Rheumatic fever and

heart disease
 Rheumatic Fever and heart
disease
Acute rheumatic fever (ARF) is a inflammatory disease
of the heart potentially involving all layers (
endocardium, myocardium, and pericardium) of heart
resulting from an autoimmune reaction to infection
with group A streptococci
Rheumatic heart disease is a chronic condition
resulting from rheumatic fever that is characterized by
scarring and deformity of the heart valves
 Incidence
ARF is mainly a disease of children aged 514 years.
Initial episodes become less common in older
adolescents and young adults and are rare in persons
aged >30 years.
There is no clear gender association for ARF, but RHD
more commonly affects females, sometimes up to
twice as frequently as males.
 Etiology
Causative Organism
Caused by group A beta haemolytic
streptococcus.
There is a latent period of ~3 weeks
(15 weeks) between the precipitating
group A streptococcal infection and
the appearance of the clinical features
of ARF.
 PATHOPHYSIOLOGY
Causative agent (Group A Beta-
hemolytic streptococci)

Untreated Strep throat

Rheumatic fever
All layers of the heart and the mitral valve and
other connective tissue inflamation

Vegetation forms

Valvular regurgitations and stenosis, joint pain

other manifestation

Heart failure
 PATHOPHYSIOLOGY
Group A strep pharyngeal infection precedes
clinical manifestations of ARF by 2 - 6 weeks.

Body produce antibodies against streptococci

 PATHOPHYSIOLOGY
These antibodies cross react with human tissues
because of the antigenic similarity between
streptococcal components and human connective
tissues (molecular mimicry)
Immunologically mediated inflammation & damage
(autoimmune) to human tissues which have
antigenic similarity with streptococcal components-
like heart, joint, brain and connective tissues
Clinical manifestations
 STREPTOCOCCUS SORE THROAT
Tender lymph nodes
Close contact with infected
person
Scarlet fever rash
Tonsillar exudates in older children
Abdominal pain

GOLD STANDARD POSITIVE THROAT CULTURE

 CLINICAL FEATURES
Cluster of signs and symptoms
A group of criteria developed by T.D jones
Following upper airway infection with GAS
Silent period of 2 - 6 weeks
Sudden onset of fever, pallor, malaise, fatigue.
JONES MAJOR CRITERIA

Polyarthritis

Carditis

Sydenhams chorea

Erythema marginatum

Subcutaneous nodules
 MINOR
MANIFESTATIONS

Elevated
ESR
Fever Epistaxis
WBC
CRP

Arthralgia Serositis
 1.POLYARTHRITIS
Most common feature: present in 90% of patients

Joint is arthritic ie inflammed.

Painful, migratory, short duration.

Usually >5 joints affected and mainly large joints

Knees, ankles, wrists, elbows, shoulders
 2.CARDITIS
Early and most serious manifestation
Manifest as pancarditis
Occur in 60-70% of cases
Heart murmer
Cardiac enlargement
Pericarditis
 Chorea (sydenhams chorea)
Major CNS manifestation
Characterized by involunatary movements,
especially of the face and limbs which cause
disturbances of speech and gait
 Erythema marginatum
Bright pink, nonpruriric,maplike macular
lesions occur mainly on the trunk and
proximal extrimities
 Subcutaneous nodules
Associated with severe carditis
Characterized by firm, small,hard ,painless swelling
located over extenser surfaces of the
joints,knee,wrist and elbow
Subcutaneous nodules
JONES CRITERIA
2 major or
1 major and 2 minor
plus evidence of streptococcal infection indicates
ARF
 Evidence of Group A streptococcal infection
Positive throat culture for strep A
Elevated or rising anti-streptococcal antibody titer
Recent scarlet fever
 DIAGNOSIS
Major and minor critera
Echocardiogram- valvular insufficiency
pericardial fluid/thickening
Chest X-ray- Cardiomegaly
ECG- AV conduction delay
 Step I - primary prevention
(eradication of streptococci)

Step II - anti inflammatory treatment

(aspirin,steroids)

Step III- supportive management &

management of complications

Step IV- secondary prevention

(prevention of recurrent attacks)
 Step II: Anti inflammatory treatment

CLINICAL CONDITION DRUG

Arthritis only Aspirin 75-100 mg/kg/day , give as 4 divided
doses for 6 weeks (attain a body level 20-30
mg/dl)

Carditis Corticosteroids 1-2 mg/kg per day for 4-6

weeks to be tapered off
 3.Step III: Supportive management &
management of complications

Bed rest
Treatment of congestive cardiac failure: -
digitalis,diuretics
Treatment of chorea: -
diazepam or haloperidol
Rest to joints & supportive splinting
STEP IV : Secondary Prevention of Rheumatic Fever (Prevention of
Recurrent Attacks)

Agent Dose Mode

Benzathine penicillin G 1 200 000 U every 3 weeks* Intramuscular
or
Penicillin V 250 mg twice daily Oral

For individuals allergic to penicillin and sulfadiazine

Erythromycin 250 mg twice daily Oral

Recommendations of American Heart Association

SURGICAL MANAGEMENT
 In patients with critical stenosis, mitral valvulotomy,
percutaneous balloon valvuloplasty, or mitral valve
replacement may be indicated.

Due to high rates of recurrent symptoms after

annuloplasty or other repair procedures, valve
replacement appears to be the preferred surgical option
 NURSING MANAGEMENT
ASSESSMENT
 Nursing diagnosis
Acute Pain related to inflammatory response in the
joints.
Interventions
Assess the level of pain, duration, intensity and
frequency of pain.
Complete bed rest and provide comfortable position.
Provide diversional therapy and psychological support.
Administer analgesics as needed.
 Nursing diagnosis
Decreased cardiac output related to valve
dysfunction or HF.
Interventions
Assess the symptoms of heart failure and decreased
cardiac output including diminished quality of peripheral
pulses, cool skin and extremities, increased respiration,
increased heart rate, neck vein distention and presence of
edema.
Assess for heart sounds.
Monitor intake and output.
Provide bed rest.
Administration of cardiac glycosides as prescribed.
Administration of antibiotics to reduce infection.
 Nursing diagnosis
Knowledge deficit related to disease condition and long
term treatment.
Intervention
Assess the clients level of knowledge.
Assess the clients ability to learn.
Explain about disease condition and about prophylactic
treatment of antibiotics.
Clarify the clients doubt clearly.