From the Guidelines
Patients with a history of rheumatic fever who develop coronary artery disease (CAD) require special management considerations due to their increased risk of complications, and should be managed with antibiotic prophylaxis and standard CAD therapies, along with vigilant monitoring of cardiac function and lifestyle modifications. The intersection between Coronary Artery Disease (CAD) and Rheumatic Fever is a complex one, with rheumatic fever increasing the risk of complications in CAD patients. According to the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1, secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically mitral stenosis. Some key considerations for managing CAD in patients with a history of rheumatic fever include:
- Continuing antibiotic prophylaxis if they have residual rheumatic heart disease, typically with penicillin G benzathine 1.2 million units IM every 4 weeks, or penicillin V 250 mg orally twice daily for those who prefer oral medication 1
- Using standard CAD therapies, including aspirin, statins, beta-blockers, and ACE inhibitors, but with careful monitoring for potential interactions with antibiotic prophylaxis
- Providing additional antibiotic coverage for invasive cardiac procedures like angiography or stenting, typically with ampicillin 2g IV (or vancomycin 1g IV for penicillin-allergic patients) 30-60 minutes before the procedure
- Monitoring cardiac function through regular echocardiograms every 1-2 years, as rheumatic heart disease can accelerate atherosclerotic processes and complicate CAD management 1
- Implementing lifestyle modifications, including a heart-healthy diet, regular exercise, smoking cessation, and stress management, to minimize cardiac risk factors. The World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease, as outlined in the 2012 guideline 1, can help identify patients with rheumatic heart disease, allowing for early intervention and prevention of further complications.
From the Research
Intersection between Coronary Artery Disease (CAD) and Rheumatic Fever
There is limited direct evidence on the intersection between Coronary Artery Disease (CAD) and Rheumatic Fever. However, the provided studies offer some insights into the relationship between rheumatic fever and heart disease.
- Rheumatic heart disease remains a significant cause of acquired heart disease in developing countries 2, 3, 4, 5.
- The optimal management of active rheumatic carditis is still unclear, with limited evidence on the effectiveness of anti-inflammatory agents such as aspirin, corticosteroids, and immunoglobulins in preventing or reducing further heart valve damage 2, 4, 5.
- Rheumatic fever can cause left ventricular dysfunction, even in the absence of valvular heart disease, and this condition is reversible with corticosteroid treatment 6.
- The development of chronic valvular lesions after an episode of rheumatic fever is dependent on the presence or absence of carditis in the previous attack and compliance with secondary prophylaxis 3.
Key Findings
- No significant difference in the risk of cardiac disease at one year between corticosteroid-treated and aspirin-treated groups 2, 4, 5.
- Use of prednisone or intravenous immunoglobulins did not reduce the risk of developing heart valve lesions in patients with acute rheumatic fever 2, 4, 5.
- New randomized controlled trials are warranted to assess the effects of corticosteroids and other anti-inflammatory agents on cardiac outcomes in patients with acute rheumatic fever 2, 4, 5.
Implications for CAD
- While there is no direct evidence on the intersection between CAD and rheumatic fever, the studies suggest that rheumatic fever can increase the risk of heart disease, particularly valvular heart disease 2, 3, 4, 5.
- The relationship between rheumatic fever and CAD may be indirect, with rheumatic fever increasing the risk of heart disease, which in turn increases the risk of CAD. However, further research is needed to fully understand this relationship.