From the Guidelines
The management of rheumatic heart disease (RHD) involves a multidisciplinary approach, with primary prevention focusing on prompt treatment of streptococcal pharyngitis with penicillin V (250 mg orally, 2-3 times daily for 10 days) or amoxicillin (50 mg/kg orally, once daily for 10 days) 1.
Secondary Prevention
For secondary prevention, patients with established RHD should receive benzathine penicillin G (1.2 million units intramuscularly every 3-4 weeks) for at least 10 years or until age 40 1.
- The duration of secondary prophylaxis may vary depending on the severity of the valvular disease and exposure to group A streptococcus 1.
- For mild RHD, prophylaxis should be continued for a minimum of 10 years after the most recent acute rheumatic fever (ARF) or until age 21 (whichever is longer) 1.
- For moderate RHD, prophylaxis should be continued for a minimum of 10 years after the most recent ARF or until age 35 (whichever is longer) 1.
- For severe RHD, prophylaxis should be continued for a minimum of 10 years after the most recent ARF or until age 40 (whichever is longer) 1.
Additional Considerations
Additionally, patients with severe valve disease may require anticoagulation with warfarin (target INR 2.0-3.0) and antiplatelet therapy with aspirin (75-100 mg orally, once daily) 1.
- Echocardiography is a crucial tool for diagnosing and monitoring RHD, and screening for asymptomatic cases can help identify patients who may benefit from secondary prophylaxis 1.
- The 2023 World Heart Federation guidelines provide a standardized approach for the echocardiographic diagnosis of RHD and recommend a two-step echocardiography algorithm for active case finding 1.
From the Research
Guidelines for Rheumatic Heart Disease Management
The management of Rheumatic Heart Disease (RHD) involves several strategies, including:
- Secondary antibiotic prophylaxis with benzathine penicillin G (BPG) injections every 4 weeks 2
- Echocardiography screening based on World Heart Federation echocardiographic criteria to identify patients earlier 2
- Population-based registries to enable optimal care and secondary penicillin prophylaxis within available resources 2
- Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves as vital therapeutic adjuncts 2
- Management of health of women with unoperated and operated RHD before, during, and after pregnancy requires a multidisciplinary team effort 2
Secondary Prophylaxis
Secondary prophylaxis with BPG is the cornerstone of RHD management, but challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues 2.
- Subcutaneous infusion of high-dose BPG may be suitable for up to 3 monthly dosing intervals for secondary prophylaxis of RHD 3
- Oral penicillin prophylaxis should be strongly considered for patients with elevated risk, including those with severe mitral stenosis, aortic stenosis, and aortic insufficiency 4
- A multifaceted strategy for vasovagal risk reduction in all patients with RHD receiving BPG is recommended 4
Treatment Adherence
Treatment adherence is a significant challenge in RHD management, with suboptimal adherence undermining most secondary prevention programs 5.
- Strategies to support treatment adherence include peer support groups and case management strategies 5
- Oral penicillin prophylaxis may improve treatment adherence due to its ease of administration compared to intramuscular BPG 5
Primary Prevention
Primary prevention interventions aim to reduce the incidence of group A streptococcal infections, acute rheumatic fever, and RHD.