RHEUMATIC ENDOCARDITIS

It is an acute, recurrent inflammatory disease that causes damage to the heart as a

sequela to group A beta-hemolytic streptococcal infection, particularly the valves,
resulting in valve leakage (insufficiency) and/or obstruction (narrowing or stenosis). There
are associated compensatory changes in the size of the heart's chambers and the
thickness of chamber walls
Acute rheumatic fever, which occurs most often in school-age children, follows 0.3% to 3%
of cases of group A beta-hemolytic streptococcal pharyngitis. Prompt treatment of strep
throat with antibiotics can prevent the development of rheumatic fever. The
streptococcus is spread by direct contact with oral or respiratory secretions. Although
the bacteria are the causative agents, malnutrition, overcrowding, and lower socioeconomic
status may predispose individuals to rheumatic fever.

INCIDENCE
The incidence of rheumatic fever in the United States and other developed countries is
believed to have steadily decreased, but the exact incidence is difficult to determine
because the infection may go unrecognized and patients may not seek treatment. As many
as 39% of patients with rheumatic fever develop various degrees of rheumatic heart
disease associated with valvular insufficiency, heart failure, and death. The disease also
affects all bony joints, producing polyarthritis. The prevalence of rheumatic heart
disease is difficult to determine because clinical diagnostic criteria are not standardized
and autopsies are not routinely performed. Except for rare outbreaks, the prevalence of
rheumatic heart disease in the United States is believed to be less than 0.05 cases per
1000 people. The number of U.S. citizens who die from rheumatic heart disease declined
from approximately 15,000 in 1950 to about 4,000 in 2001.

CLINICAL MANIFESTATIONS
 Symptoms of streptococcal pharyngitis may precede rheumatic symptoms
o Sudden onset of sore throat; throat reddened with exudate
o Swollen, tender lymph nodes at angle of jaw
o Headache and fever 101° F to 104° F (38.9° C to 40° C)
o Abdominal pain (children)
o Some cases of streptococcal throat infection are relatively asymptomatic
 Warm and swollen joints (polyarthritis)
 Chorea (irregular, jerky, involuntary, unpredictable muscular movements)
 Erythema marginatum (transient meshlike macular rash on trunk and extremities in
about 10% of patients)
  Subcutaneous nodules (hard, painless nodules over extensor surfaces of
extremities; rare)
 Fever
 Prolonged PR interval demonstrated by ECG
 Heart murmurs; pleural and pericardial rubs
MEDICAL MANAGEMENT
 Antimicrobial therapy penicillin is the drug of choice
o Note that missed doses of antibiotics due to the patient's unavailability
while off the unit for diagnostic tests are given after return to the unit.
o Missed antibiotic doses may have irreversible deleterious consequences.
o Notify health care provider if doses will be missed to make sure that
appropriate alternative measures are taken.
 Salicylates or NSAIDs to control fever and pain if present
 Prevention of recurrent episodes through long-term penicillin therapy for 5 years
after initial attack in most adults; periodic prophylaxis throughout life if valvular
damage

PATHOPHYSIOLOGY

The heart damage and the joint lesions of rheumatic endocarditis are not infectious in the

sense that these tissues are not invaded and directly damaged by destructive organisms;

rather, they represent a sensitivity phenomenon or reaction occurring in response to

hemolytic streptococci. Leukocytes accumulate in the affected tissues and form nodules,

which eventually are replaced by scar tissue.

The myocardium is certain to be involved in this inflammatory process; rheumatic

myocarditis develops, which temporarily weakens the contractile power of the heart. The

pericardium also is affected, and rheumatic pericarditis occurs during the acute illness.

These myocardial and pericardial complications usually occur without serious sequelae.

Rheumatic endocarditis, however, results in permanent and often crippling side effects.

DIAGNOSTIC AND LABORATORY EXAM

 The major diagnostic criteria include carditis, polyarthritis, chorea, subcutaneous
nodules, and erythema marginatum. The minor diagnostic criteria include fever,
arthralgia, prolonged PR interval on ECG, elevated acute phase reactants (increased
erythrocyte sedimentation rate [ESR]), presence of C-reactive protein, and
leukocytosis.
  Additional evidence of previous group A streptococcal pharyngitis is required to
diagnose rheumatic fever. One of the following must be present:
 Positive throat culture or rapid streptococcal antigen test result
 Elevated or rising streptococcal antibody titer
 History of previous rheumatic fever or rheumatic heart disease
 These criteria are not absolute; the diagnosis of rheumatic fever can be made in a
patient with chorea alone if the patient has had documented group A streptococcal
pharyngitis.
 After a diagnosis of rheumatic fever is made, symptoms consistent with heart
failure, such as difficulty breathing, exercise intolerance, and a rapid heart rate
out of proportion to fever, may be indications of carditis and rheumatic heart
disease.
 These criteria are not absolute; the diagnosis of rheumatic fever can be made in a
patient with chorea alone if the patient has had documented group A streptococcal
pharyngitis.
 After a diagnosis of rheumatic fever is made, symptoms consistent with heart
failure, such as difficulty breathing, exercise intolerance, and a rapid heart rate
out of proportion to fever, may be indications of carditis and rheumatic heart
disease.

NURSING DIAGNOSIS WITH RELATED FACTORS

 Risk for decreased cardiac output: Risk factors may include inflammations of the
lining of the heart and structural change in valve leaflets
 Anxiety may be related to change in health status and threat of death, possibly
evidenced by Additional evidence of previous group A streptococcal pharyngitis is
required to diagnose rheumatic fever. One of the following must be present:
 Positive throat culture or rapid streptococcal antigen test result
 Elevated or rising streptococcal antibody titer
 History of previous rheumatic fever or rheumatic heart disease
 apprehension, expressed concerns, and focus on self
 Acute pain related to generalized inflammatory process and effects of embolic
phenomena, possibly evidenced by verbal reports, narrowed focus, distraction
behaviors, and autonomic responses
 Risk for activity intolerance : Risk factors may include imbalance between oxygen
supply and demand debilitating condition
 Risk for ineffective tissue perfusion: Risk factors may include embolic interruption
of arterial
Flow
HEALTH TEACHINGS
A key nursing role in the care of patients with Rheumatic Fever and Rheumatic
Endocarditis are:
 Teach the patients about the disease, its treatment, and the preventive steps
needed to minimize recurrence and potential complications.
 Advise patient that after acute treatment with antibiotics, patients must take
prophylactic antibiotics on a regular schedule and before invasive procedures.
Emphasize the importance of prophylaxis against recurrent streptococcal
pharyngitis and rheumatic fever with each patient.
 Advise the patients that It is important to have long term cardiac reevaluations, to
maintain hydration, also advise them to report any signs of thromboemboli or heart
failure to health care providers.
 Emphasize to the patient and the family the importance of rest and adequate
nutrition.
 The diet should be nutritious and without restrictions except in the patient with
congestive heart failure. In these patients, fluid and sodium intake should be
restricted. Potassium supplementation may be necessary if steroids or diuretics are
used.
 Initially, pediatric patients should be placed on bed rest followed by a period of
indoor activity before being permitted to return to school. Full activity should not
be allowed until the acute phase reactants have returned to normal levels.
 Patients should be examined regularly to detect signs of mitral stenosis, pulmonary
hypertension, arrhythmias, and congestive heart failure.
 Primary prevention of rheumatic fever consists of diagnosis and treatment of group
A beta-hemolytic streptococcal pharyngitis.

Patients who have Rheumatic Endocarditis and whose valvular dysfunction is mild may
require no further treatment. Nevertheless, the danger exist for recurrent attacks of
acute Rheumatic fever, bacterial Endocarditis, embolism from vegetations or mural
thrombi in the heart, and eventually cardiac failure. The nurse monitors the patient for
signs and symptoms of valvular disease, heart failure, pulmonary hypertension,
thromboemboli and dysrhythmias.

NURSING MANAGEMENT:
 Teach patients about the disease, its treatment, and the preventive steps needed
to minimize recurrence and potential complications.
 After active treatment with antibiotics, patients must take prophylactic antibiotics
on a regular schedule and before invasive procedure.
 Have a long-term cardiac reevaluation to maintain hydration, and to report any signs
of thromboemboli or heart failure to health care providers.
 In mild cases, it may require no further treatment but still, the nurse monitors the
patient for signs and symptoms of valvular disease, heart failure, pulmonary
hypertension, thromboemboli and dysrhytmias.