Management and Treatment of Rheumatic Heart Disease
Secondary antibiotic prophylaxis is the cornerstone of rheumatic heart disease (RHD) management, with intramuscular benzathine penicillin G being the most effective regimen for preventing recurrences of rheumatic fever and disease progression. 1
Secondary Prophylaxis Regimens
Recommended Antibiotic Options
- First-line: Penicillin G benzathine - 1.2 million units intramuscularly every 4 weeks (every 3 weeks in high-risk situations) 1
- Alternative oral regimens:
Duration of Prophylaxis
Duration depends on disease severity and history:
| Clinical Scenario | Duration of Prophylaxis |
|---|---|
| Severe RHD | Minimum 10 years after most recent ARF, or until age 40, whichever is longer [3,1] |
| Moderate RHD | Minimum 10 years after most recent ARF, or until age 35, whichever is longer [3] |
| Mild RHD | Minimum 10 years after most recent ARF, or until age 21, whichever is longer [3,1] |
| RHD without carditis | 5 years or until age 21, whichever is longer [1] |
Important: Secondary prophylaxis should continue even after valve replacement surgery 3, 1
Risk Stratification for Prophylaxis Administration
Recent evidence suggests patients with severe valvular disease may be at risk for cardiovascular compromise following benzathine penicillin G injections 4. Risk stratification is essential:
Elevated risk patients (consider oral prophylaxis):
- Severe mitral stenosis, aortic stenosis, or aortic insufficiency
- Decreased left ventricular systolic function 4
Low-risk patients: Continue intramuscular benzathine penicillin G 4
Endocarditis Prophylaxis
All RHD patients should receive endocarditis prophylaxis before high-risk procedures 3, 5:
- Standard regimen: 2 g amoxicillin orally 30-60 minutes before procedure 1
- For penicillin-allergic patients: Clindamycin 600 mg orally 30-60 minutes before procedure 1, 5
- High-risk procedures include:
- Dental procedures involving gingival manipulation
- Procedures involving infected skin or musculoskeletal tissues
- Invasive respiratory tract procedures 3
Management of Acute Rheumatic Fever
- Anti-inflammatory therapy: Aspirin 75-100 mg/kg/day divided into 4-5 doses for 4-6 weeks 1
- Antibiotic therapy: Treat streptococcal infection for at least 10 days to reduce risk of rheumatic fever 6
- Monitoring: Regular assessment of acute phase reactants until normalized 1
Management During Pregnancy
For pregnant women with RHD:
- Pre-pregnancy evaluation: Women with moderate-severe mitral stenosis should be considered for percutaneous mitral balloon commissurotomy (PMBC) before pregnancy 3
- During pregnancy:
- Monitoring: Pregnant women with severe valve disease should be monitored by a dedicated heart valve team 3
Long-term Monitoring and Follow-up
- Regular echocardiographic assessment to monitor valvular function and disease progression 1
- Early detection and treatment of streptococcal infections in family members 1
- Regular cardiac follow-up with strict adherence to prophylaxis regimen 1
Evidence for Effectiveness
Recent high-quality evidence from a randomized controlled trial demonstrates that secondary antibiotic prophylaxis significantly reduces disease progression in latent RHD. Only 0.8% of participants receiving prophylaxis showed echocardiographic progression at 2 years, compared to 8.2% in the control group 7.
Potential Complications and Mitigation
- Anaphylaxis: Rare but serious complication of penicillin administration
- Vasovagal reactions: Implement multifaceted strategy for risk reduction in all patients receiving BPG 4
- Local reactions: Common but generally mild 3
Secondary prophylaxis remains the most cost-effective control strategy for RHD, particularly in developing countries where the disease burden is highest 8.