From the Guidelines
Rheumatic fever is associated with anemia, particularly anemia of chronic inflammation, which is typically a mild to moderate normocytic, normochromic anemia, and iron deficiency may also contribute to anemia in patients with heart disease, including those with rheumatic heart disease 1. The relationship between rheumatic fever and anemia is complex, and anemia can worsen cardiac function and is associated with poor outcomes, including increased risk for hospitalization and death, decreased exercise capacity, and poor quality of life 1. Some key points to consider are:
- Anemia is common in patients with heart disease, including those with rheumatic heart disease, and is present in approximately one third of patients with congestive heart failure and 10% to 20% of patients with coronary heart disease 1
- The cause of anemia in heart disease is not fully understood, but several factors probably contribute, including iron deficiency, comorbid chronic kidney disease, blunted erythropoietin production, hemodilution, aspirin-induced gastrointestinal blood loss, use of renin–angiotensin–aldosterone system blockers, cytokine-mediated inflammation, and gut malabsorption with consequent nutritional deficiency 1
- Treatment of anemia in patients with heart disease, including those with rheumatic heart disease, may include iron replacement, although it is unclear whether this strategy improves outcomes, and the American College of Physicians recommends against the use of erythropoiesis-stimulating agents in patients with mild to moderate anemia and congestive heart failure or coronary heart disease 1. The primary focus of treatment should be on addressing the underlying rheumatic fever with appropriate antibiotics and anti-inflammatory medications, and iron supplementation should only be considered if there is concurrent iron deficiency 1.
From the Research
Relationship Between Rheumatic Fever and Anemia
There is limited direct evidence on the relationship between rheumatic fever and anemia (iron deficiency) in the provided studies. However, some studies provide information on the treatment and management of rheumatic fever, as well as the prevalence of anemia in inflammatory rheumatic diseases.
- Rheumatic fever is caused by an abnormal immune reaction to group A streptococcal infection, and its treatment involves the use of antibiotics and anti-inflammatory drugs 2, 3.
- Anemia is frequently observed in patients with inflammatory rheumatic diseases, and its prevalence is positively associated with the severity of the underlying disease 4.
- The pathogenesis of anemia in inflammatory rheumatic diseases involves inflammation-induced alterations in iron homeostasis and erythropoiesis, as well as other factors such as chronic blood loss, hemolysis, and vitamin deficiencies 4.
- There is no direct evidence in the provided studies on the relationship between rheumatic fever and iron deficiency anemia. However, studies on the treatment and management of rheumatic fever suggest that secondary prophylaxis with antibiotics is essential to prevent recurrent infections and progression to rheumatic heart disease 2, 3, 5, 6.
Management of Rheumatic Fever
- Secondary prophylaxis with benzathine penicillin G is recommended for people after their initial episode of rheumatic fever to prevent recurrent group A streptococcal infections and progression to rheumatic heart disease 2, 5, 6.
- The efficacy of benzathine penicillin G prophylaxis can be improved by administering injections every 3 weeks instead of every 4 weeks 5.
- Initiatives to enhance the delivery of secondary antibiotic prophylaxis for rheumatic fever and rheumatic heart disease include register/recall systems, dedicated health teams, education, and strong staff-patient relationships 6.