Treatment Guidelines for Rheumatic Heart Disease
Secondary prophylaxis with antibiotics is the cornerstone of rheumatic heart disease management, with intramuscular benzathine penicillin G being the most effective regimen to prevent recurrences and disease progression. 1, 2, 3
Secondary Prophylaxis
- Intramuscular benzathine penicillin G (1.2 million units every 4 weeks) is the first-line antibiotic prophylaxis regimen with the strongest evidence for preventing recurrences 1, 2, 4
- For penicillin-allergic patients, alternatives include oral penicillin V, sulfadiazine, or macrolide antibiotics such as erythromycin 1, 5
- Duration of prophylaxis depends on disease severity 6:
- Rheumatic fever with carditis and residual heart disease: 10 years or greater since last episode and at least until age 40; sometimes lifelong prophylaxis 6
- Rheumatic fever with carditis but no residual heart disease: 10 years or well into adulthood, whichever is longer 6
- Rheumatic fever without carditis: 5 years or until age 21, whichever is longer 6
Risk Stratification for Prophylaxis Administration
- Recent evidence suggests patients with severe valvular disease or reduced ventricular function may be at risk for cardiovascular compromise following BPG injections 7
- Risk stratification is recommended before administering BPG 7:
- Elevated risk: Patients with severe mitral stenosis, aortic stenosis, aortic insufficiency, or decreased left ventricular function 7
- For elevated-risk patients, oral prophylaxis should be strongly considered instead of intramuscular BPG 7
- Low-risk patients without penicillin allergy history should continue receiving BPG 7
Medical Management of Cardiac Complications
- Standard guideline-directed medical therapy for left ventricular dysfunction, including diuretics, ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists when indicated 1
- Careful blood pressure management, avoiding abrupt BP lowering in stenotic lesions 1
- Anticoagulation for stroke prevention in patients with atrial fibrillation 1
Interventional Management
- Percutaneous or surgical intervention is recommended for 6, 1:
- Moderate-severe mitral stenosis with symptoms
- Asymptomatic patients with severe rheumatic mitral stenosis before pregnancy
- Valve replacement surgery when percutaneous mitral balloon commissurotomy is contraindicated or unsuccessful
Infective Endocarditis Prophylaxis
- Antibiotic prophylaxis is recommended before dental procedures involving manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa in high-risk patients 6, 1
- Patients already on secondary prevention antibiotics may not need additional prophylaxis 1, 8
Diagnostic Considerations
- Echocardiography is more sensitive and specific than auscultation for diagnosing rheumatic heart disease 6
- The 2015 modified Jones criteria include echocardiography to assess for cardiac involvement 6
- Regular echocardiographic monitoring is recommended: every 3-5 years for mild disease, every 1-2 years for moderate disease, and every 6-12 months for severe disease 1
Special Considerations in Pregnancy
- Women with moderate-severe rheumatic heart disease should be evaluated before pregnancy and interventional therapy considered 1
- Medical management during pregnancy includes beta-blockers, diuretics, and anticoagulation as needed 1
Common Pitfalls to Avoid
- Discontinuing secondary prophylaxis too early 1
- Inadequate anticoagulation monitoring in patients with atrial fibrillation 1
- Failure to recognize pregnancy as a high-risk period 1
- Neglecting regular follow-up echocardiography 1
- Overlooking the need for infective endocarditis prophylaxis during high-risk procedures 1
- Failing to perform throat culture or rapid antigen detection test for sore throat in patients with rheumatic heart disease 5