1. RHUEMATIC HEARTRHUEMATIC HEART
DISEASEDISEASE

2. Rheumatic fever (RF) is generally classified
as a connective tissue or collagen-vascular
disease
It is an inflammatory reaction that causes
damage to collagen fibrils and to the ground
substance of connective tissue
Rheumatic fever principally involves the
heart, joints, CNS (Central Nervous
System), skin, subcutaneous tissues.

3. • Recurrent attacks of RF may cause
fibrosis of heart valves, leading to
chronic valvular heart disease
• The term Rheumatic heart disease refers
to the cardiac involvement develops to
50% of patients and may affect the
endocardium, myocardium or pericardium.
It may later affect the heart valves,
causing chronic valvular disease.
• The extent of damage to the heart
depends on where the disorder strikes.

4. DEFINITION
• Rheumatic heart disease is a chronic
condition resulting from rheumatic
fever that is characterized by
scarring and deformity of the heart
valves

5. Epidemiology
•Peak incidence ages 5~15 years
•Rare before age 4 years and after age 40 years
•The incidence of RF and prevalence of rheumatic
heart disease (RHD) are markedly variable in
different countries:
•In developed country, such as the united states,
the incidence of RF ＜ 2/100,000
•In many developing countries, the incidence of
acute RF approaches or exceeds 100/100,000

6. Causative Factors
• GABS (Group A Beta- Hemolytic
Streptococci)
• Rheumatic fever

7. PATHOPHYSIOLOGY
Rheumatic fever+ recurrent infection
Cross immune response between host and streptococcal
antigens
Abnormal reaction-autoimmunity disease
rheumatic pancarditis $ Endocarditis in
valves
erosion of valve leaflets
fibrous thickening $ thickened valves
stenosis and regurgitation

10. Causative Factors
• GABS (Group A Beta- Hemolytic
Streptococci)
• Rheumatic fever

11. Risk Factors
• 5-15 years old
• Family history of RF
• Low socioeconomic status (poverty,
poor hygiene, medical deprivation)
• Untreated strepthroat

12. CLINICAL MANIFESTATION
Jones Criteria for Diagnosis of
Rheumatic Feve
MAJOR CRITERIA
• carditis
• Poly arthritis- sharp, sudden pain starts over sternum
and radiates to neck, shoulders, back and arms.
• Erythema marginatum- Erythema marginatum: A long-
lasting reddish rash that begins on the trunk or arms
as macules, which spread outward.

13. • Subcutaneous nodules- a firm,
movable, nontender collagen fibers
over bones or tendons and about 3
mm-2 cm in diameter.
• Transient chorea- involuntary
grimace and an inability to use skeletal
muscles in a coordinated manner.

14. MINOR CRITERIA
1. Fever
2. Arthralgia
3. Previous rheumatic fever or rheumatic
heart disease
4. Acute phase reactions: ESR / CRP /
Leukocytosis
5. Prolonged PR interval

15. •Supporting evidence of an
antecedent group A
•streptococcal infection:
① Positive throat culture or rapid
streptococcal antigen test
② Elevated or rising titers of
antistreptococcal antibodies
(anti-streptolysin O and anti-DNase B)

16. Daignostic Evaluation
•Modified Jones criteria were first published in 1944
by T. Duckett Jones, MD.They have been periodically
revised by the American Heart Association in
collaboration with other groups.
•Guidelines for the diagnosis of initial attacks of
RF (Jones criteria, updated 1992)
•If supported by evidence of preceding group A
streptococcal infection, the presence of two major
manifestations or of one major and two minor
manifestations establishes the diagnosis of acute RF

17.  WBC count and ESR is elevated
 C- reactive protein is positive.
 Cardiac enzmes levels may increase in
severe carditis.
 Anti streptolysin- O titser is elevated 95% of
patients with in 2 months onset.
 Throat cultures continue to presence of
GABS; however they usually occur in small
numbers. Isolating them is difficult.
 ECG reveals no diagnostic changes, but
20% of patient show a prolonged PR
interval.

18. Treatment
General Measures
Strict bed rest
Medical Measures
1. Control streptococcal infection
Penicillin is of choice
benzathine penicillin, 1.2 million
units im once,
or procaine penicillin, 600,000
units im daily, 10 days
If allergic to penicillin, erythromycin be given

19. 2. Antirheumatic therapy
(1) Salicylates
Of choice in patients with little or no
cardiac involvement;
Particularly effective in reducing
fever and relieving joint pain and
swelling
Aspirin 0.6~0.9 g / 4h in adults;
lower doses in children
(2) Corticosteroids
Used in patients who do not respond
well to adequate doses of salicylates
Prednisone 40~60 mg orally daily,
tapering over 2 weeks

20. 3. Treatment of symptoms and complications
If heart failure is present, digitalis
preparations should be used cautiously because
cardiac toxicity may occur with conventional
dosages
Prevention
Primary prevention
Early treatment of streptococcal pharyngitis
Penicillin or erythromycin
Secondary prevention
To prevent recurrence of rheumatic activity
Long-acting penicillin (benzathine
penicillin)
1.2 million units im, every 4 weeks
Sulfonamides or erythromycin may be
substituted

21. Nursing Daignosis
• Activity intolorence related to
arthralgia secondry to joint pain
• Decreased cardiac output related to
valve dysfuntion,HF
• Ineffective therapuetic regimen
related to lack of knowledge

22. • HEALTH PROMOTION
• ACUTE INTERVENTION
• AMBULATORY AND HOME CARE

23. THANK YOU

24. 1) ALL ARE FEATURES OF ACUTE RHEUMATIC FEVER
EXCEPT:
a) Pancarditis
b) Carey Coombs murmur
c) Chorea
d) Always causes residual joint damage
2) What heart problem may be caused, ironically, by the
body's attempt to protect itself from a streptococcal
throat infection?
A)Cardiomyopathy
B)rheumatic heart disease
C)coronary atherosclerosis
D)infectious endocarditis

25. 3) When teaching a patient about the long-term consequences
of rheumatic fever, the nurse should discuss the possibility
of
a. valvular heart disease
b. pulmonary hypertension
c. superior vena cava syndrome
d. hypertrophy of the right ventricle
4) Which is a priority nursing intervention for a patient during
the acute phase of rheumatic fever?
a. administration of antibiotics as ordered
b. management of pain with opioid analgesics
c. encouragement of fluid intake for hydration
d. performance of frequent, active range-of motion
exercises

26. 5) Which of the following nursing actions should the nurse
prioritize during the care of a patient who has recently
recovered from rheumatic fever?
a. Teach the patient how to manage his or her physical
activity.
b. Teach the patient about the need for ongoing
anticoagulation.
c. Teach the patient about his or her need for continuous
antibiotic prophylaxis.
d. Teach the patient about the need to maintain standard
infection control procedures.

27. 1) D
2) B
3) A
4) A
5) C