What is the initial management for heart failure due to rheumatic heart disease?

Initial Management of Heart Failure from Rheumatic Heart Disease

Start guideline-directed medical therapy for heart failure immediately while initiating mandatory lifelong secondary prophylaxis with benzathine penicillin G 1.2 million units intramuscularly every 4 weeks to prevent recurrent rheumatic fever. 1

Immediate Pharmacologic Management

Diuretics for Volume Overload

• Begin loop diuretics immediately if pulmonary congestion or peripheral edema is present to provide rapid symptomatic relief 2, 1
• Loop diuretics are essential when fluid overload manifests as pulmonary congestion or peripheral edema, resulting in rapid improvement of dyspnea and increased exercise tolerance 2
• If glomerular filtration rate is less than 30 mL/min, avoid thiazides except when prescribed synergistically with loop diuretics 2
• For insufficient response, increase the diuretic dose, combine loop diuretics with thiazides, or administer loop diuretics twice daily 2

ACE Inhibitors as First-Line Therapy

• Start ACE inhibitors as first-line therapy for left ventricular systolic dysfunction (ejection fraction <40-45%), even in asymptomatic patients 2, 1
• Begin with a low dose and uptitrate to target doses proven effective in large trials, not based on symptomatic improvement alone 2
• Review and potentially reduce diuretics for 24 hours before initiating ACE inhibitors to avoid excessive diuresis 2
• Monitor blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment, at 3 months, and subsequently at 6-month intervals 2
• If renal function deteriorates substantially, stop treatment 2

Beta-Blockers

• Add beta-blockers (bisoprolol, carvedilol, or metoprolol XL/CR) to ACE inhibitors and diuretics for all patients with stable heart failure and reduced ejection fraction in NYHA class II-IV 2, 3
• Beta-blockers attenuate ventricular remodeling, improve ventricular function, clinical class, and survival when added to ACE inhibitors 4

Aldosterone Antagonists

• Add spironolactone for advanced heart failure (NYHA class III-IV) in addition to ACE inhibitors and diuretics to improve survival and morbidity 2, 1
• Use only if hypokalemia persists after initiation of ACE inhibitors and diuretics 2
• Start with 1-week low-dose administration, check serum potassium and creatinine after 5-7 days, and titrate accordingly 2

Mandatory Secondary Prophylaxis

Initiate lifelong antibiotic prophylaxis with benzathine penicillin G 1.2 million units intramuscularly every 4 weeks immediately to prevent recurrent acute rheumatic fever 1, 5

• This is non-negotiable and must be started regardless of heart failure severity 1
• For penicillin-allergic patients, use oral penicillin V, sulfadiazine, or macrolide antibiotics as alternatives 5
• Duration depends on disease severity: 10 years after last attack or until age 40 for persistent valvular disease 5

Management of Atrial Fibrillation (Common Complication)

• Use beta-blockers or digoxin for rate control if atrial fibrillation is present 1
• Initiate anticoagulation with warfarin (preferred over direct oral anticoagulants in rheumatic heart disease with atrial fibrillation) 1
• Digoxin provides additional benefit for symptom control, particularly when atrial fibrillation coexists 1

Alternative Therapies When ACE Inhibitors Not Tolerated

• Substitute angiotensin receptor blockers (ARBs) if ACE inhibitors cause intolerable cough or angioedema 2, 1
• Use hydralazine/isosorbide dinitrate as alternative vasodilator therapy if both ACE inhibitors and ARBs are contraindicated due to hypotension or renal dysfunction 1, 3, 4

Additional Preventive Measures

• Provide infective endocarditis prophylaxis before dental procedures involving gingival tissue manipulation 1, 5
• Ensure optimal oral health maintenance 1, 5
• Administer influenza and pneumococcal vaccinations to reduce complication risk 1, 5

Monitoring Strategy

• Perform regular echocardiographic surveillance: every 6-12 months for severe disease, every 1-2 years for moderate disease, and every 3-5 years for mild disease 1, 5
• Conduct structured evaluation including volume status assessment, functional capacity, laboratory evaluation, cardiac imaging, 12-lead ECG, and chest radiograph 1

Critical Pitfalls to Avoid

• Never discontinue secondary prophylaxis prematurely—this is the most common error leading to recurrent rheumatic fever 5
• Avoid non-steroidal anti-inflammatory drugs (NSAIDs) as they interfere with ACE inhibitor efficacy 2
• Do not use potassium-sparing diuretics during ACE inhibitor initiation 2
• Avoid calcium channel blockers with negative inotropic effects (non-dihydropyridines) in patients with ejection fraction less than 50% 2
• Do not delay valve intervention in symptomatic patients with severe valve disease—medical therapy alone is not a substitute for definitive treatment 5