Guidelines for Managing Rheumatic Heart Disease
Secondary prophylaxis with long-term antibiotic therapy is the cornerstone of rheumatic heart disease management, with intramuscular benzathine penicillin G being the most effective regimen for preventing recurrences of rheumatic fever. 1
Secondary Prophylaxis Regimens
First-Line Antibiotic Options
- Penicillin G benzathine: 1.2 million units intramuscularly every 4 weeks (every 3 weeks in high-risk situations) 1, 2
- Penicillin V potassium: 250 mg orally twice daily 1
- Sulfadiazine: 1 g orally once daily 1
- Macrolide or azalide antibiotics: For patients allergic to penicillin and sulfadiazine 1
Duration of Prophylaxis
Duration depends on the clinical scenario:
| Clinical Scenario | Duration of Prophylaxis |
|---|---|
| Rheumatic fever with carditis and residual heart disease (persistent VHD) | 10 years or until age 40, whichever is longer (sometimes lifelong) [1] |
| Rheumatic fever with carditis but no residual heart disease | 10 years or until age 21, whichever is longer [1] |
| Rheumatic fever without carditis | 5 years or until age 21, whichever is longer [1] |
Important: Secondary prophylaxis should continue even after valve replacement surgery 1
Risk Stratification for Prophylaxis Method
Recent evidence suggests patients should be stratified by risk when choosing prophylaxis method:
Elevated Risk Patients (Consider Oral Prophylaxis)
- Severe mitral stenosis
- Severe aortic stenosis
- Severe aortic insufficiency
- Decreased left ventricular systolic function 3
Low Risk Patients (Intramuscular Prophylaxis Preferred)
Infective Endocarditis Prophylaxis
Antibiotic prophylaxis is reasonable before certain dental procedures in RHD patients:
Indications
- Procedures involving manipulation of gingival tissue
- Procedures involving manipulation of periapical region of teeth
- Procedures involving perforation of oral mucosa 1
Prophylaxis Regimen
- Standard: 2 g amoxicillin orally 30-60 minutes before procedure
- Penicillin-allergic: Clindamycin 600 mg orally 30-60 minutes before procedure 1, 5
Note: IE prophylaxis is not recommended for non-dental procedures (e.g., TEE, endoscopy, colonoscopy, cystoscopy) in the absence of active infection 1
Monitoring and Follow-up
- Regular echocardiographic assessment to monitor valvular function and disease progression 2
- Monitoring of acute phase reactants (ESR, CRP) until normalized 2
- Regular cardiac follow-up for patients with established RHD 2
Special Considerations
Pregnancy Management
- Interventional therapy such as percutaneous mitral balloon commissurotomy (PMBC) should be considered prior to pregnancy in women with moderate-severe mitral stenosis 1
- During pregnancy, beta blockers are reasonable for heart rate control 1
- Diuretics may be used for volume overload 1
- Anticoagulation should be considered for women in atrial fibrillation 1
Effectiveness of Prophylaxis
Recent evidence confirms that adherence to secondary prophylaxis regimens can lead to significant clinical improvement and even regression of valvular lesions:
- Mitral valve lesions showed regression in 69.9% of patients with good adherence 6
- Aortic valve lesions showed regression in 48.7% of patients with good adherence 6
- Patients with disease progression were associated with non-compliance to secondary prophylaxis 6
Common Pitfalls and Caveats
Failure to continue prophylaxis after valve surgery: Secondary prophylaxis must continue even after valve replacement 1
Inadequate duration of prophylaxis: Many patients discontinue prophylaxis prematurely, increasing risk of recurrence 4
Overlooking potential adverse reactions: Patients with severe valvular disease may experience cardiovascular compromise following BPG injections; consider oral prophylaxis for these high-risk patients 3
Neglecting IE prophylaxis: RHD patients require IE prophylaxis for dental procedures even if they are already on secondary prophylaxis for rheumatic fever 5
Assuming symptomatic infections only cause recurrence: Group A streptococcal infection does not have to be symptomatic to trigger a recurrence of rheumatic fever 1
By following these guidelines and ensuring patient adherence to prophylaxis regimens, progression of rheumatic heart disease can be significantly reduced, improving long-term outcomes and quality of life for patients with this condition.