From the Guidelines
High-grade atrioventricular (AV) block in rheumatic fever is a rare but serious complication that requires prompt recognition and treatment to prevent morbidity and mortality. The implications of high-grade AV block in rheumatic fever are significant, and management should focus on reducing inflammation and preventing long-term cardiac damage.
- Hospitalization with continuous cardiac monitoring is essential to quickly identify and respond to any changes in cardiac rhythm or function.
- Administration of high-dose corticosteroids, such as prednisone, and appropriate antibiotic therapy to eradicate group A streptococcal infection, as recommended by guidelines 1, are crucial in reducing inflammation and preventing further cardiac damage.
- Temporary cardiac pacing may be necessary for symptomatic bradycardia or hemodynamic instability, as noted in the management of acute myocarditis with symptomatic heart block 1.
- Most cases of AV block in rheumatic fever are transient and resolve with anti-inflammatory treatment, typically within 1-2 weeks, highlighting the importance of prompt and effective management.
- Long-term follow-up with a cardiologist is essential to monitor for persistent conduction abnormalities or other cardiac sequelae of rheumatic fever, and patients should receive secondary prophylaxis with monthly benzathine penicillin G injections to prevent recurrence.
- The development of cardiac rhythm disturbances, including high-grade AV block, portends a poor prognosis in rheumatic fever, emphasizing the need for aggressive and timely management 1.
From the Research
Implications of High-Grade Atrioventricular (AV) Block in Rheumatic Fever
The implications of high-grade atrioventricular (AV) block in rheumatic fever can be severe and may require immediate medical attention. Some of the key implications include:
- Complete heart block, which can lead to symptomatic bradycardia, syncope, and even asystole longer than 10 seconds 2, 3
- Need for temporary or permanent pacemaker implantation in some cases, especially if the complete heart block persists or is associated with symptoms 2, 3
- Increased risk of cardiac complications, such as mitral regurgitation and pericardial effusion 4, 2
- Potential for long-lasting AV block, requiring ongoing medical therapy and monitoring 3
Clinical Presentation and Treatment
The clinical presentation of high-grade AV block in rheumatic fever can vary, but common features include:
- Exertional dyspnea, fever, and migrating arthralgia 5, 2
- Electrocardiogram (ECG) abnormalities, such as first-degree, second-degree, or complete AV block 5, 4, 2, 6
- Elevated acute phase reactants and positive antistreptolysin O titer 5, 4, 2
- Treatment with anti-inflammatory medications, such as aspirin or naproxen sodium, and benzathine penicillin G 5, 4, 6
- Potential need for steroid therapy, especially if the patient has persistent conduction disturbances or other symptoms 3
Prognosis and Outcome
The prognosis and outcome of high-grade AV block in rheumatic fever can vary, but in general:
- Most cases of AV block are temporary and resolve with conventional anti-inflammatory treatment 4
- Complete heart block can be rare and may require specific treatment, such as temporary pacemaker insertion 2
- Persistent complete AV block may require permanent pacemaker implantation, especially if associated with symptoms or cardiac complications 3