What is the treatment for carditis in acute rheumatic fever (ARF)?

From the Guidelines

The treatment of carditis in acute rheumatic fever (ARF) involves a comprehensive approach focusing on anti-inflammatory therapy, antibiotics, and supportive care, with the primary goal of reducing inflammation, eliminating the triggering infection, and preventing recurrence to minimize morbidity, mortality, and improve quality of life.

Key Components of Treatment

• Anti-inflammatory therapy: Aspirin is the mainstay treatment, typically given at 80-100 mg/kg/day divided into 4 doses for 4-8 weeks, then tapered over 2-4 weeks while monitoring symptoms and inflammatory markers 1.
• Antibiotics: Penicillin is essential to eradicate group A streptococcal infection, with benzathine penicillin G 1.2 million units IM as a single dose for patients >27 kg (600,000 units for smaller children), or oral penicillin V 250 mg twice daily for 10 days 1.
• Supportive care for heart failure may include diuretics like furosemide 1-2 mg/kg/day, ACE inhibitors such as enalapril 0.1 mg/kg/day, and bed rest during the acute inflammatory phase.

Long-term Secondary Prophylaxis

• Long-term secondary prophylaxis is crucial, typically with benzathine penicillin G 1.2 million units IM every 3-4 weeks for at least 10 years or until age 21, whichever is longer, for patients with carditis 1.
• The decision to discontinue prophylaxis or to reinstate it should be made after discussion with the patient of the potential risks and benefits and careful consideration of the epidemiological risk factors enumerated above 1.

Considerations for Patients with Carditis

• Patients who have had rheumatic carditis, with or without valvular disease, are at a relatively high risk for recurrences of carditis and are likely to sustain increasingly severe cardiac involvement with each recurrence 1.
• Therefore, patients who have had rheumatic carditis should receive long-term antibiotic prophylaxis well into adulthood and perhaps for life 1.

From the FDA Drug Label

1. Collagen Diseases During an exacerbation or as maintenance therapy in selected cases of: ... Acute rheumatic carditis The treatment for carditis in acute rheumatic fever (ARF) is prednisone as an adjunctive therapy for short-term administration.

• Key points:
  • Prednisone is used during an exacerbation of acute rheumatic carditis.
  • It is used as maintenance therapy in selected cases. 2

From the Research

Treatment for Carditis in Acute Rheumatic Fever (ARF)

• The optimal management of active rheumatic carditis remains unclear 3, 4, 5.
• Several studies have compared the effects of anti-inflammatory agents such as aspirin, corticosteroids, and immunoglobulin in preventing or reducing further heart valve damage in patients with ARF 3, 4, 5.
• The results of these studies suggest that there is no significant difference in the risk of cardiac disease at one year between corticosteroid-treated and aspirin-treated groups 3, 4, 5.
• The use of prednisone or intravenous immunoglobulins compared to aspirin did not reduce the risk of developing heart disease after one year 3, 4, 5.
• Some studies suggest that steroids should be used when clinical and laboratory evidence of carditis exists, and aspirin should be reserved for cases of acute rheumatic arthritis with no evidence of carditis 6.
• The incidence of long-term valvular disease in active carditis may be decreased with steroid therapy 6.

Anti-Inflammatory Agents

• Aspirin, corticosteroids, and immunoglobulin have been compared in various studies to assess their effects on preventing or reducing further heart valve damage in patients with ARF 3, 4, 5.
• The results of these studies suggest that there is little evidence of benefit from using corticosteroids or intravenous immunoglobulins to reduce the risk of heart valve lesions in patients with ARF 3, 4, 5.
• New randomized controlled trials are warranted to assess the effects of corticosteroids and other new anti-inflammatory agents on cardiac outcomes in patients with ARF 3, 4, 5.

Secondary Prophylaxis

• Secondary antibiotic prevention, which includes regular long-acting intramuscular benzathine penicillin injections, aims to protect individuals against reinfection with group A streptococcus and prevent recurrent ARF and further damage to the heart valves 7.
• However, utilization of benzathine penicillin can be poor, leaving patients at risk of avoidable and progressive heart damage 7.
• Initiatives to enhance the delivery of secondary antibiotic prophylaxis, such as register/recall systems, dedicated health teams, education, and linkages with the community, may be important 7.