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. 1
Secondary Prophylaxis Regimens
Preferred Antibiotic Regimens:
- First-line: Penicillin G benzathine 1.2 million units intramuscularly every 4 weeks (every 3 weeks in high-risk situations) 1
- Alternative oral options:
Duration of Prophylaxis:
- Severe RHD: Minimum 10 years after most recent acute rheumatic fever or until age 40, whichever is longer 1
- Moderate RHD: Minimum 10 years or until age 35, whichever is longer 1
- Mild RHD: Minimum 10 years or until age 21, whichever is longer 1
- Rheumatic fever without carditis: 5 years or until age 21, whichever is longer 1
Risk Stratification for Prophylaxis Administration
Recent evidence suggests patients with severe RHD may experience cardiovascular compromise following benzathine penicillin G injections 3. Risk stratification is essential:
Elevated Risk Patients (Consider Oral Prophylaxis):
- Severe mitral stenosis
- Severe aortic stenosis
- Severe aortic insufficiency
- Decreased left ventricular systolic function 3
Low Risk Patients (Continue Intramuscular Prophylaxis):
- Patients without severe valvular disease
- Normal left ventricular function
- No history of penicillin allergy 3
Endocarditis Prophylaxis
All RHD patients should receive endocarditis prophylaxis before high-risk procedures 1:
- 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, 4
- For children under 60 lbs: 1 g penicillin V before procedure, then 500 mg 6 hours later 2
Management During Pregnancy
Pregnancy presents special considerations for women with RHD 1:
- Women with moderate-severe mitral stenosis should be considered for percutaneous mitral balloon commissurotomy before pregnancy 1
- During pregnancy:
- Beta blockers for heart rate control
- Diuretics for volume overload
- Anticoagulation for women in atrial fibrillation
- Monitoring by a dedicated heart valve team 1
Monitoring and Follow-up
Regular monitoring is essential for optimal management:
- Echocardiographic assessment to monitor valvular function and disease progression 1
- Monitoring of acute phase reactants (ESR, CRP) until normalized 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 Prophylaxis Effectiveness
The most recent high-quality evidence strongly supports the use of antibiotic prophylaxis:
A 2024 Cochrane review found that antibiotic prophylaxis reduces the risk of rheumatic fever recurrence (RR 0.39,95% CI 0.22 to 0.69), with intramuscular penicillin being approximately 10 times more effective than oral antibiotics 5
A 2022 randomized controlled trial demonstrated that secondary antibiotic prophylaxis significantly reduced disease progression in latent RHD (0.8% progression with prophylaxis vs 8.2% without, p<0.001) 6
Cautions and Pitfalls
Risk of adverse reactions: While rare, anaphylaxis and sciatic nerve injury can occur with intramuscular penicillin. Hypersensitivity reactions and local reactions are more common 5, 3
Adherence challenges: Regular administration of intramuscular injections presents adherence challenges. Ensure proper patient education and follow-up systems 1
Vasovagal reactions: Implement strategies to reduce vasovagal reactions during injections, especially in patients with severe RHD 3
Pregnancy considerations: RHD can worsen during pregnancy due to increased cardiac demands. Early consultation with a heart valve team is essential 1