What cardiac complication is associated with rheumatic fever?

Cardiac Complications of Rheumatic Fever

Rheumatic fever causes valvular heart disease (rheumatic heart disease), which manifests as progressive valve damage—most commonly affecting the mitral valve—leading to stenosis and/or regurgitation, with subsequent complications including atrial fibrillation, heart failure, and premature death. 1

Primary Cardiac Complication: Valvular Heart Disease

After recovery from the initial episode of rheumatic fever, 60-65% of patients develop valvular heart disease. 1 This represents the cardinal cardiac complication and is the direct result of the autoimmune inflammatory process targeting cardiac valve structures.

Specific Valve Involvement

• Mitral valve disease is the predominant manifestation, resulting in mitral regurgitation and/or mitral stenosis 2
• The mitral valve is invariably involved when rheumatic aortic stenosis is present, as rheumatic AS results from commissural fusion with scarring and calcification 1
• Valve damage occurs through an abnormal autoimmune response where antibodies produced against group A streptococcal throat infection cross-react with cardiac endothelial cells 3

Progressive Cardiac Sequelae

The initial valve damage from rheumatic fever leads to a cascade of serious cardiac complications:

Heart Failure

• Progressive valve damage from recurrent rheumatic fever episodes causes heart failure, which is a major cause of premature mortality 1
• Patients with acute rheumatic fever may develop varying degrees of pancarditis with associated valve disease and heart failure 2
• Heart failure represents the end-stage complication requiring lifesaving cardiac surgery 1

Atrial Fibrillation

• As rheumatic heart disease progresses, atrial fibrillation commonly develops, particularly in the setting of mitral valve disease 1
• This arrhythmic complication increases stroke risk and requires anticoagulation management 1

Additional Complications

• Stroke occurs as a consequence of atrial fibrillation and valve disease 1
• Infective endocarditis develops on damaged valves 1
• Pregnancy-related complications arise in women with moderate-severe rheumatic heart disease 4

Clinical Significance and Mortality Impact

Rheumatic heart disease remains the most common cardiovascular disease in young people aged <25 years globally, with an estimated 233,000-468,164 deaths annually 1. In studies of untreated patients, the mean age of death was <25 years 1.

Critical Pitfall to Avoid

Recurrent rheumatic fever episodes cause progressive worsening of valve damage 1, making secondary prevention with long-term antibiotic prophylaxis essential. The infection triggering recurrence does not need to be symptomatic, and rheumatic fever can recur even when symptomatic infections are treated 1. This underscores why continuous antimicrobial prophylaxis—not just treatment of acute pharyngitis—is mandatory for all patients with prior rheumatic fever 1.