAT
M.D,FACC,FESC,FCSI,FISC
CONSULTANT
CARDIOLOGIST

2. World scenario of rheumatic heart disease

3. Area Prevalence Per 1000
United States 0.6
Japan 0.7
India 6.0-11.0
Asia (other) 0.4-21.0
Africa 0.3-15.0
South America 1.0-17.0

5. RF is the most common
cause of heart disease in
5-30 yr age group

7. WORLD RHD BURDEN
RHD REMAINS A MAJOR HEALTH
CONCERN AROUND THE GLOBE
15.6 million people have RHD in the
world .
2,82,000 cases are added each year.
2,33,000 deaths occur each year.

8. I I DI ,RHEUMATIC FEVER IS ENDEMIC
NN A
AND REMAINS ONE OF THE MAJOR CAUSES
OF CV DISEASE ACCOUNTING FOR 25%-45 %
OF ACQUIRED HEART DISEASE. INDIA IS IN
A PHASE OF EPIDEMIOLOGICAL
TRANSITION ,ON ONE HAND THERE IS
BURDEN OF RHD AND ON OTHER HAND
GOVERNMENT RESOURCES ARE SCARSE .

9. RHD in India
 Prevalence: 5/1000 population of 5-15 age group
 1 million RHD cases in India
 Hospital admissions due to RHD is 20-30% of CVD

10.  Acute rheumatic fever (ARF) is a systemic disease
of childhood
 It is a delayed non-suppurative sequelae to URTI
with group A BETA-hemolytic streptococci
 It is a diffuse inflammatory disease of connective
tissue,primarily involving heart,blood
vessels,joints, subcut.tissue and CNS

12. Epidemiological Factors

13. Agent

14. Host Factors
 Age:
5-15 yrs(most susceptible)
 Sex:
both
 Environmental factors
over crowding, poor sanitation, poverty
 Incidence more during
winter & early spring

15. Prevalance of rheumatic fever in different age groups

17. IMMUNE SYSTEM RESPONSE

18. 1.Arthritis
 Flitting & fleeting migratory polyarthritis, involving major joints
 Commonly involved joints-knee,ankle,elbow & wrist
 Occur in 80%,involved joints are exquisitely tender
 In children below 5 yrs:It is mild but carditis is more prominent
 Arthritis does not progress to chronic disease

19. 2.Carditis
 Manifest as pancarditis(endocarditis, myocarditis
and pericarditis),occur in 50% of cases
 Carditis is the only manifestation of rheumatic fever
that leaves a sequelae & permanent damage to the
organ
 Valvulitis occur in acute phase
 Chronic phase- fibrosis,calcification & stenosis of
heart valves(fishmouth valves)

20. PREVALENCE OF RHD/RF AND PATTERN OF VALVE
INVOLVEMENT IN THE COMMUNITY
POPULATION SCREENED 1882
MALE 909
FEMALE 973
RF/RHD 11 (5.8/1000)
FEMALE 01(1.1/1000)
MEAN AGE OF RF/RHD PATIENTS 30.36 YRS
LESIONS
TOTAL 11
NO CARDITIS 01
ISOLATED MS 02
ISOLATED MR 01
MS WITH MR 03
MS WITH AR 01
MR WITH AS 01
ISLOATED AR 01
POST MVR 01
POST PTMC 01
KNOWN RHD 07

21. MITRAL VALVE STENOSIS AS SEEN IN RHEUMATIC HEART DISEASE

22. Rheumatic
heart
disease.
Abnormal
mitral
valve.
Thick,
fused
chordae

23. 3.Sydenham Chorea
 Occur in 5-10% of cases
 Mainly in girls of 1-15 yrs age
 Clinically manifest as-clumsiness, deterioration of
handwriting, emotional lability or grimacing of face
 Clinical signs- pronator sign, jack in the box sign ,
milking sign of hands

24. 4.Erythema Marginatum
 Occur in <5%.
 Unique,transient,serpiginous lesions of 1-2 inches in size
 Pale center with red irregular margin
 More on trunks & limbs & non-itchy
 Worsens with application of heat
 Often associated with chronic carditis

25. 5.Subcutaneous nodules
 Occur in 10%
 Painless,pea-sized,palpable nodules
 Mainly over extensor surfaces of joints,spine,scapulae &
scalp
 Associated with strong seropositivity
 Always associated with severe carditis

26. Other features (Minor features)
 Fever(mild)
 Polyarthralgia
 Pallor
 Anorexia
 Loss of weight

27. Onset and progression of different

28. LABORATORY DIAGNOSIS
High ESR
Anemia, leucocytosis
Elevated C-reactive protien
ASO titre >200 Todd units.
(Peak value attained at 3 weeks,then
comes down to normal by 6 weeks)
Anti-DNAse B test
Throat culture-GABH streptococci

30. # RHEUMATIC FEVER IS MAINLY A
CLINICAL DIAGNOSIS
#.NO SINGLE DIAGNOSTIC SIGN OR
SpECIFIC LAbORATORY TEST AVAILAbLE
FOR DIAGNOSIS
#.DIAGNOSIS bASED ON MODIFIED
JONES CRITERIA

31. Jones Criteria (Revised) for Guidance in the
Diagnosis of Rheumatic Fever*
Major Manifestation Minor Supporting Evidence
Manifestations of Streptococal Infection
Carditis Clinical Laboratory
Polyarthritis Previous Acute phase
Chorea rheumatic reactants: Increased Titer of Anti-
Erythema Marginatum fever or Erythrocyte Streptococcal Antibodies ASO
Subcutaneous Nodules rheumatic sedimentation (anti-streptolysin O),
heart disease rate, others
Arthralgia C-reactive Positive Throat Culture
Fever protein, for Group A Streptococcus
leukocytosis Recent Scarlet Fever
Prolonged P-
R interval
*The presence of two major criteria, or of one major and two minor criteria, indicates
a high probability of acute rheumatic fever, if supported by evidence of Group A
streptococcal nfection.

32.  If the patient has Chorea alone then it is
difficult to diagnose rheumatic fever
 Insidious or late-onset carditis with no other
explanation

33. PITFALLS IN JONES CRITERIA
1. DIFFICULT TO DIAGNOSE ARF WHEN CARDITIS IS
ONLY MANIFESTATION SPECIALLY IN
RECCURENCE
2. SUBCLINICAL CARDITIS IS DIFFICULT TO DETECT
CLINICALLY
3. CLINICAL CARDITIS IS PRESENT BUT
SUPPORTIVE MINOR CRITERIA ARE NOT
FULFILLED
4. WHEN PREVIOUS CARDIAC STATUS IS UNKNOWN
IT IS DIFFICULT TO SAY WHETHER THE
FINDINGS ARE USUALLY ACUTE CARDITIS OR
RECURRENCE OR IT IS OLD RHD.
5. IN CASES OF POLYARTHRALGIA IF NOT
EVALUATED FOR ARF THEY WOULD GO
UNDIAGNOSED

34. Developing role of
ECHOCARDIOGRAPHY IN
DIAGNOSIS AND MANAGEMENT OF
RHEUMATIC FEVER

35. GOALS OF ECHO INTERROGATION
1. IT CAN HELP IN PRECISE AND EARLY DIAGNOSIS OF ARF .
2. IT CAN PREVENT OVER DIAGNOSIS OF CARDITIS
DEPENDING ON THE TRADITIONAL CLINICAL AUSCULTATORY
FINDINGS
3. REGULAR CHECK UP WITH NON INVASIVE ECHO CAN HELP
TO EVALUATE THE STATUS OF RHD AND DECIDE FOR
ELECTIVE BALOON VALVULOPLASTY FOR MITRAL STENOSIS
AND TIMELY DECISION FOR VALVE REPAIR /REPLACEMENT
.THIS CAN REDUCE THE MORBIDITY AND MORTALITY ,BEFORE
THE PATIENT DEVELOPS CHF .

36. ECHOCARDIOGRAPHIC
INVESTIGATIONS
M-MODE INTERROGATION
.DIMENSIONS OF LEFT ATRIUM ,AORTA AND THEIR RATIO
.LEFT VENTRICULAR DIMENSION IN DIASTOLE AND SYSTOLE.
CROSS-SECTIONAL INTERROGATION IN LONG AXIS ,FOUR CHAMBER ,FIVE
CHAMBER AND SHORT AXIS
.THICKNESS OF VALVES WITH <3 MM TAKEN AS NORMAL AND >4 MM AS THICKENED
.BEADED APPEARANCE ,ESPECIALLY MITRAL ,TRICUSPID AND AORTIC VALVES
PROLAPSE OF MITRAL VALVE ,PARTICULARLY AORTIC LEAFLET
.DECREASED OR INCREASED MOBILITY OF VALVES
.HYPERECHOGENICITY OF THE THICKENED SUBMITRAL APPARATUS
.CHORDAL TEARS TO MITRAL LEAFLETS
.PERICARDIAL EFFUSION
END DIASTOLIC VOLUME END SYSTOLIC VOLUME AND EJECTION FRACTION
COLOUR DOPPLER INTERROGATION
.ESTABLISHMENT OF MITRAL ,AORTIC AND TRICUSPID REGURGITATION
.DIFFERENTIATION OF PHYSIO AND PATHO REGURGITATION

37. INCIDENCE OF ECHO FEATURES IN RF
MITRAL THICKNESS >4MM 93.62%
MR GRADE 1-2 83.69%
MVP 56.74%
RH NODULES 26.95%
AR 21.99%
TR 21.99%
PANCARDITIS 9.22%
PERI.EFFUSION 9.22%
CHORDAL TEAR 2.84%

38. VIJAYA’S ECHO CRITERIA
SCORE OF >=6 IS DIAGNOSTIC FOR
RHEUMATIC CARDITIS
ECHO - FEATURE SCORE
MV AND AV THICKNESS >=4MM 2
INCREASE ECHO GEN OF SUB MITRAL STR. 2
RHEUMATIC NODULES BEADED APPEARANCE 2
MVP /AVP /TVP 2
MR/PR/AR 2
REDUCED MOBILITY OF VALVES 2
CHORDAL TEAR 2
PERICARDIAL EFFUSION 2
TOTAL SCORE 16

39. ROLE OF ECHO IN MANAGEMENT OF ARF IN
FUTURE
THE ECHOCARDIOGRAM IS SIMPLE ,NON-INVASIVE,REPRODUCABLE TOOL FOR
EARLY AND PRECISE DIAGNOSIS OF CARDITIS IN ARF .
THERE IS A PROPOSAL OF INCLUDING VIJAYA’S ECHO CRITERIA OF CARDITIS
AS MAJOR CRITERIA INSTEAD OF ERYTHEMA MARGIRATUM WHICH IS
IRRELEVANT ,WHENEVER THERE IS A REVISION OF JONE’S CRITERIA

43. A, Parasternal long-axis view showing thickening of the mitral valve leaflets. AML,
anterior mitral leaflet; LA, left atrium; LV, left ventricle; RV, right ventricle; PML, posterior
mitral leaflet. B, Parasternal short-axis view showing the left ventricle and mitral valve in
cross-section. Note fine focal nodularity along the edges of the mitral valve (arrows)
suggesting verrucae. C, Electrocardiogram (lead II) with prolonged PR interval (160 ms).

44.  Juvenile rheumatiod arthritis
 Septic arthritis
 Sickle-cell arthropathy
 Kawasaki disease
 Myocarditis
 Scarlet fever
 Leukemia

45. Prevention and control
Primary prevention
• To prevent the first attack of RF,by detection and
treatment of streptococcal throat inf.
• Many inf are inapparent or undiagnosed
• High risk approach:
Surveillance for streptococcal pharyngitis
among school children

46. Primary prevention contd…
Sore throat should be swabbed and cultured
If strepto.— Give Penicillin
(If culture is not possible a sore throat can be treated
with Benzathine Benzyl Penicillin)
Dose: One IM inj.,1.2 miilion units(adults),0.6 million
units(children)
Or Oral Penicillin G/Penicillin V for 10 days
Erythromycin (In case of allergy to Penicillin)

47. Secondary Prevention

48. Other measures in Secondary Prevention
 Surveys to know the prevalence of RHD
among school children
 Every 5 years in 6-14 years age group

49.  Rheumatic fever can recur whenever the individual
experience new GABH streptococcal infection,If
not on prophylactic medicines
 Good prognosis for older age group & if no carditis
during the initial attack
 Bad prognosis for younger children & those with
carditis with valvar lesions

50. REMEMBER TOGETHER WE
CAN FIGHT RHEUMATIC FEVER
AND RHD….WE CAN HEAL THE
FUTURE OF OUR NATION AND
THE WORLD FOR SURE BY
SPREADING AWARENESS AND
TIMELY ACTION IN TREATING
THE PATIENTS .
ITS TIME TO ACT….

51. 上級醫師防止疾病醫生治療病前
明顯
對下醫生治療完全成熟的病
黃 DEE ， HAI-CHING 在公元前
2000 年（第一屆中國醫療文本