Rheumatic Heart Disease: A Preventable Threat to Young Hearts

 What is Rheumatic Heart Disease?

Rheumatic Heart Disease (RHD) is a chronic heart condition caused by damage to the heart valves due to rheumatic fever — an inflammatory disease that can occur after an untreated or poorly treated streptococcal throat infection (Streptococcus pyogenes or Group A Streptococcus).

RHD most commonly affects children and young adults, ARF is mainly a disease of children age 5–14 years. Initial episodes become less common in older adolescents and young adults and are rare in persons aged >30 years. Especially in low- and middle-income countries like India.

It has been estimated that between 29.7 and 43.1 million people worldwide are affected by RHD, with >300,000 deaths occurring each year. Some 95% of ARF cases and RHD deaths now occur in developing countries, with particularly high rates in sub-Saharan Africa, Pacific nations, Australia, and South and Central Asia.

Step 1: A child gets a sore throat due to Group A Streptococcus.

Step 2: If left untreated, the immune system attacks not just the bacteria, but mistakenly the body’s own tissues — especially the heart, joints, skin, and brain.

Step 3: This autoimmune reaction is rheumatic fever, which can cause permanent scarring of heart valves — resulting in RHD.

 What Parts of the Heart Are Affected?

•Mainly the valves — particularly:

•Mitral valve (most common)

•Aortic valve

•Common outcomes:

•Mitral stenosis

•Mitral regurgitation

Later: heart failure, atrial fibrillation, endocarditis, or stroke

Although many patients report a prior sore throat, the preceding group A streptococcal infection is commonly subclinical; in these cases, it can only be confirmed using streptococcal antibody testing.

In acute rheumatic fever:

•Fever

•Joint pain and swelling (migratory arthritis) most common feature

•Skin rashes (erythema marginatum)

•Nodules under the skin

•Shortness of breath or chest pain

In chronic RHD:

•Fatigue

•Breathlessness on exertion

•Palpitations

•Swelling of legs (in heart failure)

•Involuntary movements (Sydenham chorea)

Erythema marginatum

•Throat swab (to confirm Strep infection gram +ve purple color cocci)

•Aschoff bodies and Anitschkow cell will be seen in autopsy of heart.

•ASO titre (antibody test)

•Echocardiography (ECHO) – key to visualize valve damage

•ECG and Chest X-ray: 1^st degree AV block in ECG

Jones Criteria – for diagnosing rheumatic fever

•J – migratory polyarthritis

•O – pancarditis

•N – subcutaneous nodules

•E – erythema marginatum

•S – Sydenahum’s chorea

Acute Rheumatic Fever:

•Antibiotics: Penicillin(amoxicillin, 50 mg/kg [maximum, 1 g]orally daily for 10 days)

•Anti-inflammatory drugs (aspirin/steroids) for arthritis and pain. Aspirin is a common first-line choice, delivered at a dose of 50–60 mg/kg per day, up to a maximum of 80–100 mg/kg per day (4–8 g/d in adults) in 4–5 divided doses.

Many clinicians prefer to use naproxen at a dose of 10–20 mg/kg per day, because it may be safer than aspirin and has the advantage of twice-daily dosing.

For chronic RHD:

•Long-term penicillin prophylaxis (every 3–4 weeks IM benzathine penicillin)

For adults 12lac unit, for children 6lac unit.

•Management of complications (e.g., heart failure, arrhythmias)

•Valve surgery (if severely damaged)

• Primary Prevention:
Treat sore throats early with 10-day full course of penicillin.

• Secondary Prevention:
Monthly penicillin injections for years in those with past rheumatic fever to prevent recurrence.

3 weekly for 5 year or till 18 years of age

• Tertiary Prevention:
Manage heart complications and follow-up to avoid deterioration.

 RHD in India

•India has among the highest RHD burden globally.

•Mostly seen in rural, low-income communities with limited access to healthcare.

•Girls are often diagnosed later, worsening outcomes.

Rheumatic Heart Disease is a completely preventable disease with timely treatment of sore throat and regular follow-up care. Awareness, school health programs, and community education can reduce the burden of this silent killer.

Let’s spread the word and save young hearts from preventable pain.