From the Guidelines
Rheumatic heart disease (RHD) can exist without audible murmurs, particularly in early stages or when valvular damage is mild, and is diagnosed through echocardiography, which can detect subtle valve abnormalities not apparent on clinical examination, as supported by the 2023 World Heart Federation guidelines 1.
Diagnosis and Management
For patients with confirmed RHD without murmurs, secondary prophylaxis with penicillin is still essential to prevent recurrent streptococcal infections and disease progression. The recommended regimen is benzathine penicillin G 1.2 million units intramuscularly every 3-4 weeks (or 600,000 units for patients weighing less than 30kg), as stated in the position statement of the World Heart Federation on the prevention and control of rheumatic heart disease 1. Some key points to consider in the management of RHD without murmurs include:
- Secondary prophylaxis with penicillin to prevent recurrent streptococcal infections and disease progression
- Regular cardiac evaluations with echocardiography to monitor for disease progression, even in the absence of murmurs
- Education on maintaining good oral hygiene and seeking prompt treatment for streptococcal throat infections to prevent disease progression
Echocardiography
Echocardiography is a crucial diagnostic tool for RHD, and handheld echocardiography may be a viable alternative for screening and diagnosis in high-prevalence regions, as discussed in a systematic review to inform WHO guidelines 1. The use of echocardiography in RHD diagnosis and management is supported by various studies, including the 2023 World Heart Federation guidelines 1, which provide a standardized approach for the identification of RHD and facilitate early case detection.
Prophylaxis and Treatment
Prophylaxis with penicillin should continue for at least 10 years after the last episode of acute rheumatic fever or until age 21, whichever is longer, as recommended in the guidelines 1. For severe cases or those with carditis, prophylaxis may extend until age 40 or lifelong. In cases of penicillin allergy, oral erythromycin 250mg twice daily is an alternative, as stated in the position statement of the World Heart Federation on the prevention and control of rheumatic heart disease 1.
From the Research
Rheumatic Heart Disease with No Murmurs
- Rheumatic heart disease (RHD) is a condition where the heart valves are damaged due to rheumatic fever, and it can be challenging to diagnose, especially in cases where there are no murmurs 2.
- The updated Jones criteria increase the likelihood of diagnosis in endemic settings, including the echo diagnosis of sub-clinical carditis, polyarthralgia, and monoarthritis, as well as amended thresholds of minor criteria 2.
- Echocardiographic investigation is a crucial tool in diagnosing RHD, and advances in technology have made screening and identifying latent RHD feasible in the most burdened regions 3.
- However, uncertainty remains around best management of those with latent RHD and best methods to ensure ideal secondary prophylaxis for RHD 3.
- Secondary prophylaxis with regular intramuscular benzathine penicillin G (BPG) is the cornerstone of RHD management, but there is a growing body of evidence that patients with RHD who have severe valvular heart disease with or without reduced ventricular function may be dying from cardiovascular compromise following BPG injections 4, 5.
Diagnosis and Management
- A thorough clinical and echocardiographic investigation is essential in managing RHD, and severe disease is managed with medical, interventional, and surgical treatment 2.
- Oral prophylaxis should be strongly considered for patients with elevated risk, including those with severe mitral stenosis, aortic stenosis, and aortic insufficiency 4.
- A multifaceted strategy for vasovagal risk reduction is advocated for all patients with RHD receiving BPG 4.
- Research regarding latent RHD management, as well as continued work on innovative solutions, such as group A streptococcal vaccine, are promising as efforts to improve outcomes of this preventable disease persist 3.