From the Guidelines
Rheumatic fever typically develops 1-5 weeks after an untreated group A streptococcal throat infection, with the potential for immediate and long-term cardiac damage. The damage to heart valves occurs during the acute inflammatory phase of rheumatic fever, when the body's immune response against strep bacteria mistakenly attacks heart tissue due to molecular mimicry 1. While the initial damage happens during this acute phase, the long-term consequences can develop and worsen over years. The initial valve inflammation can lead to scarring and permanent valve damage, causing rheumatic heart disease that may not become clinically apparent until years or even decades later. This is why prompt treatment of strep throat with antibiotics like penicillin is crucial to prevent rheumatic fever. Patients who develop rheumatic fever require long-term antibiotic prophylaxis to prevent recurrent strep infections that could cause additional cardiac damage, with the duration of prophylaxis depending on the severity of rheumatic heart disease and individual risk factors, as outlined in recent guidelines 1. Key considerations for secondary prophylaxis include:
- Lifelong prophylaxis for high-risk patients
- Minimum of 10 years after most recent acute rheumatic fever, or until 21-40 years of age, depending on the severity of valve disease
- Continuation of secondary prophylaxis after valve surgery Given the potential for severe and long-lasting cardiac damage, prompt and proper treatment of strep throat, as well as long-term antibiotic prophylaxis for patients with rheumatic fever, is essential to prevent morbidity and mortality 1.
From the Research
Rheumatic Fever Onset and Damage
- Rheumatic fever typically occurs 2 to 4 weeks after a group A Streptococcus pharyngitis infection 2.
- The onset of rheumatic fever can happen within 5 weeks of a strep infection, but the exact timing may vary.
- Damage to the heart valves can occur during the initial episode of rheumatic fever or years later, leading to rheumatic heart disease (RHD) 2, 3.
Immediate vs. Long-term Damage
- Immediate damage to the heart valves can occur during the acute phase of rheumatic fever, which can lead to cardiac complications such as heart failure 4.
- Long-term damage to the heart valves can occur years after the initial episode of rheumatic fever, leading to RHD and increased risk of morbidity and mortality 2, 3.
- Secondary prophylaxis with antibiotics, such as benzathine penicillin, can help prevent recurrent episodes of rheumatic fever and reduce the risk of long-term damage to the heart valves 5, 2, 6, 3.
Prevention and Treatment
- Timely treatment of group A streptococcal infection can prevent rheumatic fever, and penicillin prophylaxis can prevent recurrence of rheumatic fever 3.
- Secondary prophylaxis with benzathine penicillin G has been shown to decrease the incidence of RHD and is key to RHD control 3.
- Intramuscular penicillin seems to be more effective than oral penicillin in preventing rheumatic fever recurrence and streptococcal throat infections 2, 6.