What is the initial treatment approach for patients with rheumatic heart disease?

Initial Treatment Approach for Rheumatic Heart Disease

The initial treatment of rheumatic heart disease centers on immediate initiation of intramuscular benzathine penicillin G (1.2 million units every 4 weeks) for secondary prophylaxis, combined with medical management of cardiac complications and timely evaluation for valve intervention. 1

Secondary Antibiotic Prophylaxis: The Foundation of Treatment

Intramuscular benzathine penicillin G is the first-line and most effective regimen for preventing disease recurrence and progression. 1, 2

• Dosing: Administer 1.2 million units intramuscularly every 4 weeks (or 600,000 units every 2 weeks as an alternative) via deep intramuscular injection in the upper outer quadrant of the buttock. 2
• Duration: Continue for 10 years after the last attack or until age 40 (whichever is longer) in patients with persistent valvular disease; for those with rheumatic fever and carditis but no residual heart disease, continue for 10 years or until age 21. 1
• Penicillin-allergic patients: Switch to oral penicillin V, sulfadiazine, or macrolide antibiotics (erythromycin twice daily). 1, 3

Critical Safety Consideration for Severe Disease

For patients with severe valvular disease (severe mitral stenosis, aortic stenosis, aortic insufficiency) or reduced left ventricular systolic function, oral prophylaxis should be strongly considered instead of intramuscular benzathine penicillin G due to risk of cardiovascular compromise following injections. 4 This represents a recent shift in thinking based on evidence of deaths following BPG injections in patients with advanced disease. 4

Medical Management of Cardiac Complications

Initiate guideline-directed medical therapy immediately for patients presenting with heart failure or left ventricular dysfunction. 1

• Heart failure regimen: Use diuretics, ACE inhibitors or ARBs, beta-blockers, aldosterone antagonists, and sacubitril/valsartan when indicated, following standard heart failure protocols. 1
• Atrial fibrillation: Start anticoagulation for stroke prevention in patients who develop atrial fibrillation. 1
• Blood pressure management: Avoid abrupt BP lowering in patients with stenotic lesions, as this can worsen hemodynamics. 1

Infective Endocarditis Prophylaxis

Prescribe amoxicillin prophylaxis before dental procedures involving manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa. 1, 3

• Exception: Patients already receiving benzathine penicillin G for secondary prophylaxis do not require additional prophylaxis unless they have recently received penicillin or amoxicillin, in which case use clindamycin. 3

Early Assessment for Valve Intervention

Evaluate all patients with symptomatic severe rheumatic mitral stenosis (mitral valve area ≤1.5 cm²) for percutaneous mitral balloon commissurotomy (PMBC) or mitral valve surgery within 3 months of diagnosis. 5

• PMBC is preferred for patients with favorable valve morphology (mobile, relatively thin leaflets free of calcium, without significant subvalvular fusion) and less than 2+ mitral regurgitation in the absence of left atrial thrombus. 5
• Surgical intervention is indicated when valve anatomy is unfavorable, PMBC has failed, or patients have moderate-to-severe tricuspid regurgitation requiring repair. 5, 1
• Long-term outcomes: 70-80% of patients with good initial PMBC results remain free of recurrent symptoms at 10 years. 5

Monitoring and Follow-Up Strategy

Establish regular echocardiographic surveillance based on disease severity: every 3-5 years for mild disease, every 1-2 years for moderate disease, and every 6-12 months for severe disease or when the left ventricle is dilating. 1

Additional Preventive Measures

• Vaccinations: Administer influenza and pneumococcal vaccines. 1
• Oral health: Maintain optimal oral hygiene to reduce risk of bacteremia and endocarditis. 1
• Patient education: Counsel on the importance of adherence to prophylaxis, recognition of symptoms requiring urgent evaluation, and pregnancy planning. 1

Special Consideration: Pregnancy

Women with moderate-to-severe rheumatic heart disease must be evaluated before pregnancy, with interventional therapy considered prior to conception. 1 During pregnancy, management includes beta-blockers, diuretics, and anticoagulation as needed, with multidisciplinary team involvement. 1, 6

Critical Pitfalls to Avoid

• Never discontinue secondary prophylaxis prematurely, as this leads to disease recurrence and progression. 1
• Do not delay valve intervention in symptomatic patients with severe disease, as medical therapy alone is not a substitute for definitive treatment. 5
• Avoid administering intramuscular benzathine penicillin G to patients with severe valvular disease or reduced ventricular function without careful risk-benefit assessment; consider oral prophylaxis instead. 4
• Do not overlook pregnancy as a high-risk period that can unmask previously undiagnosed disease or cause decompensation. 7
• Ensure adequate anticoagulation monitoring in patients with atrial fibrillation or prosthetic valves. 1